Overcoming Barriers to Insulin Therapy

04 April 2019

Diabetes is a life-long disease that we frequently hear or read about in the media and among our peers. With 2.6 million registered patients in Malaysia, the country has one of the highest numbers of diabetes cases in 2012 according to the Ministry of Health.

The National Health and Morbidity Survey (NHMS) revealed that the percentage of Malaysian adults over 30 with diabetes has risen drastically from about 6% to 20% over the span of the last two and a half decades. What’s more alarming is that diabetes is seen as no longer a disease of the middle or old age. Children as young as 10 years old are suffering from diabetes and this points to the linkage of either maternal/paternal imprinting or high rates of obesity among the children and adolescents.

The much talked about topics on diabetes include prevention and the complications of diabetes. To better understand the medicine and treatment aspect of diabetes, we spoke to a Consultant Endocrinologist, Diabetes Nurse Specialist and a patient with diabetes.

The low down on insulin

For type 1 diabetes, which is an auto-immune disease, insulin is inevitable. However, for patients with type 2 diabetes, in most cases, it is a matter of time before insulin shots replace or have to be combined with oral medication.

Pancreas, a main organ located in our abdomen, plays an essential role in converting the food we eat into energy. This important organ also secretes a hormone called insulin, which acts to lower our blood sugar. We need insulin to help our body maintain normal blood sugar levels that are crucial to the functioning of the key organs including the brain, liver and kidneys.

“In a patient with pre-diabetes, the beta function of the pancreatic cells will slowly deteriorate and insulin secretion will gradually decrease, thus it is important for these patients to act on the disease before they develop diabetes,” said Dr Wong Ming, Consultant Endocrinologist.

Social stigma on insulin therapy

The general perception of insulin tends to lean on the negative side due to many factors. For some patients, there is a need to inject themselves with insulin up to four or five times a day. This means they may not be able to give themselves insulin shots at the comfort of their own home.

Unfortunately, there seems to be a negative connotation relating to syringe or needles, especially when it involves injecting oneself. With little education and awareness on insulin needles, diabetics tend to feel embarrassed about this condition and is worried of being associated as a drug addict if the need to give themselves a shot in public arises.

Is it the end of the road after receiving insulin therapy?

It can be difficult for a patient to accept the fact that they need to be on insulin treatment for the rest of their life. “Some patients feel like it’s the end of the road once they start insulin as they find it hard to accept that they have to inject themselves everyday for the rest of their lifetime,” said Dr Wong.

When it comes to a lifetime of medication, patients will certainly have a variety of concerns. Firstly, there is the cost factor. Depending on the type and frequency of insulin a patient needs, the cost can vary, from as little as RM30 a month to as high as RM200 a month. This does not include other equipment or tools a patient needs for regular blood glucose monitoring.

Another common worry is fear of needles. However, the fact is the needle from the insulin suspension is very fine and short. The trained diabetes nurse specialists at Sunway Medical Centre’s Diabetes Care Centre play an important role in educating patients and their caregivers and helping patients eliminate the fear they associate with needles. “Some patients just can’t give themselves a shot but are completely fine with another person injecting them. We will then need to spend time to educate the caregivers in proper administration of insulin,” said Sr Wong Su Fei, Diabetes Nurse Specialist.

For most patients, once they understand and accept the fact that the pancreas ages faster than the rest of the organs and that being the reason for them to be on insulin, they tend to sail through this journey without much problem.

“Once I found out that I need to be on insulin shots, I couldn’t help but feel scared as I would have to inject myself every single day. But with the constant support and help from the nurses at Diabetes Care Centre, I realised that it is not so difficult after all. It’s not even that painful,” said Ms Mary Louise, 63, a diabetes patient.

Mary has been living with diabetes since she was 28 years old. She discovered she had diabetes after going for a medical check-up, in which she initiated herself as she was feeling tired, thirsty and the need to urinate all the time.

Lifestyle modification is key

For newly diagnosed type II diabetes patients, oral medication is usually the standard treatment until the patient develops insulin deficiency.

 “Majority of the patients will require insulin 6 – 10 years after the disease is diagnosed as beta cells of the pancreas fail to secrete sufficient insulin to control the blood sugar. This is the natural history of progression of type 2 diabetes,” added Dr Wong. In other words, most type II diabetes patients will have no choice but to switch from oral medication to insulin shots or a combination of both in order to maintain proper level of their blood glucose.

But before this happens, some form of lifestyle modification can help in delaying insulin treatment. With adequate exercise, maintenance of a healthy BMI and diet containing a balanced choice of food items in recommended portions, a diabetes patient can continue with the necessary oral medication and possibly delay starting on insulin treatment.

Some patients are fortunate to be able to delay insulin therapy for much longer than 10 years. “I only started insulin injections 30 years after I was diagnosed with diabetes. I was only on oral tablets all this while, until a year ago,” said Mary.

 “I believe that my positive mindset combined with a balanced diet and frequent exercise help in my delaying of starting insulin injections. I also think that it is important to take your medications diligently, as per the doctor’s advice,” added Mary.

Mary shared with us that she still gets to consume her favourite food, but with proper control. “If I eat ice-cream in the morning, I will cut down on my dinner. This way, I get to eat all the food I enjoy, such as durian and desserts,” said Mary.  

The future of insulin therapy

The delivery of insulin therapy has seen many developments over the years since the first mass production of insulin was produced in the 1920s. Some of the advancements are the replacement of syringe delivery to pen delivery and frequency reduction in insulin injection due to mixture of therapy. Patients used to have to wait 30 minutes after an insulin injection in order to consume food. This waiting time is non-existent now.

Consultant Endocrinologist, Dr Wong Ming said, “Clinical trials are being conducted in order to make it even easier for patients. We may reach a day when diabetes patients only need to inject insulin every other day, instead of everyday now.”

“Diabetes treatment is not a one-size-fits-all matter.  There are different regime and treatment to fit different lifestyle. So, we often ask patients to take it one step at a time. Lifestyle modification which includes diet and exercise remains the cornerstone in the management of diabetic patients,” added Dr Wong.

Early detection is the best way to find out about your health status. For more information on diabetes screening and management, including access to medical experts who are able to provide support, counselling and educational services, please visit the Diabetes Care Centre at Sunway Medical Centre located on the 1st Floor in the East Wing or contact a Diabetes Nurse Specialist at 03 7491 9191 (ext. 11139/11149).