February 27, 2020
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Glycemic management more difficult for adults who decline recommended insulin therapy

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Alexander Turchin

Adults with type 2 diabetes who decide not to take insulin are less likely to reduce their HbA1c below 7% over 12 months than those who initiate insulin when recommended, according to findings published in Diabetic Medicine.

“Many patients with diabetes reject a recommendation of insulin treatment by their health care providers,” Alexander Turchin, MD, MS, associate professor of medicine at Harvard Medical School and director of quality in diabetes in the division of endocrinology at Brigham and Women’s Hospital in Boston, told Healio. “This apparently widespread phenomenon could be an important contributor to poor blood glucose control among individuals with diabetes.”

Turchin and colleagues examined medication records from 2000 to 2014 to determine whether 5,307 adults with type 2 diabetes and an HbA1c of 7% or higher accepted or declined insulin therapy. From there, the researchers identified when participants reduced their HbA1c below 7% for the first time by reviewing HbA1c measures in medical records across 40.2 months of median follow-up.

Turning down insulin

Insulin therapy was declined by 2,267 participants (median age, 59.8 years; 50.5% women) and accepted by 3,040 (median age, 57.8 years; 45.2% women). The researchers noted that insulin therapy was eventually begun by 17.8% of those who declined the treatment at first.

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Adults with type 2 diabetes who decide not to take insulin are less likely to reduce their HbA1c below 7% over 12 months than those who initiate insulin when recommended.

“We were surprised to see that insulin acceptance went up in the later part of the study. We expected to see the opposite — that as more noninsulin diabetes medications became available, patients would be more reluctant to take insulin,” Turchin said. “But we saw the opposite — perhaps because there is generally stronger public awareness of the importance of blood glucose control in patients with diabetes.”

Every 10-year increase in age raised the odds that a participant would turn down insulin therapy (OR = 0.81; 95% CI, 0.76-0.86), as did taking two or more diabetes medications vs. taking fewer than two (OR = 0.78; 95% CI, 0.74-0.83). Conversely, the odds of insulin acceptance were higher when participants were treated by an endocrinologist (OR = 52.9; 95% CI, 18-155.3), had an HbA1c of 9.2% or more at baseline (OR = 1.1; 95% CI, 1.07-1.13) or had diabetes complications (OR = 1.32; 95% CI, 1.13-1.53). The researchers further noted that accepting insulin therapy shared associations with higher Charlson comorbidity index (OR = 1.06; 95% CI, 1.03-1.08) and more recent insulin therapy recommendations (OR = 1.04; 95% CI, 1.02-1.06).

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HbA1c challenges

At 1 year, a smaller percentage of those who did not begin insulin had an HbA1c below 7% vs. those who began insulin immediately (18.3% vs. 27.3%; P < .001). Reaching an HbA1c below 7% took a median of 50 months for participants who turned down insulin vs. a median of 38 months in those who accepted insulin therapy (P < .001). Compared with those who declined insulin therapy, the odds of reducing HbA1c below 7% were 29% lower for those who did not start insulin immediately (OR = 0.71; 95% CI, 0.61-0.82).

It took less time to reduce HbA1c below 7% for men vs. women (HR = 0.87; 95% CI, 0.81-0.95) and for those with HbA1c below 9.2% at baseline vs. those with HbA1c of 9.2% or more (HR = 0.94; 95% CI, 0.92-0.96). The researchers also noted that shorter time to reduce HbA1c below 7% shared an association with elevated Charlson comorbidity index (HR = 1.04; 95% CI, 1.03-1.06), elevated BMI (HR = 1.01; 95% CI, 1.003-1.01) and more recent insulin recommendations (HR = 1.03; 95% CI, 1.01-1.04).

“We need to better understand why so many patients with diabetes do not have their blood glucose under control. Previously whenever a patient with poorly controlled diabetes was not started on insulin, it was written off as their provider’s clinical inertia,” Turchin said. “Our study shows that the reality is more complicated. We need to remember that the patient is the ultimate decision maker for their health care, and we need to work together with the patient to improve their health.” – by Phil Neuffer

For more information:

Alexander Turchin, MD, MS, can be reached at aturchin@bwh.harvard.edu.

Disclosure: Turchin reports he has received research funding from AstraZeneca, Eli Lilly and Sanofi and owns equity and serves on the scientific advisory board of Brio Systems.