Barriers to Insulin Therapy in Type 2 Diabetes

Mark Warren, MD: There are many barriers to insulin initiation. One of them is just the inertia of the provider and the reluctance of the patient. The reluctance of the patient is usually due to their fear of hypoglycemia and the fact that they think they may have a more severe case of diabetes, if you will. But they’re really concerned about hypoglycemia because they’ve seen it in other patients. So, that’s a big issue for us when we’re talking about starting insulin with our patients.

Weight gain is a barrier and concern for patients when starting insulin. Insulin generally does cause weight gain, with the exception of Levemir [insulin detemir]. We would like to use a smaller dose of insulin, if possible, to prevent significant weight gain, but we always tell the patients that they may have some weight gain because they’re no longer having any glucosuria. They’re retaining those calories. We suggest that they really watch what they eat and exercise a little bit more to mitigate that weight gain that’s associated with insulin therapy.

The portion of patients who will ultimately require insulin therapy is anywhere from 50% to 80%. Usually by about 10 years, 50% of patients will require insulin. This requirement of insulin may be delayed by some agents, such as pioglitazone or GLP-1 receptor agonists. There may be some islet cell preservation and weight reduction with the GLP-1 receptor agonists, essentially delaying insulin requirement.