Overcoming psychological barriers to insulin use in type 2 diabetes

Type 2 diabetes mellitus (DM) is characterized by a gradual decrease in insulin sensitivity in peripheral tissues and the liver (insulin resistance), followed by a gradual decline in beta-cell function and insulin secretion. Given this decline, many patients with type 2 DM will require insulin therapy to achieve the glycemic target recommended by the American Diabetes Association of glycosylated hemoglobin (A1C) <7%. The combination of insulin plus oral antidiabetic drugs (OADs) has been shown to improve A1C values in patients who were not adequately controlled with OADs alone. Despite its established benefits, however, insulin therapy continues to be underused. The reluctance to initiate insulin therapy is often related to both provider and patient misperceptions about insulin's efficacy and side effects, as well as the perceived complexity of the treatment regimen. In addition, insulin therapy may be viewed as a "last resort" treatment option for severe disease or as "punishment" for patients' failure to manage their disease. However, patients should be made aware from the time of diagnosis that diabetes is a progressive disease and that it is likely that insulin therapy will be required at some point during the course of the disease. The subject of insulin therapy, therefore, should be approached positively and should be presented as an effective and flexible way to achieve glycemic goals for any patient at any time during therapy.