Attitudes among Adults with Type 2 Diabetes Affecting Insulin Initiation and Discontinuation

Approximately 30% of patients with type 2 diabetes (T2D) are reluctant to initiate basal insulin when recommended by their healthcare provider (HCP). Even after initiation, many patients use insulin intermittently. Examining patients’ attitudes towards insulin and their links to subsequent use can aid HCPs in improving insulin uptake and adherence. 594 T2D adults across seven countries who indicated initial reluctance to begin basal insulin but eventually agreed to do so [mean age = 53.3 (SD=11.3), 56.7% male], participated in the EMOTION survey. In addition to self-reported insulin behavior (immediate initiation vs. delay, discontinued use for ≥7 days), attitudes towards insulin immediately prior to initiating insulin were captured using a modified version of the Insulin Treatment Appraisal Scale (mITAS). An exploratory factor analysis of the 21 negatively worded mITAS items (1=strongly disagree to 5=strongly agree) yielded four factors: “concerns about injections” (M=3.4, SD=1.0), “failed diabetes management” (M=3.8, SD=0.8), “increased disease severity” (M=3.0, SD=0.9), and “concerns about side effects” (i.e., weight gain, hypoglycemia) (M=3.4, SD=0.8). In models controlling for patient characteristics and clustering by country, higher scores (more negative appraisal) in all four mITAS factors were linked with greater likelihood of delaying insulin initiation (ORs: 1.34 to 1.73; all p <0.05). Only “concerns about side effects” was associated with discontinuation and inversely related (OR=0.60, p <0.05). Overall, higher mITAS scores were associated with being female, younger, more recently diagnosed, and without previous experience with injectable medications. Negative patient appraisals of insulin are linked with delays in their insulin initiation in T2D; while other factors may be more impactful for predicting discontinuation. These patient attitudes should be considered when discussing insulin initiation.