Your Family Physician

Program Objectives

1. Review the efficacy of insulin therapy for achieving optimal glycemic control in type 2 diabetes
2. Describe barriers to insulin therapy
3. Discuss currently used insulin injection devices and their utility in reducing treatment barriers, and how clinicians can help overcome barriers to achieve successful initiation of insulin therapy
4. Discuss side effects of insulin therapy, such as hypoglycemia and weight gain, and strategies to reduce these effects

Proceed to the Case Simulations

Type 2 diabetes is a complex disease characterized by reduced insulin activity due to abnormalities in insulin secretion and/or action. Most patients also have insulin resistance that creates a need for additional (exogenous) insulin. Glucose metabolism is dysregulated, with increased hepatic glucose production and decreased peripheral glucose uptake leading to hyperglycemia.

Major symptoms of diabetes include extreme hunger, excessive thirst, frequent urination, irritability, increased fatigue, blurry vision, and unusual weight loss. However, because type 2 diabetes comes on gradually, over years as opposed to months or even weeks for type 1, the symptoms for type 2 diabetes may be less prominent. Insulin resistance is associated with abnormalities, such as dyslipidemia and hypertension, which increase the risk for cardiovascular disease in diabetic patients. Elevated triglycerides and decreased high-density lipoprotein (HDL) cholesterol levels are characteristic of type 2 diabetic subjects.

The primary goal of treatment is to lower the glucose level to as close to the normal range as is safe and beneficial to the patient. Glycated hemoglobin [A1C] levels of < 7.0% are considered normal; some patients may benefit from lower levels. To achieve this, insulin therapy is the key treatment for patients with diabetes. Oral or injectable insulin (either basal or bolus) is prescribed depending on the needs of the individual patient. Metformin, an oral agent that suppresses hepatic glucose production, is commonly used as the initial treatment. If needed, a second drug, such as a thiazolidinedione, is added -- which improves insulin sensitivity -- or an insulin secretagogue, such as sulfonylurea.

Barriers to insulin therapy leading to decreased patient adherence include fear of needles, social stigma, and hypoglycemia and weight gain associated with therapy. Clinicians can help patients better manage the disease by reducing these barriers and recommending lifestyle modifications. When individualizing insulin therapy for patients, clinicians must also consider the degree of glucose lowering needed, the side effects associated with drugs, and cost. Further, modification and monitoring cardiovascular risk factors, such as hypertension and lipids, is also critical.

Source : http://cme.medscape.com/viewarticle/576533?src=cme_mp_top