University of Calgary, Calgary, Alberta, Canada.
Curr Med Res Opin. 2011 Nov;27 Suppl 3:13-20. doi: 10.1185/03007995.2011.621416. Epub 2011 Sep 23.
Contrary to longstanding recommendations on type 2 diabetes (T2D) management, the de facto standard of care in Canada includes lag times of many years prior to introducing effective glycemic control. Even patients transitioned to insulin may continue to experience poor glycemic control, with attendant diabetic complications, suggesting poor adherence or inadequate dose titration.
To identify barriers to timely and effective use of insulin in T2D.
PubMed searches were conducted to find research articles on insulin initiation, adherence and intensification. Also, because recent data on the consequences of intensive glycemic control may be taken as justification for relaxing glycemic targets, a secondary search on this literature was conducted, including the UKPDS and ACCORD trials, plus post hoc and meta-analyses of these data. No formal evaluation of level of evidence was conducted while researching this narrative literature review.
Timely, effective glycemic control remains an important clinical goal but is complicated by patient, physician and treatment factors. Patient barriers to accepting insulin initiation include fear of hypoglycemia, injections and weight gain, and reluctance to accommodate the inflexible timing of scheduled insulin doses. Adherence issues, including dose omission, are common and are associated with some of the same factors. Fear of hypoglycemia also underlies many physicians' reluctance to prescribe insulin. Caregivers' failure to provide training or answer questions about insulin's risks and benefits was also associated with low patient adherence. Poor communication may also be at fault when patients on insulin fail to titrate or intensify their treatment adequately. Conversely, glycemic control can be significantly improved by facilitating ongoing communication between patients and caregivers.
Although innovations in injectable therapy for T2D may help address the current pattern of poor glycemic control, improved communication between patients and caregivers is also a powerful approach and can be implemented with existing therapies.
与长期以来关于 2 型糖尿病（T2D）管理的建议相反，加拿大的实际护理标准包括在引入有效血糖控制之前多年的延迟时间。即使患者过渡到胰岛素治疗，也可能继续出现血糖控制不佳，伴随糖尿病并发症，表明依从性差或剂量调整不足。
确定 T2D 中胰岛素及时有效使用的障碍。
通过 PubMed 搜索寻找关于胰岛素起始、依从性和强化的研究文章。此外，由于最近关于强化血糖控制后果的数据可能被视为放宽血糖目标的理由，因此对该文献进行了二次搜索，包括 UKPDS 和 ACCORD 试验，以及对这些数据的事后分析和荟萃分析。在研究这篇叙述性文献综述时，没有对证据水平进行正式评估。
及时、有效的血糖控制仍然是一个重要的临床目标，但由于患者、医生和治疗因素而变得复杂。患者接受胰岛素起始治疗的障碍包括对低血糖、注射和体重增加的恐惧，以及不愿意适应胰岛素剂量的固定时间。包括剂量遗漏在内的依从性问题很常见，并且与一些相同的因素有关。对低血糖的恐惧也是许多医生不愿开胰岛素处方的原因。护理人员未能就胰岛素的风险和益处提供培训或回答问题，也与患者依从性低有关。当胰岛素治疗的患者未能充分调整或强化治疗时，沟通不畅也可能是问题所在。
尽管 T2D 的注射治疗创新可能有助于解决当前血糖控制不佳的模式，但改善患者和护理人员之间的沟通也是一种强有力的方法，并且可以在现有治疗的基础上实施。
