as major barriers and contribute to the reasons that intensive insulin therapy has not gained widespread clinical acceptance. The inconvenience of having to take multiple daily injections and carry around insulin supplies may contribute to poor compliance. Further, the time required of both the provider and the patient to successfully implement the intensive insulin regimen and the resources required to do so may limit acceptance. There is obviously a psychological component— patients with type 2 diabetes may feel that advancing to insulin therapy is related to a serious progression of their disease state.
Thus, both practical and psychological hurdles contribute to the resistance to advance to insulin and, when insulin is administered, may lead to errors in technique and anxiety, further hindering improvement of metabolic control. Such real concerns are demonstrated in studies that suggest that between 60 and 80% of patients may perform some aspect of insulin administration incorrectly, e.g., timing of administration or taking correct dose. As physicians, we may not recognize the importance of injection-related anxiety in our patients. In 1999, Zamban-ini and colleagues assessed injection-related anxiety in 115 patients with either type 1 or 2 diabetes. Their findings suggest a cause for concern: J) 14% of patients admitted avoiding injections because of anxiety; 2) 42% reported concern at the prospect of having to inject more frequently, which may be essential to achieve control; and 3) of the 28% of patients with marked anxiety, 45% had avoided injections and 70% reported concern at the prospect of having to inject more frequently. These concerns will adversely influence compliance and greatly interfere with the clinical goal of achieving glucose control. What, then, is the optimal approach? On one hand, we recognize in patients with type 2 diabetes that gly-cemic control is required to reduce the complications; on the other, significant concerns exist regarding required therapy. Our traditional means of providing exogenous insulin has therefore been re-evaluated. To understand this re-evaluation, a brief review of the development of insulin may help in the understanding of the current focus on alternative insulin delivery.
The insulin era began in 1921, when Frederick Bandng and Charles Best excited the medical world by reporting that they had isolated the active ingredient in the pancreas believed to regulate blood glucose. In collaboration with a biochemist -g named Collip, Banting and Best produced an extract of insulin. The real signifi- |
cance of this work in providing a viable clinical therapy, however, was not real- ^
ized until January II, 1922. On this date, a 14-year-old boy named Leonard
Thompson was dying of diabetes in the Toronto General Hospital when Banting ?
and Best provided him with injections of pancreatic extract. The injections low- a ered the boy's blood glucose levels and the treatment allowed him to return home jj within weeks. The successful treatment of this disease, which had been consid- a
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