Ivacaftor is a new therapeutic agent that acts at the cystic fibrosis transmembrane conductance regulator (CFTR) channel to alter activity. It is approved for use in patients 6 years and older with cystic fibrosis who have at least 1 G551D mutation in the CFTR gene. It is unlike any other current pharmacologic agent for cystic fibrosis in that it specifically targets the gene defect associated with cystic fibrosis as opposed to treating resulting symptomology. Mucoactive agents, antibiotics, inhaled beta agonists, and other anti-inflammatory agents are currently the mainstay of cystic fibrosis treatment but can be associated with several side effects in addition to cumbersome frequency of administration. Ivacaftor's oral dosing regimen offers a more convenient treatment option. However, it is associated with significant drug-drug interactions.

Background: Psychological insulin resistance (PIR) refers to psychological opposition towards insulin therapy. Although not a formal psychological diagnosis, PIR is an under-recognized issue clinicians may encounter when treating patients with diabetes requiring insulin therapy. Methods: Review articles, clinical trials, and practice guidelines were located using online databases. A total of 39 abstracts were reviewed and 11 articles were included in the analysis. Results: Eleven articles were included. Proposed strategies used to mitigate the occurrence of PIR include: identifying the patient's personal obstacles via administration of PIR questionnaires, use of insulin pens as opposed to conventional syringe and needle, education on the risk of hypoglycemia and continuous emphasis of the importance of self-monitoring of blood glucose (SMBG) readings. Discussion: The management of type 2 diabetes mellitus (T2DM) in patients requiring insulin may present challenges such as PIR. Tailoring a patient's treatment plan to account for physiological, psychological, social and financial needs may thwart some of these challenges. Other factors to consider include the cost of the agent and/or devices required. Insulin-dependent patients with T2DM should be assessed for both physiological and psychological changes. Conclusion: Current treatment strategies for clinicians treating T2DM patients with PIR include administering the PIR or BIT questionnaire, initiating lower doses of insulin, switching from insulin vials to insulin pens, including assessment results in individualized treatment plans and using clinical outcomes to screen patients who are at risk for refusing the use of insulin. Further research evaluating clinical outcomes associated with treatment strategies is necessary.

Acknowledgements:The authors would like to thank Alison McCullough, Pharm.D. for her contributions to this project and design of 2 of the 3 reference cards. Disclosure: No funding was requested or received in conjunction with this project. The authors report no known or suspected conflicts of interest related, but not limited, to consulting fees, paid expert testimony, employment, grants, honoraria, patents, royalties, stocks, or other financial or material gain involve with or pertaining to the subject matter of this work.