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When the doctor told Warren O. Merrill of Menan, Idaho, he was replacing his oral medications with insulin injections to treat his diabetes, Merrill was overcome with a feeling of dread and disappointment. "It struck me that I was getting worse, and I didn't want to face that," he says.
MYTHS AND MISGIVINGS
Merrill is not alone. For many people diagnosed with type 2 diabetes, the need to transition from oral antidiabetic medication to insulin is unwelcome news. Unfortunately, misperceptions about insulin treatment—among both patients and their physicians—can present unnecessary barriers to proper treatment. But it doesn't have to be this way, and practitioners must do their part to help dissipate their patients' misgivings.
MYTH: Insulin therapy represents a failure in treatment.
This is perhaps the most prevalent misconception concerning the transition to insulin therapy. Although the need for insulin is a result of the normal course of type 2 diabetes, many patients see it as a failure on their part to combat the illness with diet and other behaviors.
"The first thing that every patient with diabetes should be told is that eventually they will take insulin," says Kathleen Wyne, MD, of University of Texas Southwestern Medical School in Dallas. "It is part of the natural progression of the disease, and you make a person's life easier if you prepare them from day one."
"My doctor did not say much to me about the possibility of starting insulin until the moment he said, `I think you need some insulin to pull these numbers down,'" Merrill says. "I was becoming more frustrated that I was doing lots of things right and was still running high numbers."
Even with near-perfect treatment, however, insulin production eventually falls to where insulin administration becomes necessary.
Similarly, some patients believe that insulin treatment is a punishment for not following earlier treatments properly.
"Patients often come to the doctor with a heavy burden of guilt, having been convinced by friends, family, and even other health care professionals that [diabetes] is a self-induced condition," says Paris Roach, MD, of Indiana University School of Medicine in Indianapolis. "Focusing on the facts and keeping judgmental comments out of the conversation is the best way to keep this from occurring."
The general practitioner, endocrinologist, nurse, dietitian, and pharmacist all have their parts to play in reinforcing the facts and counseling patients on the role of their behaviors in the progression of the disease.
MYTH: Insulin causes neuropathies, blindness—and even death.
It seems as though every patient knows someone who began insulin therapy and then had severe complications. Some see this temporal relationship and conclude that the insulin caused the complications.
Practitioners can do their part by informing patients that the reverse is true: Numerous studies show that proper control of blood glucose when using insulin greatly slows—or even stops—the progression of diabetic nerve, eye, and kidney problems.1,2 Frequently reassuring patients that insulin actually works to prevent and limit complications is an important part of easing the transition.
Wyne suggests that this misconception exists because insulin therapy often is not started early enough in a patient's treatment. She notes that, in many cases, patients adhere to oral antidiabetic treatments for 20 years or more before beginning insulin. During this time, the body is exposed to higher levels of blood glucose and already may be well on the way to diabetes-related complications.
Practitioners need to do a much better job of educating their patients about this, Wyne says. "We start insulin after they are already getting sick, and then they think it is the insulin that is causing the problems when they occur. That is a huge barrier that we have created."
MYTH: Insulin treatment automatically results in weight gain.
"Both doctors and patients think that weight gain is a bigger problem than it really is," says Philip Levy, MD, of University of Arizona College of Medicine in Phoenix. "Some of the weight gain associated with starting insulin is actually good for patients, since prior to starting on insulin they were not properly metabolizing carbohydrates."
Data from the United Kingdom Prospective Diabetes Study (UKPDS) showed an average weight gain of around 8.8 pounds following initiation of insulin therapy.2 Other studies show smaller gains.
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It appears that weight gain can be minimized by combining insulin with oral antidiabetic medications. In the highly regarded Treat-to-Target trial, weight gains of 6.1 to 6.6 pounds were observed among those on combination therapy.3 Addition of metformin in combination with insulin4 may result in less weight gain than addition of a thiazolidinedione such as pioglitazone (Actos, Eli Lilly) or rosiglitazone (Avandia, GlaxoSmithKline).
And following the diet and exercise regimens that are usually suggested upon the advent of insulin treatment may also have a mitigating effect on weight gain.
MYTH: Insulin injections are painful.
Concern about the pain associated with injecting insulin is a big issue for many patients. However, newer syringes have needles with much smaller gauges and shorter lengths, which help reduce pain during injection. Many patients actually report that the fingersticks to test insulin levels are now more painful than the insulin injections themselves.
PHYSICIAN RESISTANCE
Some doctors have a fear of insulin that can be subconsciously communicated to their patients, which further complicates treatment, a process that has been termed "physician resistance."
"I have [other] doctors call me all the time to tell me that [I] sent a patient home on too much insulin," says Wyne. "They think there is a maximum dosage that should not be exceeded. I tell them not to worry about the dosage and give as much as is needed to keep the blood glucose in a normal range."
One of the reasons that insulin use can be disconcerting to health practitioners is a fear of hypoglycemia. However, studies have shown that severe hypoglycemia is rare in type 2 diabetes.2,5 Hyperglycemia in type 2 diabetes is usually due to insulin resistance rather than complete loss of insulin production. In patients with type 2 diabetes, the body still maintains a counterregulatory system that buffers the reaction and keeps blood glucose from getting too low. And these patients are less likely than type 1 diabetes patients to lose the physiological warning signs that accompany a drop in blood glucose.
"Patients should be reassured that, if they do get a reaction [from insulin treatment], they will be able to feel the symptoms," says Levy. "They can be instructed on what to do to stop hypoglycemia while it is still mild."
The most useful—and basic—intervention is listening closely to
patients to understand their apprehensions and correcting their—or even
your own—misconceptions about insulin therapy. 
References
2. UK Prospective Diabetes Study (UKPDS) Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 352:837–853, 1998.[Medline]
3. Riddle MC, Rosenstock J, Gerich J: The Treat-to-Target Trial:
Randomized addition of glargine or human NPH insulin to oral therapy of type 2
diabetic patients. Diabetes Care 26: 3080–3086, 2003.
4. Makimattila S, Nikkila K, Yki-Jarvinen H: Causes of weight gain during insulin therapy with and without metformin in patients with type 2 diabetes. Diabetologia 42:406–412, 1999.[Medline]
5. Hayward RA, Manning WG, Kaplan SH, et al.: Starting insulin therapy in patients with type 2 diabetes: Effectiveness, complications, and resource utilization. JAMA 278:1663–1669, 1997.[Abstract]
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