Barriers to initiating insulin in type 2 diabetes patients: development of a new patient education tool to address myths, misconceptions and clinical realities

Tests employed in the psychometric validation of the Insulin Treatment Appraisal Scale (ITAS) in T2DM patients; a systematic review of the literature

BACKGROUND

Psychological Insulin Resistance (PIR) and negative perceptions regarding insulin treatment are noteworthy challenges in T2DM management, which hinder the timely initiation of insulin treatment. To get past these obstacles a reliable tool is required to evaluate patients' perspectives on insulin administration. Our study aims to conduct a comprehensive systematic review to evaluate the validity and reliability of different validation tests used in the psychometric validation of the ITAS in T2DM patients.

METHODS

A literature search was carried out, using PubMed, Google Scholar, EMBASE, Cochrane Library and Science Direct. Only those studies assessing content validity, construct validity, concurrent validity, discriminant validity, internal consistency reliability (Cronbach' α), and items-total correlation were retrieved.

RESULTS

A total of 14 studies illustrated the validity and reliability of ITAS in T2DM patients. Content validity results of S-CVI was 0.97, and I-CVI was 0.8-1.00. Construct validity with factor loading was greater than the threshold value of 0.3. The concurrent validity of ITAS vs. PAID, WHO-5, and SPI was 0.35 (P < 0.05), -0.14 (P < 0.05), and 0.80 (P < 0.001) respectively. The mean difference between insulin and non-insulin group was significant (P < 0.001) showing reliable discriminant validity. Reported results of Cronbach's α for the main scale (0.79-0.89), subscale-1 (0.72-0.9), and subscale-2 (0.61-0.89) showed "good to excellent" internal consistency reliability of ITAS. Item-total correlation results for the main scale, subscale-1, and subscale-2 were (0.40-0.82), (0.31-0.74) and (0.34-0.58) respectively. Test-retest reliability of ITAS was 0.571-0.87.

CONCLUSIONS

Study findings confirm the robustness of various validation tests utilized in the psychometric validation of ITAS in T2DM patients. ITAS is a well-validated and reliable tool for determining the perspectives, PIR, and changes in patients' perception over time and it can be used to overcome hurdles in the timely initiation of insulin treatment in T2DM patients.

Patient's barrier to initiate insulin therapy for type 2 D.M

BACKGROUND

Diabetes Mellitus is a health challenging of the century, more than 300 million people lives with diabetes, and it is one of the biggest global health concerns, awing to its complications. Good glycemic control is the cornerstone to decrease risk of type 2 diabetes complications. Even though, many people still have poor glycemic control which can be partly attributed to late insulin initiation, that can be challenging and forced by numbers of barriers. Identification and analysis of these barriers is crucial to find out effective way to overcome them.

AIM

To assess patient's barriers to initiate insulin therapy among diabetic patients.

METHOD

A case series study was conducted during the period extending from July 2023 to June 2024, and a total of 360 participants with type two diabetes were included in this study from four Family Medicine Health Centers. Collected data tabulated and analyzed using Excel sheets and applying the Statistical Package for the Social Sciences (SPSS) Version 24.

RESULTS

26% of the participants were 45-55 years age group, 40% has been diagnosed with diabetes for 5-10 years, and 66% have developed diabetic complications. Fear from hypoglycemia was the comments barrier to initiate insulin therapy and is seen in 84% of the participants.

CONCLUSION

Many barriers have been identified to influence the initiation of insulin therapy, fear from hypoglycemia was found to be the most influencing barrier. Increasing patient's awareness of symptoms of hypoglycemia, and always take their meal after insulin injection can help to overcome hypoglycemia.

Impact of Socio-Demographics and Knowledge, Attitudes, and Practices (KAP) on Misconceptions of Metformin Use in Diabetes: A Potential Myth and Disbelief in South Asia

BACKGROUND

The influence of misconceptions and related socio-demographics on metformin use could hamper adherence to medications. This study aimed to assess the rates and causes of metformin non-adherence and to investigate knowledge, attitudes, and practices (KAP) on misconceptions of metformin use including the association with socio-demographic variables.

METHODS

An observational analytical cross-sectional study was conducted at the diabetes clinic of Karapitiya Teaching Hospital in Galle, Sri Lanka. Causes of metformin non-adherence, associations with socio-demographics, and KAP on misconceptions on metformin use were assessed using the chi-squared test, t-tests, and ANOVA using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States) (p<0.05).

RESULTS

Metformin non-adherence was reported as 55%. Use of complementary and alternative therapies was 14.7%. Fear of major organ failure was the commonest (20.5%) reason quoted within the non-adherence group (N=223). Socio-demographic factors like ethnicity, lower education, unemployment, use of complementary and alternative therapies, and obtaining medications for other diabetes-related diseases significantly influenced adherence to the metformin-prescribed doses (p<0.05). Among all participants (N=400), the most common misconception was that long-term use of metformin caused organ damage (kidney 72.5%, liver 64.3%, and heart 34.8%), while 44% believed higher doses (two tablets or more for a day) caused organ damage. The KAP scores were reported as 24.5% with low, 52.7% moderate, and 22.7% satisfactory levels. Significantly lower KAP scores were associated with lower education levels and patients obtaining complementary and alternative therapies (p<0.05).

CONCLUSION

Misconceptions are not merely kept in mind but lead to non-adherence with metformin doses prescribed and warrant evidence-based educational interventions with the high-risk groups.

A user-centered approach to the development of a diet education tool for older adults with tooth loss

BACKGROUND

Tooth loss is associated with suboptimal nutrient intake and greater risk of malnutrition.

OBJECTIVE

To develop and field-test a stakeholder-informed diet education tool that addresses the unique needs of older adults with tooth loss who do not wear dentures.

METHODS

An iterative user-centered approach was used. Initial content was developed based on findings from previous research. Stakeholder panels of older adults with 20 or fewer teeth, and dentists, were conducted at two time points to obtain feedback on the tool, which was revised following each panel. The tool was field-tested in a dental school clinic and evaluated using the Patient Education Materials Assessment Tool; it was further revised based on feedback.

RESULTS

A diet education tool entitled "Eating Healthier With Tooth Loss" was developed. Sections for fruits and vegetables, grains, and proteins food groups, and one addressing socioemotional aspects of eating with missing teeth were included. Panel members provided constructive, positive feedback; recommendations for editing text, images, design, and content were integrated. Field-testing in the dental clinic with 27 pairs of student dentists and their patients resulted in scores of 95.7% for understandability and 96.6% for actionability, with over 85% agreement with each item. The tool was revised based on field-testing feedback.

CONCLUSION

A diet education tool for older adults with tooth loss was developed using a user-centered approach, integrating the 'patient voice' and patient experiences with US dietary guidelines. Use of this tool is feasible in a dental clinic setting. Future research should explore usage in larger settings.

Can pharmaceutical care decrease the oxidative stress in type 2 diabetes mellitus?

Type 2 diabetes mellitus (T2D) is a chronic metabolic disorder characterized by an increase in oxidative stress, which is itself related to development of T2D's main chronic complications. Oxidative stress caused by elevated production of reactive species of oxygen and decrease of antioxidant defense system level, leads to activation of lipid peroxidation (LPO) and oxidative lipoprotein modification with increasing atherogenicity. Therefore, the aim of this study was to evaluate whether pharmacotherapeutic follow-up in patients with T2D, users and non-users of insulin, interferes with the levels of oxidative stress, measuring lipid peroxidation and protein oxidation, nitric oxide and superoxide dismutase levels. After the follow-up, there was a decrease in nitric oxide levels and an increase in superoxide dismutase concentration for the group with insulin therapy. Accordingly, these results show that the proposed pharmaceutical care program reduced the oxidative stress levels, mainly in patients in insulin therapy, as a consequence, can impact in the surging of the main chronic complications in T2D.

The diabetes insulin self-management education (DIME) intervention for people with type 2 diabetes starting insulin: a pilot feasibility randomised controlled trial

OBJECTIVE

To determine the feasibility and acceptability of a diabetes insulin self-management education (DIME) group intervention for people with type 2 diabetes starting insulin.

DESIGN

Single-centre parallel randomised pilot trial.

SETTING

Primary care, South London, UK.

SUBJECTS

Adults with type 2 diabetes, requiring insulin treatment, on maximum tolerated dose of 2 or more oral antidiabetic drugs with HbA1c > / = 7.5% (58 mmol/mol) on 2 occasions. We excluded people who were non-fluent in English; morbid obesity (BMI > / = 35 kg/m²); in employment that contraindicates insulin treatment; and those with severe depression, anxiety disorders, psychotic disorders, personality disorders, or cognitive impairment.

METHODS

Participants were randomised using blocks of 2 or 4 to 3, 2-h group, face-to-face, DIME sessions or standard insulin group education sessions (control). We assessed feasibility according to consent to randomisation and attendance at intervention (DIME) and standard group insulin education sessions. Acceptability of the interventions was determined using exit interviews. We additionally measured change in self-reported insulin beliefs, diabetes distress and depressive symptoms between baseline and 6-month post-randomisation.

RESULTS

There were 28 potentially eligible participants, of which 17 consented to randomisation, 9 were allocated to the DIME group intervention and 8 were allocated to the standard group insulin education. Three people withdrew from the study (1 from DIME and 2 from standard insulin education) before the start of the first session and did not complete baseline questionnaires. Of the remaining participants (n = 14), all DIME participants (n = 8) completed all 3 sessions, and all standard insulin education participants (n = 6) completed at least 1 standard insulin education session. The median group size was 2, the mean age of participants was 57.57 (SD 6.45) years, and 64% were female (n = 9). Exit interviews demonstrated that all participants (n = 7) found the group sessions acceptable, and thematic analysis of interview transcripts indicated social support, the content of group sessions and post-group experiences were positive, especially amongst DIME participants. There was improvement on self-report questionnaires.

CONCLUSIONS

The DIME intervention was acceptable and feasible to deliver to participants with type 2 diabetes starting insulin in South London, UK.

TRIAL REGISTRATION

International Study Registration Clinical Trial Network (ISRCTN registration number 13339678).

Practical Guidance for Healthcare Providers on Collaborating with People with Type 2 Diabetes: Advancing Treatment and Initiating Injectable Therapy

Type 2 diabetes (T2D) progresses over time, and to achieve and maintain adequate glucose control, many people eventually require injectable therapies such as insulin. However, there can be significant barriers to the initiation of these medications, both from people living with T2D and from healthcare practitioners (HCPs). Misconceptions and misinformation relating to the potential risks and benefits of injectable therapies are common and can contribute to negative perceptions regarding their use. Additionally, HCPs are often unaware of the emotional burden associated with T2D. In particular, diabetes distress is a key contributory factor that needs to be addressed to alleviate fears before diabetes education can be successful. The onus is often on the HCP to initiate effective, individualized communication with each patient and make that person feel an active and equal participant in the management of their T2D. Shared decision-making has been demonstrated to improve understanding of the pathophysiology and treatment options, to increase risk awareness, adherence, and persistence, and to improve self-management behaviors (e.g., exercise, self-care) and patient satisfaction. While therapeutic inertia can result from both patient and HCP, HCPs need to bear the responsibility for escalating therapy when necessary. A proactive approach by the HCP, combined with shared decision-making and a patient-centric approach, are important for optimal T2D management; therefore, an open and effective relationship between the HCP and the person living with T2D is essential. This article is written by a person with T2D, a nurse practitioner/Certified Diabetes Care and Education Specialist, and a clinical endocrinologist, with the goal of providing a holistic view of the management experience, exploring patient needs and expectations, recognizing and avoiding HCP and patient barriers, and providing practical advice to HCPs to empower patients who would benefit from injectable therapy.Infographic and video abstract available for this article.

Myths and beliefs about insulin therapy in patients with diabetes mellitus and their family caregivers from a hospital in northern Peru, 2020

OBJECTIVE.

To analyze and explore the myths and beliefs about insulin therapy in patients with diabetes mellitus and their family caregivers from a general hospital in northern Peru in 2020.

MATERIALS AND METHODS.

This qualitative study used a thematic analysis model, following the interpretative paradigm. Sociodemographic and clinical data were obtained from medical records. Patients with diabetes that used some type of insulin for at least three months prior to the study were interviewed, as well as their family caregivers. Patients participated in a focus group and in-depth interviews; family caregivers participated only in in-depth interviews.

RESULTS.

Twelve patients with diabetes (11 with type 2 diabetes mellitus) were included; six in the focus group and six in the in-depth interviews. Seven family caregivers were included. After analysis, we obtained four categories: 1) beliefs related to starting insulin treatment: treatment of choice after failure of other drugs, cures diabetes, regulates sugar, fear of injectables; 2) beliefs related to treatment adherence: decompensation for not using insulin, insulin is necessary to live; 3) beliefs related to alternative therapies and cost: use of alternative therapies, high cost of insulin; and 4) myths related to the use of insulin: generates dependence, dependence for insulin administration, negative effects of insulin.

CONCLUSIONS.

The beliefs and myths of patients treated with insulin arise from the beginning of treatment, remain throughout the course of treatment, and are often reinforced by the worldview of family members.

Pharmacokinetic and Pharmacodynamic Characteristics of Insulin Icodec After Subcutaneous Administration in the Thigh, Abdomen or Upper Arm in Individuals with Type 2 Diabetes Mellitus

BACKGROUND AND OBJECTIVE

Individuals with diabetes mellitus may prefer different body regions for subcutaneous insulin administration. This trial investigated whether choice of injection region affects exposure and glucose-lowering effect of once-weekly basal insulin icodec.

METHODS

In a randomised, open-label, crossover trial, 25 individuals with type 2 diabetes received single subcutaneous icodec injections (5.6 U/kg) in the thigh, abdomen or upper arm (9-13 weeks' washout). Pharmacokinetic blood sampling occurred frequently until 35 days post-dose. Partial glucose-lowering effect was assessed 36-60 h post-dose in a glucose clamp (target 7.5 mmol/L). Steady-state pharmacokinetics following multiple once-weekly dosing were simulated using a two-compartment pharmacokinetic model.

RESULTS

Total icodec exposure (area under the curve from zero to infinity after single dose; AUC_0-∞,SD) was similar between injection in the thigh, abdomen and upper arm (estimated AUC_0-∞,SD ratios [95% confidence interval]: abdomen/thigh 1.02 [0.96-1.09], p = 0.473; upper arm/thigh 1.04 [0.98-1.10], p = 0.162; abdomen/upper arm 0.98 [0.93-1.05], p = 0.610). Maximum icodec concentration (C_max) after single dose was higher for abdomen (by 17%, p = 0.002) and upper arm (by 24%, p < 0.001) versus thigh. When simulated to steady state, smaller differences in C_max were seen for abdomen (by 11%, p = 0.004) and upper arm (by 16%, p < 0.001) versus thigh. Geometric mean [coefficient of variation] glucose-lowering effect 36-60 h post-dose was comparable between the thigh (1961 mg/kg [51%]), abdomen (2130 mg/kg [52%]) and upper arm (2391 mg/kg [40%]).

CONCLUSION

Icodec can be administered subcutaneously in the thigh, abdomen or upper arm with no clinically relevant difference in exposure and with a similar glucose-lowering effect.

CLINICALTRIALS

GOV IDENTIFIER

NCT04582448.

Fatigue and depression in elderly patients with poorly controlled diabetes

In this study, it was aimed to evaluate the severity of depression and fatigue in patients with type 2 diabetes mellitus (T2DM), aged ≥ 60 years, with poor diabetes control. Between December 2018 and June 2019, 310 patients aged ≥ 60 years, with hemoglobin A1C ≥ 10%, followed-up with the diagnosis of T2DM for at least 3 years in the internal medicine outpatient clinics of Bursa Yüksek İhtisas Training and research hospital were included in the study. The geriatric depression scale (GDS) and fatigue severity scale (FSS) questionnaires were administered. Patients were analyzed according to their sociodemographic and clinical characteristics, according to their GDS and FSS scores. The GDS and FSS scores were higher in the female patients than in the male patients, those with diabetes aged ≥ 21 years than those aged < 21 years, those using premixed insulin than those using basal bolus insulin and oral antidiabetic drug for + basal insulin, and those living alone than in those living with their families. The FSS score was higher in patients with vitamin D levels < 20 ng/mL. The factors affecting the GDS score were the FGS and FSS scores in the multivariate analysis. The factors affecting the FSS score were the GDS, diabetes age, hemoglobin level, and vitamin D level in the multivariate analysis. Poorly controlled diabetes affects elderly patients more in terms of their mental and physical health. Therefore, these patients should be considered in terms of psychosocial aspects to increase treatment compliance and effects.

Barriers and facilitators to insulin treatment: a phenomenological inquiry

BACKGROUND

Despite being the most effective treatment for advanced type 2 diabetes, the choice to start and maintain insulin therapy is based on a variety of criteria, including the patients' acceptance and willingness to adhere to it. The patients' beliefs and experiences, on the other hand, could not be revealed without a thorough exploration.

OBJECTIVES

This study investigated the barriers and facilitators to insulin treatment from the perspectives of patients with type 2 diabetes following treatment at Dessie Comprehensive Specialized Hospital, North-East Ethiopia.

METHODS

A phenomenological study was conducted from July 2019 to January 2020. Twenty-four (11 males and 13 females) participants were recruited purposively. Data were collected through face-to-face in-depth interviews, lasted about 23 to 71 min, until theoretical saturation was reached, and then organized using QDA Miner Lite v2.0.9. The transcripts were thematically analyzed using narrative strategies and the themes that arose were discussed in detail.

RESULTS

The most common facilitator of insulin treatment was its relative effectiveness, which was followed by its convenience (fewer gastrointestinal side effects, small needle size and ease of use), the concept of it is life, faith in doctors' decisions, family support, and health insurance membership. The most common impediments, on the other hand, were market failures (expensiveness and supply shortages), followed by its properties and patients' circumstances.

CONCLUSIONS

Market failures due to supply shortages and associated costs were identified to be the most significant barriers to insulin treatment, necessitating the availability of an effective pharmaceutical supply management strategy that targets on insulin supply and affordability. It is also strongly recommended that health insurance coverage be increased.

Key factors for overcoming psychological insulin resistance: A qualitative study in Japanese people with type 2 diabetes

AIMS

We report the key factors that motivate reluctant Japanese people with type 2 diabetes (T2D) to initiate insulin treatment.

METHODS

Participants were asked questions pertaining to 2 primary areas of exploration in a concurrent mixed methods approach: (a) understanding people's thoughts and perceptions before and after insulin initiation and any related factors; and (b) exploring the reasons behind people's responses. Data were analyzed using Steps for Coding and Theorization.

RESULTS

Participant responses broadly related to 3 themes which influence insulin initiation; 1. Advice from a health care provider (HCP) that insulin is an appropriate treatment; 2. Demonstration by HCPs on how to use the insulin pen/needle and the injection process; and 3. Resignation/surrender/acceptance of insulin, where participants felt there was no other choice but to commence insulin.

CONCLUSIONS

Based on the 3 identified themes, it is important for HCPs to explain the benefits of insulin and demonstrate and explain the injection procedure to reluctant Japanese people with T2D. We also identified resignation/surrender/acceptance of insulin as a reason for treatment commencement. This study provides important information to assist HCPs in helping reluctant Japanese people with T2D to initiate basal insulin therapy.

Web-based intervention to reduce psychological barriers to insulin therapy among adults with non-insulin-treated type 2 diabetes: study protocol for a two-armed randomised controlled trial of 'Is insulin right for me?'

INTRODUCTION

Psychological barriers to insulin therapy are associated with the delay of clinically indicated treatment intensification for people with type 2 diabetes (T2D), yet few evidence-based interventions exist to address these barriers. We describe the protocol for a randomised controlled trial (RCT) examining the efficacy of a novel, theoretically grounded, psychoeducational, web-based resource designed to reduce psychological barriers to insulin among adults with non-insulin treated T2D: 'Is insulin right for me?'.

METHODS AND ANALYSIS

Double-blind, parallel group RCT. A target sample of N=392 participants (n=196/arm) will be randomised (1:1) to 'Is insulin right for me?' (intervention) or widely available online resources (control). Eligible participants include adults (18-75 years), residing in Australia, currently taking oral hypoglycaemic agents to manage T2D. They will be primarily recruited via invitations and reminders from the national diabetes registry (from a purposefully selected sample of N≥12 000).

EXCLUSION CRITERIA

experience of self-administered injectable; previously enrolled in pilot RCT; 'very willing' to start insulin as baseline. Outcomes will be assessed via online survey at 2 weeks and 6 months. Primary outcome between-group: difference in mean negative Insulin Treatment Appraisal Scores (ITAS negative) at 2-week and 6-month follow-up.

SECONDARY OUTCOMES

between-group differences in mean positive insulin appraisals (ITAS positive) and percentage difference in intention to commence insulin at follow-up time points. All data analyses will be conducted according to the intention-to-treat principle.

ETHICS AND DISSEMINATION

Deakin University Human Research Ethics Committee (2020-073). Dissemination via peer-reviewed journals, conferences and a plain-language summary.

TRIAL REGISTRATION NUMBER

ACTRN12621000191897; Australian and New Zealand Clinical Trials Registry.

Sufferings of its consequences; patients with Type 2 diabetes mellitus in North-East Ethiopia, A qualitative investigation

Background

The burden of diabetes in Ethiopia is exponentially increasing with more than 68% of people with it being undiagnosed and a death rate of 32%. It is a disease impacting patients with negative somatic, psychological, social, and economic consequences. Patients in Ethiopia have very low awareness about chronic complications, which is very worrying. The study aimed to explore the consequences of their disease experienced by type 2 diabetes patients in North-East Ethiopia.

Methods

The study employed a phenomenological approach informed by the consequences dimension of the Common-Sense Model. It was conducted from July 2019 to January 2020 using purposive sampling with face-to-face in-depth interviews, for about three weeks, until reaching theoretical saturation. The data were collected from twenty-four type 2 diabetes patients, who were selected to include various socio-demographic characteristics. The data were organized by QDA Miner Lite v2.0.8 and analyzed thematically using narrative strategies.

Results

Using Common-Sense Model as a framework, the diabetes consequences experienced by the participants were categorized as complications and impacts. While the most common complications were cardiovascular disorders (hypertension, erectile dysfunction, heart and kidney problems, hyperlipidemia, edema, stroke, and fatigue) and ocular problems; the most common impacts were psychosocial (dread in life, suffering, family disruption, hopelessness, dependency, and craving), and economic (incapability and loss of productivity) problems.

Conclusion

The patients here were bothered by diabetes complications as well as its psycho-social, economic and somatic consequences; being the psycho-social impacts the most common. As a result, the patients have been suffering in the dread of “what can come next?” This dictates that holistic care, based on Common-Sense Model, is needed in providing special emphasis to psycho-social issues.

Weight Change and the Association with Adherence and Persistence to Diabetes Therapy: A Narrative Review

PURPOSE

Type 2 diabetes (T2D) medication adherence is poor and is impacted by individual drug characteristics. Treatment-associated weight change can affect medication-taking behavior. This review aimed to explore weight change on T2D therapy and consider its impact on adherence and discontinuation.

METHODS

Searches were conducted in MEDLINE and EMBASE (2005 to September 2020), and among recent congress abstract books for studies providing data on medication adherence or discontinuation and weight change in people with T2D (PwD).

RESULTS

Nine studies meeting the inclusion criteria were identified from 9188 bibliographic records. All three studies exploring weight change and discontinuation reported weight loss to be associated with higher persistence. Seven studies of varying design explored weight change and adherence. Four reported absolute weight change (kg) and adherence: one pooled data from different diabetes medications and demonstrated that self-reported adherence was significantly associated with weight loss; however, three studies found that weight change in adherent PwD was in the direction of the known weight profile (loss/gain) of the evaluated drug. Categorical weight loss (≥3%) and adherence were reported in two studies: one reported that numerically more adherent versus non-adherent PwD lost ≥3% weight regardless of the drug's weight profile, the other showed that early weight loss with a glucagon-like peptide-1 agonist was significantly associated with better adherence. One study reported adherence by categorical weight change; as weight loss increased, adherence scores improved, regardless of drug type.

CONCLUSION

Findings suggest that discontinuation rates may be lower in PwD who lose as compared to those who gain weight on T2D treatment. The evidence base on adherence and weight change is more challenging to interpret due to the range of study designs. Given the importance of weight control in T2D, further research exploring the individual's treatment, weight journey, and behaviors over time should be undertaken.

Perceptions of injectable therapies with cardiovascular benefit: an ACNAP survey of healthcare professionals to explore facilitators and barriers

AIMS

Injectable medicines are increasingly used to manage risk factors for cardiovascular (CV) events, such as dyslipidaemia and diabetes. These include proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. Little is known about perceptions of injectable therapies among CV healthcare professionals (HCPs). This study explores their views to identify relevant facilitators and barriers to the use of injectables with CV benefit.

METHODS AND RESULTS

A 22-question survey was distributed internationally via online channels. In total, 192 anonymous responses were received (43.7% physicians, 32.6% nurses, 16.8% pharmacists, 6.8% others). Among respondents with experience of these medicines, 69.1% had used an injectable PCSK9 inhibitor and 67.0% had used an injectable GLP-1 receptor agonist. Commonly raised issues were resource problems (36.5%), lack of knowledge among colleagues (32.3%), paperwork (32.3%), and lack of patient knowledge (28.1%). Key barriers respondents felt made patients decline these treatments were fear of injection (56.6%), lack of awareness or education (26.4%), and administration issues (15.1%); potential reasons for discontinuation included side effects (46.4%), perceived lack of benefit (28.6%), and local reactions (21.4%). The main topics around injectables requiring further support included managing non-adherent patients (16.2%), troubleshooting with patients (16.2%), and educating colleagues about injectables (12.2%). Preferred educational methods to support HCPs were face-to-face training (43.5%) and online learning (26.1%); favoured formats were based on role playing and case studies.

CONCLUSION

Healthcare professionals highlighted various potential barriers to initiation, continuation, and adherence with injectable therapies in CV medicine. Although some require healthcare system changes, many could be addressed through simple measures based primarily on enhanced training and support for patients and HCPs.

Attitudes and beliefs of South African primary healthcare practitioners on initiating insulin in people with type 2 diabetes: Findings from the Tshwane Insulin Project (TIP)

AIMS

To investigate the attitudes and beliefs of primary healthcare practitioners (HCPs) towards initiating insulin therapy for people with type 2 diabetes (T2D) in South Africa.

METHODS

A cross-sectional survey was conducted amongst HCPs from 23 clinics. The nurses' questionnaire was administered by research nurses while doctors completed an online version about their attitudes, beliefs and perceived barriers to initiating insulin.

RESULTS

Of the 73 HCPs surveyed, 68% were nurses and 84% were women. Only 24% of HCPs believed that most patients would eventually need to initiate insulin regardless of their adherence to treatment regimens and 86% preferred to delay insulin therapy. Doctors were reluctant to initiate insulin, citing patient-related reasons such as low socio-economic level (41%), inability to refrigerate insulin (77%) and inability to self-monitor blood glucose (55%). Doctors mentioned that patient behaviour including not adhering to treatment regimen and appointments (91%) and reluctance to start insulin therapy (82%) influenced their prescription practices. Doctors mentioned that health system factors, including the pressure to see patients quickly (68%) and lack of continuity of care (64%) were barriers to initiating insulin.

CONCLUSIONS

Optimising insulin therapy in primary care requires health system changes including promoting person-centred care and continuing training for HCPs.

'Is Insulin Right for Me?' Development of a theory-informed, web-based resource for reducing psychological barriers to insulin therapy in type 2 diabetes

OBJECTIVE

To develop a theory and evidence-based web intervention to reduce psychological barriers towards insulin therapy among adults with non-insulin-treated type 2 diabetes (T2D).

METHODS

Salient psychological barriers towards insulin were identified from the literature and classified using the Theoretical Domains Framework (TDF). Relevant TDF domains were mapped to evidence-based behaviour change techniques (BCTs), which informed the content for each barrier. Acceptability was explored using cognitive debriefing interviews (n=6 adults with T2D).

RESULTS

'Is Insulin Right for Me' addresses eight barriers, phrased as common questions: Does insulin mean my diabetes is more serious? Do insulin injections cause complications? Is it my fault I need to inject insulin? Will I gain weight? Will injecting hurt? What about hypos? Will injecting insulin be a burden? What will others think of me? BCTs, including persuasive communication and modelling/demonstration, were delivered using appropriate methods (eg, demonstration of the injection process). Participant suggestions for improvement included clear and direct messages, normalising insulin and avoiding confronting images.

CONCLUSIONS

'Is Insulin Right for Me' is the first theory and evidence-based, web intervention designed to reduce psychological barriers towards insulin therapy for adults with T2D. Evaluation is needed to determine its impact on negative appraisals and receptiveness towards insulin.

Assessment of medication adherence and quality of life among patients with type 2 diabetes mellitus in a tertiary hospital in Kelantan, Malaysia

Introduction: Previous studies have reported the relationship between medication adherence and quality of life are interrelated. However, many of the results were found to be conflicting. This study aimed to assess the level and association of medication adherence and quality of life among type 2 diabetes mellitus patients in Raja Perempuan Zainab II Hospital, Kelantan, Malaysia. Materials and methods: A cross-sectional survey was conducted among adult type 2 diabetes mellitus patients on treatment for over 1 year using convenience sampling at outpatient.  Medication Compliance Questionnaire (MCQ) and revised Diabetes Quality of Life Questionnaire (DQOL) instrument were self-administered to eligible subjects. Data were analysed using GNU PSPP version 0.8.5 and reported for descriptive statistics as well as correlation of both parameters. Results: A total of 200 patients were recruited and they were mostly at the age of 40 to 60 years old. The mean (SD) score for MCQ was 26.0 (1.6) with the majority of them were non-adherent (55.0%, n=110). The mean (SD) score for overall revised DQOL instrument was 25.5 (8.9) while each domain of “satisfaction”, “impact” and “worry” had mean (SD) scores of 12.0 (5.0), 7.7 (3.4) and 5.9 (2.7), respectively. The scores obtained were only approximately half of the possible range of scores for QoL. There was no significant correlation between total score of medication adherence and quality of life when tested using Pearson’s correlation (r=-0.083, p=0.240). Independent t-test also demonstrated no significant relationship between medication adherence status and quality of life (p=0.883). Conclusion: Type 2 diabetes mellitus patients in our setting had unsatisfactory adherence but exhibited acceptable quality of life. We observed that both variables were not associated with one another. Further research is warranted to identify potential factors affecting non-adherence to medication.

Efficacy of Semaglutide in a Subcutaneous and an Oral Formulation

Despite the benefits of early and effective glycemic control in the management of type 2 diabetes (T2D), achieving glycated hemoglobin (HbA1c) targets is challenging in some patients. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) provide effective reductions in HbA1c and body weight. Semaglutide is the only GLP-1RA that is available in both an injectable and oral formulation. The efficacy of once-weekly subcutaneous semaglutide and once-daily oral semaglutide has been investigated in the global SUSTAIN and PIONEER phase III clinical trial programs in a range of clinical settings, including early T2D managed with diet and exercise only, more established T2D uncontrolled on one to three oral antidiabetic drugs, and advanced disease treated with insulin. Across the SUSTAIN program, once-weekly subcutaneous semaglutide 1.0 mg reduced HbA1c by 1.5-1.8% after 30-56 weeks, which was significantly more than sitagliptin, liraglutide, exenatide extended release, dulaglutide, canagliflozin, or insulin glargine. Across the PIONEER program, once-daily oral semaglutide 14 mg reduced HbA1c by 1.0-1.4%, significantly more than sitagliptin or empagliflozin, and to a similar extent as liraglutide after 26 weeks. In addition, subcutaneous semaglutide reduced body weight significantly more than all active comparators tested, while oral semaglutide reduced body weight more than sitagliptin and liraglutide, and to a similar extent as empagliflozin. Neither formulation of semaglutide has been associated with an increased risk of hypoglycemia and both improve various measures of health-related quality of life. Semaglutide offers the benefits of a highly effective GLP-1RA in both injectable and oral formulations. Selection of the most appropriate formulation can be made on an individual basis to best suit the patient's preferences and needs.

Prevalence of Primary Non-adherence with Insulin and Barriers to Insulin Initiation in Patients with Type 2 Diabetes Mellitus - An Exploratory Study in a Tertiary Care Teaching Public Hospital

INTRODUCTION

There is a paucity of data analysing the reasons for primary non-adherence following first prescription of insulin among patients with uncontrolled type 2 diabetes mellitus (T2DM) in India. To address this, and to attempt to understand these reasons, an exploratory study was undertaken to assess the prevalence of primary non-adherence with insulin and barriers to insulin initiation in these patients.

METHODS

Study participants were randomly selected from patients with T2DM who visited the diabetes clinic of a tertiary care teaching public hospital in Rishikesh, Uttarakhand, India, and were prescribed insulin for the first time in last 2-year period. All participants were evaluated for history of primary non-adherence, and those who were non-adherent were subsequently interviewed face-to-face using a modified, validated semi-structured questionnaire to identify the reasons for primary non-adherence. A focused group discussion was also conducted with eight physicians to elicit their views about reasons for primary non-adherence with insulin.

RESULTS

A total of 225 patients were identified and interviewed; of these, 105 were identified with a history of primary non-adherence and underwent a subsequent face-to-face interview. There was a high prevalence of primary non-adherence with insulin among the participants of this study. The main reasons for non-adherence were low self-efficacy, doubt about clinical benefits of insulin, fear of hypoglycaemia, needle phobia, unaffordability of insulin and blood glucose monitoring device, strong faith in alternative medicines and mythical ideologies, and fears of insulin being addictive and that it may cause rapid aging.

CONCLUSION

With the high prevalence of primary non-adherence, and the multitude of reasons for this, it is clear that we need to eliminate these barriers to treatment. Thus, provision of dedicated diabetes educators in each diabetes clinic and availability of cost-effective insulin and blood glucose monitoring devices for the underprivileged population are key to achieve this.

An integrative review on facilitators and barriers in delivering and managing injectable therapies in chronic conditions: A part of the ACNAP project 'injectable medicines among patients with cardiovascular conditions'

INTRODUCTION

Although preventive health and therapeutics have benefited from advances in drug development and device innovation, translating these evidence-based treatments into real-world practice remains challenging.

AIM

The current integrative review aims to identify facilitators and barriers and perceptions in delivering and managing injectable therapies from patient perspectives.

METHODS

An integrative review was conducted in the databases of PubMed, CINAHL, PsycINFO and Cochrane. Keywords were used "Injectable therapy", "IV therapy", "SC therapy", "long term injectable therapies", "self-administered injectable therapy", "patients", "caregivers", "family", "carers", "facilitators", "barriers", "perspectives", "needs", "expectations", "chronic disease", "cardiovascular disease" linked with the words "OR" and "AND". The search was limited from January 2000 to July 2019. Inclusion and exclusion criteria were used.

RESULTS

Twenty studies were identified from the literature search. Studies followed qualitative, quantitative methodology and mixed methods. Facilitators included: health improvement, prevention of disease complications, taking control of their disease, effectiveness of the medication and convenience in management. Barriers included: fear of needles, insulin will cause harm, poor perception of the benefits of injectable therapies on their quality of life, inconvenience in self-management, social stigma, impact on daily living, financial barriers, lack of education. Perceptions included: 'treatment of last resort', 'life becomes less flexible', 'injectables were punishment/restriction', 'personal failure of self-management'.

CONCLUSION

Evidence shows how to create effective communication and shared decision-making relationships to provide best possible care to patients who need injectable therapy and support for self-management. Future research might help guide response to the fears and barriers of the patients using patients' perspectives.

Psychosocial aspects and contributions of behavioural science to medication-taking for adults with type 2 diabetes

The aim of this narrative review was to determine the contribution of behavioural and psychosocial research to the field of medication-taking for adults with type 2 diabetes over the past 25 years. We review the behavioural and psychosocial literature relevant to adults with type 2 diabetes who are treated with oral antidiabetes agents, glucagon-like peptide-1 receptor agonists and insulin. Delayed uptake of, omission of and non-persistence with medications are significant problems among adults with type 2 diabetes. At each stage of the course of diabetes, during which medication to lower blood glucose is initiated or intensified, ~50% of people take less medication than prescribed. Research aimed at increasing optimal medication-taking behaviour has targeted 'forgetfulness', developing interventions which aid medication-taking, such as reminder devices, with limited success. In parallel, investigation of beliefs about medication has provided insights into the perceived necessity of and concerns about medication and how these inform medication-taking decisions. Guidance is available for health professionals to facilitate shared decision-making, particularly with insulin therapy; however, interventions addressing medication beliefs are limited. Optimal medication-taking behaviour is essential to prevent hyperglycaemia in adults with type 2 diabetes. Evidence from the past 25 years has demonstrated the association between medication beliefs and medication-taking behaviour. Health professionals need to address medication concerns, and establish and demonstrate the utility of diabetes medication with the individual within the clinical consultation. There are interventions that may assist diabetes health professionals in the shared decision-making process, but further development and more robust evaluation of these tools and techniques is required.

Decisional Balance for Insulin Injection: Scale Development and Psychometric Testing

Background

Insulin-naive patients are often reluctant to receive insulin treatment, and even insulin-treated patients frequently have poor rates of adherence to their prescribed insulin injection regimes. Assessing attitudes toward insulin injection may help in the design of interventions that improve the insulin injection behaviors of patients with type 2 diabetes (T2DM). The concept of decisional balance has been associated with behavior in many studies and may be useful in assessing the attitude of patients with T2DM toward insulin injection. Decisional balance for insulin injection (DBII) has not been widely assessed in patients with T2DM.

Purpose

The aim of this study was to develop an insulin injection (DBII) scale that is valid for insulin-naive and insulin-treated patients and to test the psychometric characteristics of this scale based on the concept of decisional balance.

Methods

This cross-sectional study administered an 18-item DBII scale, including pro and con subscales, to 95 insulin-naive and 237 insulin-treated patients in Taiwan. The decisional balance score was calculated as the mean score of the pro subscale minus the mean score of the con subscale. Construct validity was examined using exploratory factor analysis and confirmatory factor analysis; concurrent validity was assessed by examining the association between the score of the DBII scale and the stages of behavioral change and of hemoglobin A1c for, respectively, insulin-naive patients and insulin-treated patients; and reliability was assessed using internal consistency and test–retest reliability.

Results

A 13-item DBII scale supported by exploratory factor analysis and confirmatory factor analysis was developed. The stages of behavioral change and hemoglobin A1c levels were found to be significantly associated with the scores of decisional balance of the 13-item DBII scale for both insulin-naive and insulin-treated patients. The Cronbach's α ranged between .78 and .92.

Conclusions

The 13-item DBII scale is appropriately short and possesses satisfactory validity and reliability for both insulin-naive and insulin-treated patients with T2DM. Healthcare providers may use this scale as a checklist to guide clinical discussions related to insulin therapy with both insulin-naive and insulin-treated patients with T2DM across time.

The Misconceptions and Determinants of Diabetes Knowledge in Patients with Diabetes in Taiwan

AIM

This study aimed at (1) examining the misconceptions of patients with diabetes in Taiwan and (2) examining the association between patients' diabetes knowledge and their demographic characteristics.

METHODS

A cross-sectional survey was conducted at a metropolitan hospital in northern Taiwan. A total of 501 outpatients with diabetes were recruited, mostly from the hospital's endocrinology and metabolism clinic, nephrology clinic, and dialysis center. A self-developed questionnaire that consisted of demographic information and a diabetes knowledge test was administered. The knowledge test included 10 True/False questions and 6 multiple-choice questions that aimed at identifying patients' common misconceptions about diabetes.

RESULTS

A perfect score on the diabetes knowledge test was 16 points, and the mean ± SD score of the respondents was 11.5 ± 2.8. The most common misconception was "People can always feel when their blood sugar level is high." (64%), followed by "Taking insulin hurts the kidneys and may result in a need for dialysis." (52%) and "Being a vegetarian helps control blood sugar levels." (48%). The total knowledge scores were significantly associated with education levels (r _s = 0.39, p < 0.001), average monthly income (r _s = 0.28, p < 0.001), and age (r _s = -0.34, p < 0.001).

CONCLUSIONS

Certain misconceptions are prevalent among patients with diabetes, particularly in those with older age, lower education levels, or lower income. Healthcare providers need to work to eliminate common misconceptions and modify diabetes educational programs accordingly to help patients manage diabetes more effectively.

Experiences of Attending Group Education to Support Insulin Initiation in Type 2 Diabetes: A Qualitative Study

INTRODUCTION

Type 2 diabetes is a progressive condition and many people require insulin therapy 5-10 years post diagnosis. Considering the global increase in type 2 diabetes, group education programmes to initiate insulin are beneficial as they are cost-effective and provide peer support. However, group education to initiate insulin has not been widely evaluated and there is a need to elicit the views and experience of people with type 2 diabetes who start insulin in groups. The aim of this study was to explore the perspectives of people with type 2 diabetes who receive nurse-led group-based insulin education.

METHODS

Qualitative, semi-structured interviews of people with type 2 diabetes in south London, UK, who had attended group education sessions to start insulin. Inductive thematic analysis identified themes within the data.

RESULTS

Fifteen people with type 2 diabetes were interviewed. Three main themes were identified: creating a supportive environment; facilitator skills; and effectiveness of group. Factors which created a supportive environment included peer support, providing reassurance and printed materials. Facilitator skills associated with positive experiences included addressing negative insulin beliefs and managing group dynamics. The effectiveness of the group was determined by ongoing self-management success, need for more peer support, and insulin concerns post insulin education group.

CONCLUSION

Positive experiences of insulin group education for people with type 2 diabetes were associated with sharing experiences with other people starting insulin, reassurance from healthcare professionals, appropriate supportive materials, and skill of the facilitator to address insulin concerns and manage group dynamics. People with type 2 diabetes may benefit more from education if healthcare professionals are skilled in psychological techniques to facilitate group education aimed at addressing concerns around insulin therapy. Further research needs to assess the effectiveness of structured insulin group education for people with type 2 diabetes.

Efficacy of Dulaglutide as a First Injectable Option for Patients with Type 2 Diabetes: A Post-Hoc Pooled Analysis

INTRODUCTION

The ADA-EASD consensus report recommends using glucagon-like peptide-1 receptor agonists (GLP-1RAs) as the first injectable therapy prior to basal insulin in most patients with type 2 diabetes (T2D) not at glycemic goals after oral anti-hyperglycemia medications (OH). The objective of this analysis was to assess the glycemic efficacy of once-weekly dulaglutide 1.5 mg in patients with T2D when added on a background of commonly used OH regimens.

METHODS

Patients from seven phase 3 AWARD [Assessment of Weekly AdministRation of LY2189265 (Dulaglutide) in Diabetes] trials, where once-weekly dulaglutide 1.5 mg was added to OHs, were pooled into the following categories based on OH regimens: metformin (MET), sulfonylurea (SU), MET + SU, MET + pioglitazone, and MET + SGLT2i. Change from baseline in glycated hemoglobin A1c (HbA1c), fasting serum glucose and body weight, proportion of patients reaching target HbA1c < 7%, and safety parameters were assessed.

RESULTS

A total of 1784 patients treated with once-weekly dulaglutide 1.5 mg were included in this analysis. Baseline characteristics of the overall population were (mean ± standard deviation): age, 55.4 ± 9.8 years, HbA1c: 8.2 ± 1.0%, body mass index: 31.4 ± 5.4 kg/m2, duration of diabetes: 8.0 ± 5.6 years, and 878 (49.2%) were female. At 6 months, the addition of once-weekly dulaglutide 1.5 mg to various OH regimens significantly reduced HbA1c (- 1.3 to - 1.6%) and fasting blood glucose (- 29 to - 45 mg/dl) from baseline in all groups (p < 0.001), with 39-61% and 52-76% of these patients achieving HbA1c targets of ≤ 6.5% and < 7%, respectively. Significant reductions in body weight (- 0.8 to - 2.9 kg) were also observed in all groups (p < 0.001). Nausea, vomiting, and diarrhea were reported by 10-35%, 4-19%, and 6-28% of patients, respectively. Severe hypoglycemia occurred in one patient (MET + SU).

CONCLUSION

The addition of a once-weekly GLP-1RA, dulaglutide, demonstrated clinically meaningful HbA1c reduction in patients with T2D on different background OH regimens, making it an effective first injectable option.

FUNDING

Eli Lilly and Company.

Successful Healthcare Provider Strategies to Overcome Psychological Insulin Resistance in Japanese Patients with Type 2 Diabetes

INTRODUCTION

EMOTION was a multinational, noninterventional study surveying current insulin-using adults with type 2 diabetes mellitus (T2D) who were initially reluctant to begin insulin treatment. In this Japanese population subanalysis of EMOTION, we identify the frequency and level of helpfulness of healthcare provider (HCP) actions, and we analyze life events ('actions/events') that assist T2D patients with psychological insulin resistance in the decision to initiate insulin.

METHODS

Participants were selected from Survey Sampling International and their local partners' market research panels in Japan. Quantitative surveys were administered between December 2016 and August 2017 to patients who met the study criteria. Participants were asked whether 45 actions/events occurred, and to rate the level of helpfulness of the actions/events in contributing to their decision to initiate insulin.

RESULTS

Among the 594 eligible participating adults in the EMOTION study, 99 were from Japan. Despite initial reluctance to begin insulin treatment, 80.8% of the Japanese participants immediately commenced insulin. Practical demonstrations by HCPs on how to use insulin were rated by participants as most helpful. Examples of such practical demonstrations, reported as helping moderately or a lot, were 'HCP walked patient through the process of exactly how to take insulin' (82.8%), 'HCP showed an insulin pen' (79.7%), and 'HCP helped patient to see how simple it was to inject insulin' (79.1%).

CONCLUSION

This study identifies actions that HCPs can use to assist Japanese patients in deciding whether to initiate insulin. These findings may aid the development of clinical interventions addressing reluctance to begin insulin treatment among Japanese patients with T2D.

FUNDING

Eli Lilly and Company and Boehringer Ingelheim. Plain language summary available for this article.

Identifying solutions to psychological insulin resistance: An international study

AIMS

To identify actions of healthcare professionals (HCPs) that facilitate the transition to insulin therapy (IT) in type 2 diabetes (T2D) adults.

METHODS

Included were T2Ds in seven countries (n = 594) who reported initial IT reluctance but eventually began IT. An online survey included 38 possible HCP actions: T2Ds indicated which may have occurred and their helpfulness. Also reported were delays in IT start after initial recommendation and any period of IT discontinuation.

RESULTS

Exploratory factor analysis of HCP actions yielded five factors: "Explained Insulin Benefits" (EIB), "Dispelled Insulin Myths" (DIM), "Demonstrated the Injection Process" (DIP), "Collaborative Style" (CS) and "Authoritarian Style" (AS). Highest levels of helpfulness occurred for DIP, EIB and CS; lowest for AS. Participants who rated DIP as helpful were less likely to delay IT than those who rated DIP as less helpful (OR = 0.75, p = 0.01); participants who rated CS and EIB as helpful were less likely to interrupt IT than those who rated these as less helpful (OR = 0.55, p < 0.01; OR = 0.51, p = 0.01, respectively).

CONCLUSIONS

Three key HCP actions to facilitate IT initiation were identified as helpful and were associated with more successful initiation and persistence. These findings may aid the development of interventions to address reluctance to initiating IT.

Primary Care Management of Patients With Type 2 Diabetes: Overcoming Inertia and Advancing Therapy With the Use of Injectables

Type 2 diabetes (T2D) is a progressive disease caused by insulin resistance and associated progressive β-cell functional decline, as well as multiple other related metabolic and pathophysiologic changes. Left unchecked, T2D increases the risk of long-term microvascular and cardiovascular complications and is associated with excess morbidity and mortality. Despite multiple effective options for reducing hyperglycemia, patients are not optimally managed, largely due to delays in appropriate and timely advancement of therapy. Glucagon-like peptide-1 receptor agonists and basal insulin are recommended by treatment guidelines as effective options for advancing therapy to achieve glycemic control. However, injected therapies often face resistance from patients and clinicians. Glucagon-like peptide-1 receptor agonists are associated with weight loss, low risk of hypoglycemia, and potential beneficial cardiovascular effects. The class is recommended for patients across the spectrum of disease severity and represents an attractive option to add to basal insulin therapy when additional control is needed. Newer second-generation basal insulin analogues offer advantages over first-generation basal insulins in terms of lower hypoglycemia rates and greater flexibility in dosing. Incorporating injectable therapy into patient care in a timely manner has the potential to improve outcomes and must not be overlooked. Primary care clinicians play a significant role in managing patients with T2D, and they must be able to address and overcome patient resistance and their own barriers to advancing therapy if optimal treatment outcomes are to be achieved. The purpose of this expert opinion article was to provide a commentary on the key principle of advancing therapy with injectables to control hyperglycemia.

Patients' Perspectives of Oral and Injectable Type 2 Diabetes Medicines, Their Body Weight and Medicine-Taking Behavior in the UK: A Systematic Review and Meta-Ethnography

The aim of this review is to identify peoples' perspectives of their glucose-lowering and anti-obesity drugs in relation to diabetes and weight control and to explore how these views affect medication adherence. Theoretical perspectives associated with medicine-taking behavior are also explored. The systematic review was based on a meta-ethnography of qualitative studies identified through a search of 12 medical and social science databases and subsequent citation searches. The quality of all studies was assessed. Sixteen studies were included with data from 360 UK individuals. No relevant studies were identified which focused on anti-obesity and non-insulin injectable drugs. The review revealed that the patients' perspectives and emotional state were influenced by starting and/or changing to a new glucose-lowering medicine. These were also influenced by prior medication experience, disease perceptions and interactions with clinicians. Despite reports of positive experiences with and positive perceptions of medicines, and of participation in strategies to regain life control, medication non-adherence was common. Accepting glucose-lowering medicines impacted on the individual's perception of lifestyle changes, and it was notable that weight loss was not perceived as a strategy to support diabetes management. Synthesis revealed that more than one theory is required to explain medicine-taking behavior. New insights into the underlying factors of poor adherence and the specific practical issues identified in this review can help in the development of patient-centered interventions.

FUNDING

Diabetes UK.

Safety and Efficacy of High Versus Standard Starting Doses of Insulin Glargine in Overweight and Obese Chinese Individuals with Type 2 Diabetes Mellitus Inadequately Controlled on Oral Antidiabetic Medications (Beyond VII): Study Protocol for a Randomized Controlled Trial

BACKGROUND

Treatment with basal insulin in Chinese populations is currently sub-optimal, with delayed initiation of insulin treatment and inadequate dose titration. Increasing the initial dose of insulin may be a practicable and effective solution to the problem of titration. A higher initial dose will be helpful for patients to achieve the blood glucose target and improve treatment satisfaction and compliance as well require fewer steps to titrate. Considering that overweight and obese patients usually require higher insulin doses because of insulin resistance, a higher initial dose of the basal insulin is feasible in overweight and obese patients with type 2 diabetes. However, safety is an important issue needing to be considered for higher initial dose treatment. The aim of this study is to assess the safety and efficacy of higher (0.3 U/kg) compared with standard (0.2 U/kg) starting doses of basal insulin in overweight and obese Chinese patients with type 2 diabetes who have failed to achieve glycaemic control using oral antidiabetic drugs (OADs).

METHODS

This is a phase IV, randomized, non-inferiority, open-label trial that will be conducted at approximately 50 centers in China. Eight hundred eighty overweight and obese adult Chinese patients with type 2 diabetes will be randomized to receive higher (0.3 U/kg) or standard (0.2 U/kg) starting doses of basal insulin glargine (100 U/ml) during a 16-week period. The primary endpoint is whether a higher initial dose of basal insulin (0.3 U/kg) is non-inferior to a standard initial dose (0.2 U/kg) based on the percentage of patients with at least one episode of hypoglycaemia (≤ 3.9 mmol/l or severe) over 16 weeks. Secondary endpoints include evaluation of glycosylated haemoglobin A1c (HbA1c), fasting blood glucose, postprandial blood glucose, insulin dose and safety.

DISCUSSION

This study is the first randomized-controlled study to evaluate the safety and efficacy of basal insulin treatment with a higher starting dose versus standard starting dose in overweight and obese Chinese patients with type 2 diabetes. Results of this study could generate evidence to support the feasibility of a higher starting dose of basal insulin in diabetes management of overweight and obese Chinese patients, therefore providing an easy approach to improve diabetes management.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02836704. Registered on July 7th 2016.

FUNDING

Sanofi China.

Second-Generation Insulin Analogues - a Review of Recent Real-World Data and Forthcoming Head-to-Head Comparisons

Insulin analogues play a key role in the effective management of type 2 diabetes. However, there are several behavioural barriers to appropriate early initiation of insulin therapy, despite compelling evidence supporting the benefits of this strategy in those patients for whom oral anti-diabetes agents provide insufficient control. The development of second-generation insulin analogues (insulin glargine 300 U/mL and insulin degludec) has provided physicians with agents that can provide comparable glycaemic control to first-generation insulin, but with a reduced risk of hypoglycaemia and modes of action suited to once-daily regimens. These characteristics may help overcome patient and physician concerns about early insulin use in disease management. To date, there have been no head-to-head comparisons of second-generation insulins: here we consider recent real-world evidence and the forthcoming direct comparison in the BRIGHT randomised controlled study, as presented at the recent 11^th International Conference on Advanced Technologies & Treatments for Diabetes (ATTD) 2018.

Assessing prevalence of and barriers to medication adherence in patients with uncontrolled diabetes attending primary healthcare clinics in Qatar

BACKGROUND

Studies conducted in Qatar have reported a high prevalence of diabetic nephropathy, retinopathy, and neuropathy. These complications are often associated with poor medication adherence and uncontrolled diabetes. The objectives of this study were to determine the rate of medication adherence among patients with uncontrolled diabetes, and to compare the characteristics and identified barriers between patients with good and those with poor medication adherence.

METHOD

A cross-sectional quantitative study was conducted among patients living in Qatar with uncontrolled diabetes attending primary healthcare clinics from October 2016 to January 2017. An interviewer-administered questionnaire comprising three sections was utilized in the study: patients' characteristics, Adherence to Refill and Medications Scale in Diabetes (ARMS-D), and barriers to medication adherence. ARMS-D is a validated tool that is used to identify adherence level among patients with diabetes. Descriptive and inferential statistics including regression analysis were used for data analysis.

RESULTS

A total of 260 patients were included in the analysis. Overall, 73% (n=191) were nonadherent to their diabetes medications (ARMS-D score above 11). Nonadherent patients reported the majority of the pre-determined barriers to medication adherence with forgetfulness being the most commonly reported barrier. Multivariate linear regression analysis found age, ethnicity, education level, income level and HbA1c to be independent predictors of adherence.

CONCLUSION

The findings of this study reaffirm the notion that non-adherence to medications among patients with uncontrolled diabetes within primary care setting is higher than the general diabetes population. This high prevalence is concerning and necessitates urgent interventions. Nonetheless, an in-depth understanding of barriers to medication adherence often requires qualitative research approach as these barriers are very complex and multifactorial in nature.

Primary care physician perspectives on basal insulin initiation and maintenance in patients with type 2 diabetes mellitus

AIMS

To describe primary care physicians' (PCPs) perceptions of patient reactions and concerns about insulin initiation and identify opportunities for increased support.

METHODS

Cross-sectional, online survey of PCPs prescribing basal insulin to adults with type 2 diabetes mellitus (T2DM). PCPs were identified from administrative claims of a large commercial health plan and descriptive results of PCP responses were reported.

RESULTS

PCPs (N=100) treated an average of 17 patients receiving insulin during a typical week. More than 85% of insulin initiation recommendations originated with PCPs. Most offered glucose monitoring instructions (96%) and advice on diet, exercise, and diabetes management (96%); 35% provided insulin titration algorithms; 93% reported that patients often or always took their insulin daily within 3 months of initiation; 31% of PCPs reported monthly office contacts with patients for the first 3 months; 16% reported no outreach efforts; fewer than 20% connected patients with support groups. When starting basal insulin, PCPs reported patients feeling personal failure regarding their diabetes treatment (33% often/always) and lacking confidence in their ability to manage insulin therapy (38% often/always).

CONCLUSIONS

Study results identify additional opportunities for assisting patients in making the transition to insulin, including more frequent direct outreach to monitor insulin usage.

A qualitative exploration of barriers to medication adherence among patients with uncontrolled diabetes in Qatar: integrating perspectives of patients and health care providers

PURPOSE

To develop an in-depth understanding of the barriers to medication adherence among patients with uncontrolled diabetes attending primary health care (PHC) centers in Qatar by exploring and integrating patients' and health care providers' perspectives.

PARTICIPANTS AND METHODS

A descriptive qualitative methodology was used in this study. A trained researcher conducted semi-structured face-to-face interviews at two PHC centers. Patients with uncontrolled diabetes (with varied sociodemographic characteristics) and their respective health care providers (physicians, pharmacists, nurses, dieticians, and others) were purposively selected from the two PHC centers. All interviews were audio recorded, transcribed verbatim, and analyzed using thematic content analysis.

RESULTS

Thirty interviews (14 patients and 16 health care providers) were conducted. A number of barriers to medication adherence were identified and classified broadly under three main themes: 1) patient-related factors, which included patients' individual characteristics and patients' perception, attitude, and behavior; 2) patient-provider factors, which included communication and having multiple health care providers caring for the patient; and 3) societal and environmental factors, which included social pressure and traveling to visit friends and relatives.

CONCLUSION

Patients with uncontrolled diabetes face multiple barriers to medication adherence. Similar themes emerged from both patients and their care providers. This research highlights the need for concerted multidimensional efforts and series of interventions to overcome these barriers. One vital intervention is expanding the scope of pharmacists' role within the PHC centers through providing medication reconciliation, patient-tailored medication counseling, and medicines use review, which may improve treatment outcomes among patients with diabetes.

Depressive symptoms among elderly diabetic patients in Vietnam

BACKGROUND AND AIMS

Depression and diabetes are becoming increasingly prevalent within the Vietnamese elderly population. However, the linkage between these health conditions in the Vietnamese elderly has not yet been fully investigated. This study aimed to assess the level of depressive symptoms and associated factors among elderly diabetic patients.

METHODS

A cross-sectional study was conducted at National Geriatric Hospital in the elder patients aged ≥60 years with type 2 diabetes mellitus (T2DM). Depressive symptoms were assessed using the Geriatric Depression Scale, with three categories: normal (0-4 points), mild (5-9 points), and moderate/severe depressive symptoms (≥10 points). We obtained information on the patient's sociodemographic, medical history, glycemic control (fasting plasma glucose and HbA_1c), daily activities (activities of daily living [ADLs] and instruments activities of daily living [IADLs] scale), and fall risks (Time Up and Go test). Logistic regression was used to analyze the factors associated with the presence of depressive symptoms.

RESULTS

Among 412 patients, 236 (57.3%) had HbA_1c level at 7.0% or higher. There were 327 (79.4%) patients having depressive symptoms. The level of HbA_1c was significantly different between the depressive symptom group and the non-depressive symptom group (7.74% and 6.61%, P<0.05). The increased likelihood of having depressive symptoms was associated with having risk of falls (OR: 5.50; 95% CI: 1.88-16.11), suffering from 5-10 years of diabetes (OR: 2.74, 95% CI: 1.28-5.85), uncontrolled fasting plasma glucose (OR: 4.06, 95% CI: 1.81-9.12), and an impairment of IADLs (OR: 5.74, 95% CI: 2.24-14.7).

CONCLUSION

This study highlights a high prevalence of depressive symptoms among elderly T2DM patients in Vietnam, suggesting an urgent need for screening depressive symptoms and providing mental health care services to this population promptly, particularly to those suffering from diabetes for a long period of time or co-functional impairments.

User Experience of an Innovative Mobile Health Program to Assist in Insulin Dose Adjustment: Outcomes of a Proof-Of-Concept Trial

BACKGROUND

Many patients with diabetes require insulin therapy to achieve optimal glycemic control. Initiation and titration of insulin often require an insulin dose adjustment (IDA) program, involving frequent exchange of blood glucose levels (BGLs) and insulin prescription advice between the patient and healthcare team. This process is time consuming with logistical barriers.

OBJECTIVE

To develop an innovative mobile health (m-Health) mobile-based IDA program (mIDA) and evaluate the user adherence and experience through a proof-of-concept trial.

METHODS

In the program, an m-Health system was designed to be integrated within a clinical IDA service, comprising a Bluetooth-enabled glucose meter, smartphone application, and clinician portal. Insulin-requiring patients with type-2 diabetes mellitus and stable BGL were recruited to use the m-Health system to record and exchange BGL entries, insulin dosages, and clinical messages for 2 weeks. The user experience was evaluated by a Likert scale questionnaire.

RESULTS

Nine participants, aged 58 ± 14 years (mean ± SD), completed the trial with average daily records of 3.1 BGL entries and 1.2 insulin dosage entries. The participants recognized the potential value of the clinical messages. They felt confident about managing their diabetes and were positive regarding ease of use and family support of the system, but disagreed that there were no technical issues. Finally, they were satisfied with the program and would continue to use it if possible.

CONCLUSIONS

The m-Health system for IDA showed promising levels of adherence, usability, perception of usefulness, and satisfaction. Further research is required to assess the feasibility and cost-effectiveness of using this system in outpatient settings.

A review of current models for initiating injectable therapy for people with type 2 diabetes in primary care

AIMS

To systematically identify and describe models of injectable therapy initiation for people with type 2 diabetes mellitus (T2DM) in primary care.

METHODS

Eight electronic databases and the grey literature were searched. Studies examining models of injectable therapy initiation for adults with T2DM in primary care settings were included.

RESULTS

Successful models included: 1) Nurse-led one-to-one approach; 2) Nurse-led group sessions; and 3) Providing education to GPs and nurses.

CONCLUSIONS

Few robust studies were found. Studied models were mainly in general practices, with limited evidence documented about starting people with T2DM on an injectable in the home setting.

Prevalence of unwillingness to use insulin therapy and its associated attitudes amongst patients with Type 2 diabetes in Saudi Arabia

AIMS

This study aimed at determining the prevalence of unwillingness to use insulin and its associated attitudes amongst participants with Type 2 diabetes in Saudi Arabia. A further aim was to investigate whether demographic characteristics such as age, gender, educational level and duration of diabetes are associated with unwillingness to use insulin among these participants.

METHODS

This is a cross-sectional study conducted among participants with Type 2 diabetes using a self-administered questionnaire. The study sample consisted of 408 insulin-naive participants with Type 2 diabetes who were recruited between May and August 2014 from the primary care outpatient clinics at King Khalid University Hospital in Riyadh, Saudi Arabia.

RESULTS

Unwillingness to commence using insulin was common in about one third (34.6%) of Saudi participants with Type 2 diabetes. Negative attitudes most frequently raised by participants towards commencing insulin therapy were: keeping insulin as a last resort (57.1%), restriction of lifestyle (48.8%), problematic hypoglycemia (45.1%), perception of failure to care for diabetes previously (44.6%), and weight gain worries (40.7%). In a multivariable logistic regression analysis, after adjustment for a participant's age, gender, educational level, location and duration of diabetes, participants with tertiary education were 48% less likely to be willing to initiate insulin therapy as compared to those who had only a primary education (OR=0.52, 95% CI=0.30-0.91, P=0.023). However, there were no significant associations between unwillingness to commence insulin and other study variables.

CONCLUSIONS

Participants have several negative attitudes concerning initiating insulin therapy. Exploring the reasons for participant reluctance to commence insulin can help address his or her specific concerns and beliefs, and promote the future uptake of insulin.

Efficacy and Safety of Once-Daily Insulin Degludec/Insulin Aspart versus Insulin Glargine (U100) for 52 Weeks in Insulin-Naïve Patients with Type 2 Diabetes: A Randomized Controlled Trial

Purpose

The efficacy and safety of insulin degludec/insulin aspart (IDegAsp) once daily (OD) compared with insulin glargine U100 (IGlar) OD over 52 weeks in insulin-naïve adults with type 2 diabetes mellitus (T2DM) was investigated.

Methods

In this open-label, parallel-group treat-to-target trial, participants were randomized (1:1) to receive IDegAsp OD (breakfast, n = 266) or IGlar OD (as per label, n = 264). Participants then entered a 26-week extension phase (IDegAsp OD, n = 192; IGlar OD, n = 221). The primary endpoint was change from baseline to Week 26 in HbA_1c.

Results

After 26 and 52 weeks, mean HbA_1c decreased to similar levels in both groups. After 52 weeks, the mean estimated treatment difference was –0.08% (–0.26, 0.09 95%CI), confirming the non-inferiority of IDegAsp OD versus IGlar OD evaluated at Week 26. After 52 weeks, there was a similar reduction in mean fasting plasma glucose in both treatment groups. The rate of confirmed hypoglycemic episodes was 86% higher (p < 0.0001) whereas the rate of nocturnal hypoglycemia was 75% lower (p < 0.0001) for IDegAsp versus IGlar.

Conclusion

Nocturnal-confirmed hypoglycemia was higher with IGlar whereas overall and diurnal hypoglycemia were higher with IDegAsp dosed at breakfast. These results highlight the importance of administration of IDegAsp with the main meal of the day, tailored to the individual patient’s needs.

Trial Registration

ClinicalTrials.gov: NCT01045707 [core]) and NCT01169766 [ext]

[Perception of insulin therapy in uncontrolled patients with type 2 diabetes mellitus]

OBJECTIVE

To determine the perception of insulin therapy by patients with uncontrolled type2 diabetes mellitus, who have been treated with oral hypoglycaemic agents or insulin.

DESIGN

Prospective comparative cross-sectional study.

SETTING

Family Medicine Unit No. 53 León, Guanajuato of Mexican Institute of Social Security.

PARTICIPANTS

Patients between 40 and 80years old with uncontrolled type2 mellitus diabetes, treated with insulin or oral hypoglycaemic agents.

MAIN MEASUREMENTS

Perception was assessed using the insulin treatment appraisal scale (ITAS). The rating of the survey is from 20 to 100 points, as such that when score increases the greater is the negative opinion.

RESULTS

A sample of 459 diabetes patients were interviewed and split into 2 groups of patients according to their treatment. The OH group were patients treated with oral hypoglycaemic drugs only (56.9%), and the IN group were patients treated with insulin alone or combined with an oral hypoglycaemic (43.1%). Perception score was significantly higher in OH group (56.95±7.78 versus 49.55±8.89 points) than in the IN group (P<.001).

CONCLUSIONS

The perception of insulin therapy was worse in patients treated with only oral hypoglycaemic agents than in patients using insulin.

Self-reported Barriers to Adherence and Persistence to Treatment With Injectable Medications for Type 2 Diabetes

PURPOSE

This study explored the barriers that adult Americans experience when taking injectable medications for type 2 diabetes, from the time of filling the initial prescription through the decision to discontinue the medication.

METHODS

An Internet-based survey was conducted in 2 waves among adult patients (N = 2000) who had received a physician prescription for insulin, liraglutide, or exenatide once weekly (QW), regardless of whether the prescription was filled by a pharmacy. In wave 1, patients were surveyed on their medication history and experience and, if relevant, the medication discontinuation process. Those still taking their injectable medication at the time of wave 1 were contacted 6 months later (wave 2, n = 585) to assess any changes in their medication experience.

FINDINGS

Among patients who delayed filling their prescription by ≥1 week, cost was a common reason for delay for refilling of liraglutide (63%) and exenatide QW (49%). The most commonly reported barrier to maintaining injectable medication was injection concerns (42%) such as aversion to needles, pain, or needle size. Lack of perceived need was the most common reason for discontinuation for basal (47%) and prandial/premixed (44%) insulin. For liraglutide, the most common reason for discontinuation was experiencing an adverse event (33%); for exenatide QW, it was injection concerns (38%).

IMPLICATIONS

The diverse barriers we identified underscore the need for better patient-prescriber communication to ensure that newly prescribed injectable medications are consistent with a patient's ability or willingness to manage them, to appropriately set expectations about medications, and to address new barriers that arise during the course of treatment.

A Patient-Driven Approach to Manage Mealtime Insulin Titration: Tools From the AUTONOMY Study

PURPOSE

Patient-centric methods to support diabetes management are important to overcome barriers associated with initiating mealtime insulin. This article describes the subject-driven titration tools implemented in the AUTONOMY trial to initiate and adjust mealtime insulin dose and the methods used to apply these tools in clinical practice.

CONCLUSIONS

The methods used to initiate and escalate mealtime insulin in the AUTONOMY trial proved to be safe and effective, and the patient-friendly guide to self-adjusting mealtime insulin dose may mitigate the complexities associated with treatment intensification while empowering patients to reach their glycemic goals.