Paul Dromgoole RGN, RNMH, PGDip.
Lecturer/Practitioner - Diabetes, York Hospitals NHS Trust and the University of YorkTwo key disorders typically characterise Type 2 diabetes: a relative deficiency of insulin due to beta cell failure and the body's resistance to the individual's own (endogenous) insulin. Furthermore people with Type 2 diabetes may lose the ability to effectively regulate meal-time blood glucose levels, due to disruption of first phase (post-meal) insulin release.
Two key disorders typically characterise Type 2 diabetes: a relative deficiency of insulin due to beta cell failure and the body's resistance to the individual's own (endogenous) insulin. Furthermore people with Type 2 diabetes may lose the ability to effectively regulate meal-time blood glucose levels, due to disruption of first phase (post-meal) insulin release.
Consistently raised blood glucose levels put the individual at risk of microvascular complications such as eye and kidney disease. This is in addition to the greatly increased risk of macrovascular disease such as heart disease and stroke.
A progressive disease
In response to the publication of the UK Prospective Diabetes Study (UKPDS, 1998), Diabetes UK published a position statement acknowledging the progressive nature of the condition. 'For people taking tablets, it is often necessary to increase the dose, add other tablets or eventually to commence insulin treatment.'
Diabetes UK recommends that people with diabetes be made aware of alternative treatments, including insulin therapy. It advocates broaching the subject of insulin therapy with the patient at an early stage to help address any concerns. In addition, it is crucial to reassure patients that the change in their condition is not their fault - that diabetes progressively worsens with time (Diabetes UK, 1999).
Insulin therapy in Type 2 diabetes
The National Service Framework for Diabetes (Department of Health, 2002) sets out targets for achieving HbA1c levels of less than 7.5%. The progressive nature of Type 2 diabetes means that, for many patients, attaining this target will involve insulin therapy.
A decision to put this group of patients on insulin therapy will be based on the following:
- The patient will have an HbA1c above 8.0% (glycosylated haemoglobin, known as the long-term diabetes test)
- The patient will have significant symptoms of polyuria, polydypsia, nocturia and recurrent infections, including balanitis or thrush
- The patient will have been treated with the maximum doses of oral agents
- They must be willing to make lifestyle changes in terms of diet and exercise.
Many patients have concern regarding having insulin therapy (Box 1). Once the fear of having insulin treatment has been overcome, the next fear is that of having an injection or using one to self-administer the injections. Performing a 'dummy' insulin injection as soon as discussions about insulin therapy have taken place is important (Diabetes UK, 2002). A demonstration of what it feels like to be injected with a modern insulin needle and what it feels like to self-administer an injection will help allay a patient's anxieties about the treatment.
True needle phobia is rare, but those who find it distressing to see the needle or insert it into the skin, can be offered alternative devices, such as the NovoNordisk Penmate and MHI 500 compressed air delivery system. Local diabetes centres can provide more information.
Patients often presume that weight gain is inevitable with insulin therapy. Franz et al (2002) stated that perhaps 70% of weight gain could be explained by decreased glycosuria with consequent retention of calories after beginning diabetes treatment.
Glycosuria represents a loss of calories in terms of glucose from the body, estimated at 4.1kcal for every gram of glucose excreted. Improving blood sugar control with insulin treatment will reduce glycosuria and, therefore, calorie loss. This may result in weight gain unless this effective calorie gain can be countered.
Potential weight gain may be reduced by:
- Use of metformin 850mg to 1000mg twice daily as an insulin sensitiser in those who are already overweight (BMI >28m2) unless contraindicated
- Earlier intervention with insulin at lower levels of HbA1c
- A dietary review that focuses on portion size and fat content
- A redistribution of calorie intake to allow for snacks
- Use of low glycaemic index (long-acting) foods, especially fibrous or complex starchy foods, as a way of ensuring satiation and reducing hunger between meals.
Dietary review is important because the psychological benefits of feeling well after starting insulin therapy may be countered by the negative impact of weight gain.
Self-adjustment of insulin
Historically, insulin therapy was 'owned' by the health professional and, in some instances, patients may have been discouraged from adjusting their own insulin treatment. Specialist nurses directed treatment, 'spoon-feeding' increases of two units of insulin to address raised blood sugars.
Today, self-management is actively encouraged, with patients being educated about the principles and practicalities of insulin adjustment. This approach offers more effective management of the condition in terms of dealing with the hyper- or hypoglycaemia associated with increased activity or exercise, illness, stress, and holidays in hot countries (heat increases sensitivity to insulin.)
Educating the patient about insulin self-adjustment should be done soon after the therapy is started to avoid physical and psychological dependence on health-care professionals. Diabetes UK (2001) states that 'few people with diabetes have the confidence to adjust their insulin to suit their lifestyle and in our experience usually adjust their lifestyle to their insulin dose. Not only is this ineffective but it also has a profoundly negative effect on their quality of life.'
Insulin therapy in primary care
In response to requests by local GPs for more insulin-related study days, the Diabetes and Endocrine Centre at York Hospital developed a short course.
This is aimed at staff who wish to start patients with Type 2 diabetes on insulin therapy in general practice (Figure 1). Algorithms and protocols were developed to support this. In addition to the theoretical component, the course offers practical learning on coaching patients towards self-management.
All local GP surgeries were informed of the new course once it was in place. The initial response involved three of the larger surgeries but since then staff at a further eight surgeries have been trained and are initiating insulin therapy for patients with Type 2 diabetes.
GP practices whose staff have attended the initial one-and-a-half-day training receive support in the commencement of insulin from an experienced diabetes specialist nurse. At the outset the nurse leads the process, while the practice nurse or GP observe. Thereafter, the PN or GP are involved in starting the patient on insulin therapy, while the diabetes specialist nurse observes. This allows for discussion, problem-solving and feedback.
After two or three sessions under the supervision of the diabetes specialist nurse, the GP or PN generally have the confidence to initiate the process unsupervised, although telephone support from the specialist nurse is always available. The time taken by PNs or GPs in starting patients on insulin soon matched that of an experienced diabetes specialist nurse at 25-35 minutes, as demonstrated by a PN-conducted audit.
The choice of insulin was either 30/70 soluble or an analogue mix, administered using the NovoNordisk Innolet and Flexpen devices. These are easy to use, reliable and offer a degree of patient choice.
In our experience, the use of a twice-daily insulin mixture is preferable to a once-daily dose of isophane or a long-acting insulin analogue, because it offers greater flexibility for insulin adjustment.
This is useful for a range of scenarios relating to varying day-to-day activity levels, which may predispose the patient to hypoglycaemia. For example, on more active days the patient can reduce the risk of hypoglycaemia by eating snacks. However, some 75% of people with Type 2 diabetes are overweight (Krentz, 2000) and an extra snack will generally mean extra calories. Hence, for many diabetes patients, a reduction in insulin to counter the risk of hypoglycaemia may be preferable.
Benefits of the programme
An audit by one of the Insulin in Practice surgeries showed a drop in the number of follow-up appointments in the three-month period following the transfer of patients to insulin therapy compared with appointments in the three months leading up to the change.
Before the patients were started on the therapy most appointments had focused on attempts to improve glycaemic control (through frequent follow-up appointments and intensive dietary and exercise advice) because oral medication had become less effective, resulting in a range of symptoms related to high blood sugar levels.
Continuing support for patients via telephone consultations is vital. For the majority of patients these consultations, alongside occasional face-to-face appointments, work well and reduce follow-up appointment times.
It is important that the patient has previously monitored their blood glucose levels at home. This avoids them having to learn two new skills at the same time.
A recent audit of HbA1c and body mass index changes at six months after initiation of the insulin therapy programme showed a significant reduction in HbA1c and a slight increase in BMI (statistical significance p=0.04) (Figure 2). Further audit will be undertaken at 12 months.
Although there has been no formal qualitative evaluation of the programme, feedback from GPs, nurses and patients has been overwhelmingly positive. Patients were asked to submit anonymous feedback on their experiences. All those involved have highlighted the ease of attending the local GP surgery to commence insulin therapy (Box 2).
Comments from PNs involved in the programme have included: 'The patients seem really happy to have avoided attending the hospital to start insulin', while GPs have highlighted the benefits of starting patients on insulin therapy when it is appropriate, rather than having to give patients a hospital referral and then wait for an appointment date.
Patients acknowledged feeling well after starting insulin therapy and commented on their ability to self-adjust their doses. 'Because I generally feel much better, I feel I have better control, particularly regarding dose versus food,' said one.
The project was valued highly by all the health professionals involved. One GP said that it was 'going very smoothly', while another said: 'The patients are very happy, and so am I.'
Patients found the skills workshops particularly helpful (see box above).
Type 2 diabetes is progressive and treatment needs to be increased with time. Some 20-30% of patients will require oral insulin, as hypoglycaemic agents will eventually fail to have the required effect. An understanding of the progressive nature of the condition is crucial to avoid erroneously blaming the patient for deteriorating glucose control.
Starting insulin therapy in primary care allows for a more timely transfer on to an insulin regimen with the support of a health-care professional known to the patient. The majority of patients have concerns about having insulin therapy, which can usually be allayed by demonstrating a 'dummy' insulin injection.
The time spent on patient follow-up after initiating insulin therapy need not be prohibitive - the model described in the paper proposes ongoing consultations, mainly by telephone, as a valuable alternative to face-to-face meetings.
Diabetes specialist nurses in secondary care are used to patients saying that they wish they had started on insulin therapy months, if not years, previously. By putting in place structured education and training, the process of initiating insulin in primary care can be made a relatively straightforward and valuable intervention.
Author's contact details
Paul Dromgoole, Diabetes Specialist Nurse, York Hospital, Wigginton Road, York Y031 8DE.
Royal College of Nursing. (2004)RCN Guide to Insulin Therapy in Type 2 Diabetes. London: RCN.
Department of Health. (2002) The National Service Framework for Diabetes. London: DH.
Diabetes UK. (1999)UKPDS: Implications for the care of people with Type 2 diabetes. London: Diabetes UK.
Diabetes UK. (2001)Self-adjustment on trial. Diabetes Update Summer.
Diabetes UK. (2002)Patient Education for Effective Diabetes Self-management: Report, recommendations and examples of good practice. London: Diabetes UK.
Franz, M.J., Bantle, J.P., Beebe, C.A. et al. (2002)Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications (Technical Review). Diabetes Care 25:148-198.
Krentz, A.J. (2000)Churchill's Pocketbook of Diabetes. Edinburgh: Churchill Livingstone.
UK Prospective Diabetes Study Group. (1998)Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with Type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study Group. Lancet 352: 837-853.