Confronting insulin qualms of diabetic patients, MDs
Reluctance of type 2 patients – and physicians who lack confidence or resources to start insulin regimens – needlessly forestalls helpful care.
Potent pharmacology and new research have increased diabetic patients’ potential gains from treatment. One persistent obstacle, though, is reluctance toward insulin – a stance that may be exacerbated by the inability or hesitance of primary care physicians (PCPs) to prescribe it.
“Often offices don’t have the nurses or staff to teach patients,” said Dr. Irl Hirsch, medical director of UW Medicine’s Diabetes Care Center. “When you start insulin, the patient needs to get blood sugar levels back to the physician within a few days. Someone has to be there to take the call or fax.”
PCPs may resist insulin starts for other reasons, Hirsch suggested: A lack of instruction as a medical student can leave a doctor unconfident about directing a patient’s insulin management. Insulin can be interpreted, too, as a “failure” that the physician isn’t ready to concede.
Hirsch cited a 2007 study reflecting type 2 patients’ willingness to forgo insulin for years despite inadequate glycemic control with first-line therapy.
“There can be a feeling of negativity about insulin that patients pick up on,” he said. “Out in the community, the most common thing we see is type 2 patients who clearly need insulin.”
Type 2 patients can be very well served by PCPs, he added, but physicians who lack resources for insulin management “should consider referring patients to a center like ours, at least for part of their care.”
Type 2 ‘shoe’ may not fit
Recent research calls into question long-held standards of diabetes care. For instance, guidance to aggressively drive down blood sugars in all type 2 patients has been narrowed to include only those known to be early in the disease process. Longtime cases, specialists now understand, can respond adversely to intensified therapy.
New data also questions whether a three-month measure of glycated hemoglobin, known as the “A1C,” reliably represents the progress of a diabetic patient’s therapy, said Dr. Dace Trence, the center’s director.
“This is a measure on which physicians rely on and are graded on, in terms of how well they do -- and yet it is a measurement fraught with potential pitfalls and for many individuals does not tell the picture at all,” Trence said.
She also recounted cases in which Metformin, the standard first-line therapy for type 2 patients, as well as statins used commonly to reduce cholesterol are not well tolerated by patients with a subtype of diabetes that involves deafness.
Such findings “cause us to rethink our approach for many type 2 patients,” which for years has been “one shoe fits all,” she said.
“Here we can take a step back to confirm, for instance, whether a patient really does have type 2. It's not unusual to change the diagnosis when suspicion has been raised after examining the patient and getting a family history.”
Increasing referral access
Hirsch said two additional practitioners this year and a third in the following year will improve referral access to UW Medicine’s center. The team meshes the talents of endocrinologists, dietitians, a pharmacist, clinical nephrologist and, distinctly, a psychiatrist.
“People with diabetes, no matter what type, have greater mental-health challenges: depression, anxiety, eating disorders. Our antennae are always up, especially for patients who are not doing good self-management,” he said.
In March, the new practitioners also began staffing a new inpatient diabetes team at UW Medical Center. This aims to extend expertise about insulin management to diabetic patients who come to the hospital for a related or unrelated condition.
To refer a patient or learn more, contact the UW Medicine Diabetes Care Center at 206.598.4882.
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