Initiation and Titration of Basal Insulin in Primary Care: Barriers and Practical Solutions

Abstract

Basal insulin therapy is a critical part of effective type 2 diabetes (T2D) management for many patients, yet its initiation and titration are often delayed or avoided. Aversion to basal insulin therapy contributes to unnecessary hyperglycemia and poorer outcomes for patients. Primary care physicians often make decisions regarding the initiation of basal insulin in T2D, as they work closely with patients and are well placed to discuss and manage the transition to basal insulin therapy. However, many primary care clinicians hesitate to initiate basal insulin due to concerns regarding time or effort needed to educate patients, doubts about patient acceptance or ability to manage titration or injection, or patient fears of hypoglycemia. Resistance to basal insulin therapy is often linked to the outdated perception that the need for insulin represents a failure to control the disease, or that insulin is dangerous or toxic. Time concerns can be addressed via group classes and mobile technology and by working with diabetes educators in the community. Hypoglycemia or weight gain can be minimized with proper titration and use of second-generation basal insulins. This article reviews strategies for the initiation of basal insulin therapy, with an emphasis on the characteristics and titration of second-generation basal insulins, introducing current guidelines and offering suggestions for recognizing and overcoming barriers to insulin therapy in the management of T2D. (J Am Board Fam Med 2019;32:431-447.)

Pattern of Disease and Therapy for Diabetes along with Impact of Generic Prescribing on Cost of Treatment among Outpatients at a Tertiary Care Facility

“…Use of insulin in T2DM remains a contentious issue, with delay in institution or intensification recognized as common and counterproductive. [ 25 26 ] It was encouraging to find that insulin was prescribed in 20% of T2DM individuals, similar to a study done in Gujarat,[ 16 ] which can be considered appropriate for tertiary care especially looking at the “inadequate glycemic control” status of individuals coming here, and considering previous evidence where significantly lower usage has been reported in similar setups. [ 13 14 ]…”

A practical approach to the clinical challenges in initiation of basal insulin therapy in people with type 2 diabetes

“…The introduction of basal insulin analogues has changed the treatment paradigm for T2DM 5–7 . Initiating insulin therapy with a basal insulin analogue has become a standard of care in T2DM 8,9 . The simplicity of therapy, ease of dose adjustment and blood glucose monitoring, the low relative risk of hypoglycaemia, and limited weight gain, has increased the confidence of non‐endocrinologists to make prescribing decisions and today basal insulin treatment is often initiated by general practitioners and nurses 10,11 .…”

Delphi-Based Consensus on Treatment Intensification in Type 2 Diabetes Subjects Failing Basal Insulin Supported Oral Treatment: Focus on Basal Insulin + GLP-1 Receptor Agonist Combination Therapies

“…A metaanalysis of cardiovascular outcome trials on glucose-lowering drugs found that a decrease in bodyweight of 1 kg with glucose-lowering interventions led to a statistically significantly reduction of 5.9% in the relative risk of heart failure [29,30]. Therefore, weight gain is considered to be a crucial aspect, representing an important challenge in the management of patients with T2D on insulin treatment [31].…”