Identification of barriers to insulin therapy and approaches to overcoming them

Russell‐Jones, David; Pouwer, Frans; Khunti, Kamlesh

doi:10.1111/dom.13132

Cited by 238Diabetes Treatment and ManagementDiabetes Management and ResearchDiabetes, Cardiovascular Risks, and Lipoproteins

Identification of barriers to insulin therapy and approaches to overcoming them

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Russell‐Jones, David, Pouwer, Frans, Khunti, Kamlesh·2018·Diabetes, Obesity and Metabolism

DOI 10.1111/dom.13132PMC PMC5836933

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Abstract

Poor glycaemic control in type 2 diabetes (T2D) is a global problem despite the availability of numerous glucose‐lowering therapies and clear guidelines for T2D management. Tackling clinical or therapeutic inertia, where the person with diabetes and/or their healthcare providers do not intensify treatment regimens despite this being appropriate, is key to improving patients’ long‐term outcomes. This gap between best practice and current level of care is most pronounced when considering insulin regimens, with studies showing that insulin initiation/intensification is frequently and inappropriately delayed for several years. Patient‐ and physician‐related factors both contribute to this resistance at the stages of insulin initiation, titration and intensification, impeding achievement of optimal glycaemic control. The present review evaluates the evidence and reasons for this delay, together with available methods for facilitation of insulin initiation or intensification.

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For some therapies, such as insulin, the perceived lack of efficacy may be a consequence of suboptimal titration due to patient and physician concerns such as weight gain, fear of hypoglycaemia, multiple daily injections, complexity of therapy or therapeutic burden.
“However, it is important to consider that for some therapies, such as insulin, the perceived lack of efficacy may be a consequence of suboptimal titration due to patient and physician concerns such as weight gain, fear of hypoglycaemia, multiple daily injections, complexity of therapy or therapeutic burden [16, 17].”
From Understanding Reasons for Treatment Discontinuation, Attitudes and Education Needs Among People Who Discontinue Type 2 Diabetes Treatment: Results from an Online Patient Survey in the USA and UK (2020) · cites this paper as [17]
Among patients with type 2 diabetes who initiate basal insulin, only about 30% achieve their individual glycaemic target, primarily because fear of hypoglycaemia limits proper titration.
“Among patients with type 2 diabetes who initiate BI, only about 30% achieve their individual glycaemic target, primarily because a fear of hypoglycaemia limits proper titration.10,13”
From Early hypoglycaemia and adherence after basal insulin initiation in a nationally representative sample of Medicare beneficiaries with type 2 diabetes (2019) · cites this paper as [10]

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[23]Hicks D, McAuley K. Meeting the educational needs of primary care practitioners: MERIT. J Diabetes Nursing. 2007; 11(7): 271– 275.
[107]Rosenstock J, Aronson R, Hanefeld M, et al. Clinical impact of titratable fixed‐ratio combination of insulin glargine/lixisenatide vs. each component alone in type 2 diabetes inadequately controlled on oral agents: lixilan‐o trial. Diabetes. 2016; 65(suppl 1): A48. 27527848

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Authors: Russell‐Jones, D., Pouwer, F., & Khunti, K.
Affiliations: Department of Diabetes and Endocrinology Royal Surrey County Hospital NHS Foundation Trust Guildford UK
University of Southern Denmark (DK)
University of Leicester (GB)
Corresponding author: Khunti, Kamlesh
ORCID: Pouwer, Frans
Khunti, Kamlesh
Venue: Diabetes, Obesity and Metabolism
Publisher: Wiley
Published: 2017-11-22
Volume: 20
Issue: 3
Pages: 488-496
ISSN: 1462-8902 (ISSN-L)
1463-1326
DOI: 10.1111/dom.13132
PMC: PMC5836933
OpenAlex: W2765159569
Cited by: 238
References: 103
Citations by year: 2026: 18 · 2025: 12 · 2024: 30 · 2023: 24 · 2022: 34 · 2021: 32 · 2020: 42 · 2019: 35 · 2018: 8 · 2017: 1
FWCI: 3.44
Type: journal article
Language: en
Open access: hybrid
doi.org
Licence: cc-by-nc-nd
creativecommons.org/licenses/by-nc-nd/4.0/ (vor)
Locations: Diabetes Obesity and Metabolism (publishedVersion, cc-by-nc-nd)
Europe PMC (PubMed Central) (publishedVersion, cc-by-nc-nd)
PubMed Central (publishedVersion, cc-by-nc-nd)
PubMed (publishedVersion)
University of Southern Denmark Research Portal (University of Southern Denmark) (publishedVersion, cc-by-nc-nd)
Figshare (submittedVersion, cc-by-nc-nd)
Minerva Access (University of Melbourne) (submittedVersion, cc-by-nc-nd)
Leicester Research Archive (University of Leicester) (submittedVersion, cc-by-nc-nd)
Funders: Novo Nordisk
Topics: Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
Keywords: type 2 diabetes, insulin therapy, insulin initiation, insulin intensification, insulin dose adjustment, glycemic control, therapeutic inertia, patient factors, physician characteristics, treatment intensification
MeSH terms: Diabetes Mellitus, Type 2, Dose-Response Relationship, Drug, Humans, Hypoglycemic Agents, Insulin, Patient Acceptance of Health Care, Time-to-Treatment

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Identification of barriers to insulin therapy and approaches to overcoming them

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