Background: One in 3 people with diabetes (88% with type 2 diabetes [T2D]) do not take insulin as recommended an average ∼3.3 days per month. Insulin omission (IO) is associated with suboptimal A1c. Reasons for IO are multifactorial (e.g., cost, fear, stigma). Unclear are what matters most for reducing IO and improving A1c.

Objective: We assessed 10 reasons for IO among a national sample of people with T2D, and identified reasons that, if addressed, might improve A1c.

Methods: Adults (age 18-75 years) with T2D self-selected to be in a randomized control trial comparing inhalable, ultra-rapid-acting insulin (Afrezza) with One Drop’s digital therapeutics solution vs. injectable, rapid-acting insulin with One Drop. A HIPAA protected, online survey screened potential participants. Eligible persons completed a baseline survey and NGSP certified A1c test. Survey items collected demographics, reasons for IO, and responses to the ARMS-D and SDSCA-IS to assess IO. We used SPSS v25 for psychometric, descriptive, and multivariate statistics, and PROCESS v3 for unadjusted and adjusted mediation models with bootstrapped (10K) CIs.

Results: Participants (N=269) were 50±11 years old, 51% male, 30% non-white, 90% insured, with 13±8 years since a T2D diagnosis, and A1c 8.8%±1.8%. ARMS-D insulin had internal consistency reliability (α=.82), and convergent validity with SDSCA-IS (rho=.46, p<.001). IO was associated with higher A1c (β=.39, p<.001). Cost (coef.=.08; 95% CI:.02-.15), disruption (coef.=.07; 95% CI:.001-.15), fear of side effects (coef.=.15; 95% CI:.07-.26), and burnout (coef.=.11; 95% CI:.05-.19) had indirect effects on higher A1c through IO. Reasons were not directly related to A1c.

Discussion: Cost, disruption, fear, and burnout were associated with IO, and higher A1c through IO. Given time and resources constraints, clinic visits and self-care interventions must prioritize and address modifiable factors contributing to both non-adherence and higher A1c. Such efforts may be more effective than other approaches.


C.Y. Osborn: Employee; Self; One Drop. Research Support; Self; MannKind Corporation. Stock/Shareholder; Self; One Drop. L.E. Sears: Employee; Self; Informed Data Systems Inc.. Research Support; Self; MannKind Corporation. A. Hirsch: Employee; Self; One Drop. Research Support; Self; MannKind Corporation. J. Raymond: None. M. Heyman: Employee; Self; One Drop. R. Head: None. J. Dachis: Stock/Shareholder; Self; One Drop. Board Member; Self; One Drop. Employee; Self; One Drop.

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