Insulin Resistance: When We Are the Problem

Jay H. Shubrook, DO; Stephen A. Brunton, MD


April 10, 2017

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Jay H. Shubrook, DO: I am Jay H. Shubrook, family physician and diabetologist at Touro University in California. We are going to continue our series on practical insulin use in primary care. I am happy today to have Stephen Brunton, MD, executive director of the Primary Care Metabolic Group, who is going to talk not about physiologic insulin resistance but rather about clinician resistance to the use of insulin. Welcome, Steve.

Stephen A. Brunton, MD: Thank you. It is a pleasure to be here. It's a very interesting topic. I like the way you introduced it. We have always talked about insulin resistance being something that is the result of patient resistance. However, a lot of insulin resistance comes from practitioners. We resist using insulin for many reasons, and that has an impact on getting our patients to target.

Dr Shubrook: Tell me more. What is clinician insulin resistance?

Dr Brunton: Traditionally, we have been reticent to use insulin because of the impact it would have on slowing the flow in the office, and even in terms of our feelings of expertise. When the basal insulins came out, it made things so much easier—insulin could be initiated with 10 units daily. At that dose, there is a very low risk for hypoglycemia or any other problems. With the insulin pens, it became so much easier.

Part of it, however, is that we assume that our patients do not want to start insulin. Perhaps, in the past, we used insulin as a threat: "If you do not behave, you are going to get insulin." Now we have realized that it is the most effective regimen for getting patients under control. Part of the problem is that the patients may still have some of those other considerations that we may have originally laid upon them. It is our resistance to start patients on a very therapeutic regimen.

Dr Shubrook: Does this come from the complexity of care or the fear of hypoglycemia?

Dr Brunton: It is probably both of those things. Part of the issue is that when patients come for the management of diabetes, many don't have only diabetes. They may have eight to 10 different comorbidities. We are so busy trying to manage all of that that we tend to put off starting insulin. We may have them on three or four oral antidiabetic drugs. So we need to look at where our patients are and how we can get them to target.

A lot of studies show how long it takes us to make a change. It's therapeutic inertia. It has been shown that sometimes for years, the patient is out of control, and we will give them one more chance. We will add another oral agent, but it is not going to have a benefit, particularly when these patients have glucotoxicity.

Patients are not as frightened of needles as we think.

We need to recognize that we have a broad base of different therapeutic options and that today's insulin is not your grandparents' insulin. We have better analog insulins. We have pens. We have very small needles, so patients are much more likely to accept insulin than we think. Insulin resistance is really our problem. Patients are not as frightened of needles as we think.

Patients may have misconceptions about what insulin means; for example, they might have heard, "I started insulin and my leg dropped off." That, as you and other clinicians know, is not why that person lost their leg, but the patient still holds onto that, and insulin becomes a big fear. It is up to us to help them overcome that.

How to Address Our Own Resistance

Dr Shubrook: You mentioned many things that make it easier for us to overcome our resistance—insulin pens, easy-to-titrate insulins, and algorithms for treatment. How do we address the clinician resistance to using insulin that remains?

Dr Brunton: The issue is to try to develop a system in the office so that you do not have to do everything yourself. Educate the staff to overcome some of the barriers to implementation in the office. Introduce insulin early on in the diagnosis. With people who have type 2 diabetes, insulin seems to be far in the future, and the thinking is, "Oh my God, I hope not." I say, "I have a natural therapy that eventually you might use." We recognize that diabetes is a progressive disease and eventually a significant proportion of patients are going to need insulin. I view this as a positive and say, "This natural therapy is insulin, and we will talk about that as it gets a little closer, but let me tell you a little bit about it." I explain the pathophysiology of diabetes and where insulin fits in. Then, I also have staff who can go over injection techniques and some of the algorithms, so that it is not all laying on my shoulders.

Dr Shubrook: Those are important points, but I can still see some of my partners being resistant to the use of insulin. Maybe it's based on a bad experience they have had in the past, maybe it's just a lack of experience, or maybe it's the math. If I wanted to talk to one of my colleagues about starting insulin more frequently, what are some steps that they can follow?

Dr Brunton: First, try to understand the concerns. Sometimes it relates to misconceptions. Not only do we have an easier process now with basal insulin, but show them how to titrate it. A lot of patients will start on 10 units and if they stay on that, they are not going to get the benefits. The benefit of basal insulin comes with titration. One does not have to go from a basal all the way to a basal bolus with four injections a day. We can use the basal-plus approach where you provide some short-acting insulin for the main meal. That makes things a little easier. Now we also have GLP-1 agonists that we can use in concert with insulin. There are many ways that we can use insulin to help get our patients to goal.

Dr Shubrook: This is really still a very important topic because we know that most of our patients with type 2 diabetes and all of our patients with type 1 are going to need insulin. If clinicians are not comfortable, these patients are certainly not going to get the treatment they need.

What I have heard you say today is: (1) Clinician insulin resistance is still an issue despite many advances, and sharing these advances with providers might be a first step; (2) Get someone in your office who can help you so that it is not on the clinician alone to have to do this; and (3) Trust some of these tools and get some positive experiences.

Dr Brunton: Yes. We have come a long way, Jay, and that is one of the exciting things about managing diabetes today. We have so many tools at our fingertips that can help our patients get to goal. We have been at a plateau—about 55% of patients are getting to goal and 45% are not. Now that clinicians have these tools, if they feel more comfortable with them, we can help our patients.

Dr Shubrook: Thank you so much—you shared some very important topics today.


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