To Add an Injectable - or Not?

October 18, 2018

A patient may resist the move to insulin in the face of even irrefutable evidence that it's time. A GLP-1 RA is often moe attractive. Why? Also, why not?

Your patient has tried, and tried.

She’s tried some more - to control her type 2 diabetes (T2DM).

Metformin, and ([insert your favorite oral agent] in combination with Metformin) - no longer are keeping her at goal. Neither are redoubled efforts at therapeutic lifestyle changes.

So, after a bit of clinical inertia (ie, “Please, give me 6 more months to get back on track. I’ll get back to exercising more.” Or, “I’ll test more often”), or other changes promised, which will you recommend?

A glucagon-like peptide-1 receptor agonist (GLP-1 RA)? Insulin?

We can discuss the stats, and the need for better control. But, for some patients, the seemingly theoretical beta-cell burnout pales in the face of the daily reality and immediacy of sticking oneself.

This question, along with what patients select, has intrigued me. I’ve made some observations over the last several years. Why do many patients, the same ones who may decline insulin out of hand, appear to be more receptive to a GLP-1 RA?

1. The once-weekly factor
Convenience seems to play a prominent role. Understandably, it’s easier to think of injecting yourself once per week, than 7, (or 28 or more times, if on a basal-bolus regimen).

2. The potential for weight loss
Insulin’s potential for weight gain and hypoglycemia can lead both patients and their physicians to hold back. But, GLP-1 RAs can be more attractive due to their modest weight loss, also a very issue with which many T2DM patients struggle.

3.  But, wait...
Many patients may have built up over time, more misconceptions and negative associations with insulin. “My grandmother started insulin, and not long after, she got toes amputated.”

Yet, sometimes, this kind of pattern doesn’t hold. I see a patient who’d for years, been asking for more time, yet his hemoglobin A1c remained largely unchanged. Oscillating between a rather narrow A1c range of approximately 11 to 13%, he faithfully followed up with me every 3 mos. Despite his disappointed mien when I informed him of his latest A1c, he just as reliably, flatly declined adding another medication, especially insulin. When I broached the subject of a GLP-1 RA, he seemed a bit more open, but was still hesitant about an injectable. Several 3-month follow-ups later, he agreed to see our pharmacist, so she could demonstrate injecting. They discussed details of using GLP-1 RAs.

To my surprise, when I read her note the next day, he opted for long-acting insulin.

The reason? He found reconstituting the GLP-1 RA too cumbersome. 

What have been your observations and experiences? I look forward to hearing from you!