Unsurprisingly, the most common conditions requiring insulin therapy are type 1 and type 2 diabetes. Because patients with type 1 diabetes do not produce insulin, they require lifelong insulin therapy. While patients with type 2 diabetes still produce insulin, their bodies do not respond to it as they should. As the disease progresses, many patients will not produce enough insulin, which in turn inhibits glycemic control. Such patients will require insulin therapy, usually in addition to or as a replacement for oral hypoglycemic agents.

Patients with other types of diabetes may also require insulin therapy. These may include diabetes associated with conditions of the exocrine pancreas, such as cystic fibrosis or pancreatitis; chemically-induced diabetes, such as diabetes associated with use of glucocorticoids, treatment of HIV, or diabetes resulting from an organ transplant. Other rarer types of diabetes include monogenic diabetes (such as neonatal diabetes and maturity-onset diabetes of the young) and gestational diabetes mellitus.

There are indications for insulin therapy among patients who do not have diabetes. These include critical care patients and patients with myocardial infarction, both of whom require glucose control.

Despite its proven efficacy, starting insulin therapy faces several barriers. Because primary care physicians are playing an increasingly involved role in diabetes management, the responsibility of educating patients and ensuring their continued adherence to the therapy falls on their shoulders. Physicians generally lack the time with patients needed for such education. In addition, patients may be wary of insulin therapy due to its association with hypoglycemia and weight gain, the potential pain of injections, the complexities of understanding titration, and more frequent and consistent glucose monitoring. Patient nonadherence is also a factor. A recent report indicated that 25 percent of patients prescribed insulin never used it or did not refill their prescriptions, 62 percent interrupted therapy at some point, and 18 percent stopped using insulin within a year of initiation.

To combat these barriers, it is important to provide comprehensive education to all patients who require insulin therapy, including understanding blood glucose monitoring, diet, and hypoglycemia risk and management. Physicians should also discuss with patients the typical progression of type 2 diabetes and avoid framing insulin therapy as an indication of patient failure. Group-based diabetes self-management and support (DSMES) programs, mobile technologies (such as video training, titration algorithms, and FDA-approved applications), as well as diabetes educators can help to not only reduce the time burden for physicians but also help patients overcome individual barriers to insulin therapy.

For more information, see the DynaMed topics in the Insulin Management suite, including Initiating Insulin in Type 1 and Type 2 Diabetes.

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