The Asia–Pacific region faces a huge healthcare challenge from the rising prevalence of T2D. Moreover, T2D can have a relatively early onset in many patients in this region, hence aggressive glycemic control is vital to limit the burden of diabetic complications, and insulin therapy is therefore likely to be widely beneficial. Many healthcare systems in the region are ill prepared to meet this challenge, however, due to being under-resourced, or from national healthcare policies that make insulin therapy widely unaffordable by excluding the reimbursement of insulin, or of insulin administration equipment, glucose monitors, test strips etc. Even where insulin is easily available, there are significant barriers to its timely use. These include a lack of time and confidence on the part of physicians, lack of integrated care, lack of patient education, and widespread misconceptions about the risks and difficulties of insulin use, and what the decision to start insulin therapy signifies about disease progression and life expectancy. These barriers are reported globally but there are others that are more intrinsic to the Asia–Pacific region, such as skepticism about ‘Western’ medicine, and a tendency for perceptions to be guided from parochial traditions, peer groups, and unverified (and often untrue) reports on social media. Meeting these challenges is a vitally important goal in the years ahead. In the long term, it will require HCPs to organize and lobby for increased patient education, systems of integrated care and resources, and patient access to insulin. In the shorter term, we must be alert to the indications for initiating insulin in individual patients, the barriers that we might need to be overcome to gain patient acceptance, and individualized tactics that might help to achieve this.

Illustrative Case Histories

Please note, the case histories included on the following pages are purely hypothetical and intended to illustrate the barriers discussed in the main text, with some suggested approaches to overcome these.

Case 1: Dae-Seong, Busan, South Korea: Common fears and misconceptions about insulin

Dae-Seong is a 54-year-old technician with type 2 diabetes of 6 years’ duration. He is married with two sons in secondary school and has a sedentary lifestyle. His oral glucose-lowering drugs have been slowly increased since diagnosis to attempt to achieve glucose control. Dae-Seong is currently on metformin 2000 mg daily, gliclazide 80 mg twice daily, linagliptin 5 mg daily, and atorvastatin 40 mg daily. He is not hypertensive and has no history of diabetes-related chronic complications. He has a body mass index of 25.3 kg/m2, with fasting glucose of 168 mg/dl (9.3 mmol/l), HbA1c 8.6%, and serum creatinine of 0.8 mg/dl (0.04 mmol/l).

Due to the fact that Dae-Seong is taking multiple glucose-lowering drugs but remains poorly controlled, it is suggested that his gliclazide should be substituted for basal insulin. Dae-Seong expresses a reluctance to start insulin and becomes visibly upset. On questioning, he reveals that he is concerned about injections and hypoglycemia, and he feels he has failed to manage his diabetes and asks how long he can expect to live.

Dae-Seong is reassured when the following points are explained to him:

There is no evidence of diabetic complications yet, so he can expect many years of good-quality life.

Insulin is used by patients with type 1 diabetes for an entire lifetime, and its role is to prevent complications and maintain health. Many patients with type 2 diabetes who begin insulin wish they had done so years earlier.

Modern basal insulins carry a very low risk of hypoglycemia, and impending hypoglycemia can be recognized and addressed. A regimen will be designed that introduces insulin at a low dose and builds slowly and simply until an appropriate dose is reached.

A meeting can be arranged with a specialist nurse who will demonstrate how easy and painless it is to administer insulin via a modern injector device.

Case 2: Pranav, Bangalore, India: Urgent need to initiate insulin earlier than guidelines appear to recommend, and risk of loss to follow-up

Pranav is a 32-year-old single man who works as a software development engineer. Six months ago, he was routinely assessed and found to have a body mass index of 30.2 kg/m2 and HbA1c 7.8%. He was diagnosed with type 2 diabetes (T2D) and started on metformin 1000 mg per day along with sitagliptin 100 mg per day. Pranav recently returned to his surgery complaining of balanoposthitis and symptoms of lethargy, and questioning revealed that he also had signs of polyuria and polydipsia, and recent weight loss. Blood tests revealed his fasting blood glucose to be 280 mg/dl (15.5 mmol/l), his postprandial blood glucose to be 412 mg/dl (22.9 mmol/l), and his HbA1c to be 11.4%.

It is explained to Pranav that he really needs to begin insulin therapy immediately due to symptoms of gluco- and lipotoxicity. However, Pranav has read widely about T2D since being diagnosed because he has a family history of this disease. He is aware of guideline recommendations and understands insulin to be a ‘last-resort’ therapy. He argues that he could try other drugs such as glucagon-like peptide-1 receptor agonists, and sodium-glucose co-transporter-2 inhibitors, which could delay the need for insulin. He makes veiled suggestions about seeking a second opinion from another physician.

Pranav is reassured, however, when the following points are explained:

Guideline recommendations cover the broad T2D population and provide scope for individualization. His clinical course is atypical and likely to be linked to his family history.

Insulin is, in fact, not recommended as a treatment of last resort; other, less potent, therapies are included as alternatives in early stage T2D only because traditional insulin products carried a risk of hypoglycemia and were considered more ‘invasive’. In fact, modern insulins carry a low risk of hypoglycemia, and impending hypoglycemia can be recognized and addressed.

People with type 1 diabetes (T1D) have no other options than insulin, and use it successfully for their entire lifetime to prevent complications and maintain health. Pranav’s presentation of T2D is similar to that of T1D.

In fact, Pranav has decompensated diabetes that could potentially be corrected by a temporary course of insulin. It is important for his health to get his glucose levels controlled, and then modifications of therapy can be considered, including withdrawal of insulin.

However, due to his young age, Pranav will live with diabetes for many years, so is at risk of developing complications. It is therefore illogical to delay the most effective therapy of all just because other T2D therapies are available; it is better to achieve good glycemic control now and maintain that for life.

Case 3: Inaya, Lahore, Pakistan: Peer-driven skepticism about insulin and modern medicine

Inaya is a 48-year-old mother of six who works part-time in a bakery. She has been diagnosed with type 2 diabetes for 4 years and, at a recent health check, she was found to have a body mass index of 27.7 kg/m2 and HbA1c of 9.2%. Since Inaya has shown little interest in her diabetes, she has been prescribed a very simple regimen of two tablets per day of a metformin + dapagliflozin combination product. Due to worsening HbA1c, an attempt was made to prescribe liraglutide 18 months ago, but this was unsuccessful after she was initially resistant to injections and then complained of nausea.

Eye examinations show early signs of diabetic retinopathy, although Inaya does not perceive any loss of visual acuity.

It is suggested to Inaya that she should add basal insulin to her therapy to improve her glycemia, halt the progression of retinopathy, and prevent other potential complications. However, Inaya counters that she feels perfectly well and does not understand why she needs medicine at all, especially insulin. On further questioning, she reveals that she has read on social media that insulin is a dangerous drug that is over-hyped by ‘the establishment’ and pharmaceutical industry. Her mother has also persuaded her that such medicines were never needed by her generation, so she would rather not take any new drugs. Notes made by the team nurse who attempted to train Inaya in the use of liraglutide reveal, however, that she and Inaya share a love of cricket.

These case notes were then used to change the conversation towards subjects about which Inaya felt more positive. Inaya was persuaded to attend a further educational session with a diabetes nurse to learn more about her diabetes and insulin where she was told that:

Former Pakistan cricket captain Wasim Akram has insulin-treated diabetes.

This hero of hers has produced short educational films encouraging people like her to take their diabetes seriously, as they themselves had done.

Inaya is not alone in being influenced by social media platforms and non-expert peer groups, but she owes it to herself and to her children to seek out other perspectives on matters related to her health.

In this regard, her cricket hero and healthcare providers have her best interests at heart.

The nurse would provide Inaya with an opportunity to watch the videos made by her cricket heroes and to access other patient education assets with no obligation on her part.

Case 4: Aranya, Bangkok, Thailand: Difficulty affording insulin therapy due to lack of reimbursement

Aranya is a 62-year-old grandmother whose type 2 diabetes was no longer being controlled with metformin plus sulphonylurea (HbA1c of 8.6%). It was therefore suggested to her that basal insulin should be added, but the choice of agent was driven by cost, as Aranya is from a lower socio-economic background and universal health coverage provides only basic insulin products (neutral protamine Hagedorn, regular and premix) free of charge. However, twice-daily neutral protamine Hagedorn insulin resulted in a few mild hypoglycemia episodes (fasting blood glucose or overnight glucose of > 56 mg/dl to < 70 mg/dl [> 3.1 mmol/l to < 3.9 mmol/l]) not requiring assistance, and, as insulin titration progressed, these episodes became more frequent, but not severe. To reduce hypoglycemia, the sulphonylurea was discontinued and insulin re-titrated. With very careful meal management, Aranya was able to achieve her glycemic goal.

Nevertheless, Aranya developed negative feelings towards insulin because of the hypoglycemia. It was explained to Aranya that ‘second-generation’ insulins reduce the risk of hypoglycemic episodes, but Aranya remained reluctant to consider these, as they are not covered by universal health coverage.

In Thailand, cost can be a major issue, especially for underprivileged individuals. The universal health coverage, which covers approximately 80% of the Thai population, provides only basic insulins for people with diabetes free of charge, and glucose strips are not covered for patients with type 2 diabetes. Therefore, many insulin-treated patients have suboptimal glycemic control due to lack of adequate glucose monitoring and suboptimal insulin regimens.

The hospital diabetes care team and diabetes educators worked with Aranya to assess her willingness to pay to switch to a newer basal insulin once she was informed of the following:

Poor glycemic control leads to an increase in micro- and macrovascular complications.

Prevention of complications and glycemic control are well-recognized ways to effectively manage diabetes treatment costs.

The newer insulins reduce the occurrence of hypoglycemic episodes.

Well-managed diabetes can benefit a patient’s quality of life.

Case 5: Jirayu, Phuket, Thailand: Overcoming systemic difficulties through education of GPs

Jirayu is a 43-year-old IT specialist who works in Bangkok and has a body mass index of 32.6. He has been self-administering insulin for several months, with the advice and support from the diabetes care team from the hospital. Jirayu is due to move to a new area where face-to-face contact with a diabetes specialist will not initially be possible. Although Jirayu has been self-administering insulin successfully until now, he is concerned that healthcare professionals (HCPs) at the clinic near his new home will not be able to manage his diabetes treatment effectively and his condition will worsen.

Telehealth has been implemented in many hospitals in Thailand, and provides an alternative option for HCPs to keep in regular contact with their patients or patient caregivers. This system also allows HCPs to counsel on titration or adjustment of insulin dosage in patients who are not easily able to see a diabetes specialist. Jirayu decided to discuss with his new general practitioner (GP) about continuing keeping in contact with his diabetes care team via a teleconference app. His GP agreed upon this and suggested that treatment be based on shared decision-making. With this strategy, Jirayu’s diabetic condition could be well managed without regular face-to-face visits with a diabetes specialist.

To increase the number of diabetes educators in Thailand, the Thai Association of Diabetes Educators, among others, has provided regular training courses and a curriculum for HCPs or other medical personnel who are interested in diabetes care. This is a good opportunity for GPs who have to take care of patients with diabetes and want to improve their knowledge of and skills in diabetes management. They can also send their nurses or other medical personnel to attend the curriculum to better manage patients with diabetes. This is a practical strategy to improve diabetes care, including insulin management, in hospitals where there are no diabetes specialists.

Case 6: Peter, Sydney, Australia: Overcoming systemic difficulties through establishment of a multidisciplinary team

Peter is a 68-year-old retired man with an 8-year history of type 2 diabetes. He was admitted to the emergency department following a fall from a ladder. Medications on admission included metformin 1 g twice daily, empagliflozin 25 mg once daily, and linagliptin 5 mg once daily. He had previously trialed a glucagon-like peptide-1 receptor agonist but did not persist on this treatment due to gastrointestinal side effects. He had not consulted his family doctor for several years. Peter’s HbA1c on admission was 12%, his estimated glomerular filtration rate was 65 ml/min/1.73 m2, and his lipid levels were at target. He was not known to have any diabetes-related complications. He was assessed by the diabetes team, then discharged on twice-daily insulin. Due to hospital restrictions, a review was organized for 3 months. Peter was uncertain how to titrate his insulin or how long he should persist with the injections and what monitoring he needed. He was referred by his family doctor to an endocrinologist and diabetes educator. Management consisted of revision of injection technique, change of insulin needle length to 4 mm, advice regarding rotation of injection sites, and monitoring of his glucose levels prior to the injections prior to breakfast and dinner, as well as education regarding prevention and treatment of hypoglycemia.

A management plan was made in conjunction with the family doctor, including guidelines as to how to titrate the insulin and what glucose targets were appropriate. The family doctor continued to review Peter every few weeks, with the endocrinologist seeing Peter at 3- then 6-month intervals. The key factors in management were:

Communication between all healthcare professionals in a timely manner after discharge.

Guidelines delivered by the endocrinologist to the family doctor, with insulin adjustment algorithm based on self-monitoring of glucose.

A diabetes educator ensuring that insulin injections were appropriate with revision of sick day management.

Oversight by the endocrinologist.

Case 7: Dr. Thomas, Chennai, India: Reluctance to start insulin due to lack of confidence and clinical support

Dr. Thomas is a successful 35-year-old physician practicing in Chennai. However, he is often overwhelmed by the number of patients he has to see in a day. Although he has a special interest in diabetes care, he runs a solo practice with no dedicated dietician or diabetes educator, and has found it difficult to educate his patients regarding diabetes. He admits that he often sees patients with severe uncontrolled diabetes who are already taking 3–4 oral antidiabetic drugs, yet many continue to have a HbA1c value greater than 9%. While he is aware that he needs to consider initiating insulin, he is reluctant to do so because it would mean an extra 20–30 min of his time. Due to the long list of patients waiting outside his consultation room on any given day, he does not feel he can spare this time to initiate insulin.

When one of his patients develops a severe diabetic foot problem, Dr. Thomas decides that it is time he changes his daily practices. He joins a certificated course, which vastly improves his overall knowledge of treating diabetes. He also starts attending various diabetes meetings, where he learns the value of avoiding clinical inertia and the need for starting insulin early if multiple oral antidiabetic drugs are not effective. He begins to employ a dietician, whom he enrolls in a program to gain certification as a diabetes educator. The dietitian learns how to administer insulin, and how to teach patients about blood glucose and continuous glucose monitoring. She also prescribes healthy diets and increasing physical activity for patients. Together, Dr. Thomas and the dietitian develop specialized educational materials for patients with diabetes.

Dr. Thomas finds that, with the addition of the dietitian/diabetes educator to his clinic, his own time is freed up and he is under less pressure. Moreover, his patients benefit considerably from the extra attention that is given to them by the diabetes educator. Over time, Dr. Thomas finds that the general level of diabetes control in his patients improves considerably. Moreover, as he now starts seeing more patients with diabetes, he focuses his practice on diabetes and its associated comorbid conditions.

The lessons Dr. Thomas learns are as follows:

It is difficult for an individual physician to spend enough time to educate people with diabetes.

Addition of a dietitian/diabetes educator greatly enhanced his practice and improved the control of diabetes in his clinic.

His own self-improvement in knowledge of diabetes gave him the confidence to treat even difficult cases of diabetes.

Dr. Thomas does not hesitate anymore to use insulin whenever indicated. In fact, he has even started using a short course of insulin early in the treatment of those who present with infectious ketonemia, grossly elevated HbA1c, weight loss, or other symptoms of uncontrolled diabetes.

Case 8: Mrs. Karim, Ashulia, Bangladesh: Overcoming sudden stoppage of insulin

Mrs. Karim is a 45-year-old woman. Two years ago, she was experiencing typical symptoms such as polyuria and polydipsia. Mrs. Karim’s OGTT revealed her fasting blood glucose to be 14 mmol/l and her postprandial blood glucose to be 26 mmol/l. Regular pre-mixed insulin was initiated, as well as the introduction of dietary modifications and exercise.

As advised by a local village physician, Mrs. Karim stopped taking insulin after she experienced nocturnal hypoglycemia. Three months later, she developed the same symptoms of hyperglycemia that she experienced 2 years prior at the initial diabetes detection. Mrs. Karim then began to omit her nightly dose of insulin, taking it only in the morning.

Mrs. Karim experienced a recent non-healing ulcer on her left toe following a trauma. She was referred to BIRDEM, a tertiary care hospital. Mrs. Karim’s HbA1c levels were 11.3% with normal renal function.

The management plan for Mrs. Karim consisted of a split-mixed regimen, antibiotic prescription, and diabetes education. As patients may sometimes feel more comfortable with local physicians, education on future diabetic management, including insulin management, was provided to Mrs. Karim’s local physician.

The key features of the management plan were:

Split-mixed insulin regime of short-acting postprandial insulin, to keep postprandial blood glucose between 8 and 10 mmol/l and intermediate-acting insulin to keep pre-prandial blood glucose between 6 and 7 mmol/l.

Diabetes education including advice on self-adjustment of insulin and hypoglycemia.

Education on self-empowerment in Mrs. Karim’s diabetes management.

Dietary advice and adjustment, as well as frequent home monitoring.

Communication with Mrs. Karim’s local physician.