Patient approval of insulin therapy in type 2 diabetic patients.

To the Editor: The primary goal of therapy in diabetes mellitus is to reach and sustain near-normal glycemic levels to prevent acute metabolic complications. (1) When insulin is initiated early in the disease process, this therapy has the potential to preserve [beta]-cell function and delay disease progression. (2,3) However, the discomfort and inconvenience of self injection are significant deterrents, to many patients. (4)

According to the rate of insulin treatment, there are some differences between countries. Few studies have addressed this issue in the Turkish population. For this reason, we aimed to evaluate the relation between patient approval of insulin therapy and sociocultural features in Type 2 diabetic patients who had recently been started on insulin therapy.

One hundred and eighty Type 2 diabetic patients who had recently begun insulin therapy were evaluated at two stages; a) the status of patients' approval of insulin therapy following a brief informational session (SPAIT-1), and b) the status of patients' approval of insulin therapy after a more thorough instruction of initially reluctant patients (SPAIT-2).

The number of patients who initially approved the insulin therapy (SPAIT-1), was slightly less than those who did not approve [74 (41.1%)--106 (58.9%), respectively, P = 0.09]. Following diabetic and insulin therapy teaching in the group who had initially refused therapy, (SPAIT-2), more individuals approved insulin therapy than refused [66 (62.3%)--40 (37.7%), respectively, P = 0.07]. In both situations, differences were not significant. But overall, (status before and after teaching), patients who approved insulin therapy were significantly more than those who refused [140 (77.8%) - 40 (22.2%), P < 0.001].

In regards to gender, in the SPAIT-1, SPAIT-2, and overall categories, more male patients approved of insulin therapy than females.

Regarding age, duration of diabetes and health insurance in all three groups (SPAIT-1, SPAIT-2 and overall), we found no significant relation between insulin approval and each of these parameters.

The reasons for insulin therapy refusal in SPAIT-1 and SPAIT-2 were the same. The most common reasons given were injection fear, vision problems, inability to read and write, living alone and prejudice to insulin. Visual problems were secondary to diabetic complications and aging.

Regarding the level of formal schooling in the SPAIT-1 group, as the level of formal schooling increased, the number of patients who approved the use of insulin increased significantly (P < 0.001). On the other hand, in the SPAIT-2 group, we found no relation between level of formal schooling and approval of insulin therapy.

In conclusion, increases in formal schooling facilitates early approval of insulin treatment. Furthermore, the ability of the health care provider to provide sufficient diabetic teaching elevates the rates of insulin treatment. In our study, education efforts increased approval of insulin treatment in our uneducated population by over 60% (Table).

Murat Suher, MD

Eyup Koc, MD

Ozlem Barak Serkan, MD

Department of Internal Medicine Ataturk Teaching and Research Hospital Ankara, Turkey

References

1. Rosenstock J, Riddle MC. Insulintherapy in type 2 diabetes. In: Cefalu, WT, Gerich JE, LeRoithD, eds. The CADRE Handbook of Diabetes Management. New York, NY: Medical InformationPress; 2004.

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 (UKPDS 33). Lancet 1998; 352: 837-853.

3. Home PD, Boulton AJM, Jimenez J, et al. Issues relating to the early or earlier use of insulin in type 2 diabetes. Pract Diab Int 2003;20:63-71.

4. Gardner S, Dunachie SJ, Levy JC. Real gains but practical limitations to glycemic control with insulin in type 2 diabetes. Br J Diabetes Vasc Dis 2004;4:98-102.

Table. Contents of teaching about diabetes mellitus

1. Help patients understand what diabetes mellitus is.
2. Make patients aware of normal and abnormal blood glucose levels.
3. Help patients understand insulin treatment
4. Help patients understand that it is possible to prevent and reduce
   development of acute and chronic complications.
5. Inform patients of recommended values of HbA1c and help them
   understand the benefits of achieving these levels.