Overcoming Objections to Injections

Overcoming Objections to Injections

There was a time when doctors couldn't get anywhere near Sherri Buffington with a needle. "I was deathly afraid of needles," recalls the 44-year-old senior legal secretary from Sicklerville, N.J. "I've been petrified of needles since I was a little kid."
Then in 2004, Buffington was diagnosed with diabetes. When oral medications didn't control her disease, her doctor prescribed an injectable prescription medication along with insulin. Taking these drugs meant she would have to inject herself, sometimes three times a day. "I was apprehensive," she says. "But I felt that if this was going to help me, I'd have to grin and bear it and just do it."
Buffington is far from the only diabetes patient with needle anxiety. More than a third of people with diabetes approach their injections with a sense of dread, and nearly as many feel that injections are the hardest part of managing their condition. The fear can be severe enough to prevent some diabetes patients from taking the medicines they need to control their blood sugar. In fact, one survey found that more than half of patients skipped insulin injections from time to time, often because they feared the pain.
"I always tell patients that having a fear of needles is normal and natural," says Evan Sisson, PharmD, a diabetes educator and assistant professor in the Department of Pharmacotherapy and Outcomes Science at the Virginia Commonwealth University School of Pharmacy. Sisson and other diabetes educators help diabetes patients overcome their fear of shots, so it doesn't become an obstacle to controlling their blood sugar.

Why Injections Are Important

Everyone with type 1 diabetes must take insulin injections, because their body doesn't produce this hormone. People with type 2 diabetes take injected insulin or other prescription injectables when pills and lifestyle changes aren't lowering their blood glucose enough.
Why injections? “Injections are the most effective," says Robert R. Henry, MD, professor of medicine in the Division of Endocrinology and Metabolism at the University of California, San Diego and president of Medicine & Science at the American Diabetes Association.
Skipping insulin injections can be extremely dangerous for people with type 1 diabetes. When glucose isn't available for energy, the body starts burning fat instead. That can lead to a state called ketoacidosis, in which acids called ketones build up and poison the body.
With type 2 diabetes, the risk of skipping medications or injections isn't as immediate. But over time, fluctuating blood sugar levels can damage organs like the eyes, kidneys, and heart. Research has found that people who are afraid of their insulin injections have poorly controlled blood sugar and experience more diabetes-related complications. Overcoming needle anxiety can be a key element to preventing these complications.

Combination Therapy for Diabetes

Combination Therapy for Diabetes

Many people with type 2 diabetes can manage blood sugar levels effectively on oral diabetes medications and lifestyle changes alone. Others will need to combine oral diabetes medications with injectable diabetes drugs in order to bring their blood glucose levels into a healthy range. Finding the right combination is the key to managing diabetes successfully.
For years, insulin was the only injectable diabetes medication available to help control blood sugar. Today, several newly approved injectable diabetes drugs are available. A growing number of medication options are also available, so doctors can individualize diabetes treatment with greater precision than ever before.

Combining Diabetes Medications for Optimal Effect

How will your doctor decide the best diabetes drug regimen for you? “The first principle is to make life as easy and therapy as effective as possible,” says Daniel Einhorn, MD, president of the American Association of Clinical Endocrinologists and medical director of the Scripps Whittier Diabetes Institute in La Jolla, Calif. “Type 2 diabetes is a lifelong problem. We want to choose therapies that people can easily live with.”
One factor is how comfortable people feel giving themselves injections. “Some patients are fine with injectable medications. Others will do anything not to have to give themselves injections,” says Eleftheria Maratos-Flier, MD, professor of medicine at Beth Israel Deaconess Medical Center in Boston.
 The second principle of combination diabetes drug therapy, according to Einhorn, is choosing medication therapies that work in complementary ways. “Today we have a variety of drugs that work in very different ways, so combinations can be especially effective,” says Einhorn.
One of the most commonly used oral drugs, metformin (sold under the brand names Blumetza, Fortamet, Glucophage, and Riomet), is considered the cornerstone of most combination therapy. It works by decreasing the amount of glucose produced by the liver. Metformin can be paired with insulin or with a GLP-1 agonist, which stimulates insulin production.
Doctors may also combine insulin with a GLP-1 agonist and a thiazolidinedione oral medication  (Actos and Avandia), which sensitizes the body to insulin. For people comfortable with using injectable drugs, doctors may recommend one of the two new GLP-1 agonists, Byetta and Victoza.  For people who don’t want an injectable drug, the alternative is a DPP-4 inhibitor (Januvia, Tradjenta, and Onglyza), which is taken orally. Both of these classes of drugs work in a similar way and are considered equivalent.

Weighing the Pros and Cons of Drug Combinations

Minimizing adverse effects is also important. Some diabetes medications can cause blood sugar levels to drop too low, causing hypoglycemia. The oral medication sulfonylurea (DiaBeta, Glynase, Micronase), which has long been used for type 2 diabetes, poses a moderate risk of causing hypoglycemia. Many doctors prefer to prescribe metformin, which is much less likely to cause hypoglycemia. Metformin is often paired with a GLP-1 agonist because these new injectable drugs work only when blood sugar levels are high, further avoiding  hypoglycemia.

Non-Insulin Diabetes Injectables

Non-Insulin Diabetes Injectables

When insulin was first discovered in 1921, it's not an overstatement to say that it revolutionized the treatment of diabetes. No longer was diabetes considered a death sentence. For the first time, people with diabetes could expect to live longer, fuller lives.
Insulin transformed diabetes treatment, but for many decades it was the only drug available to treat diabetes. Then came another mini-revolution with the introduction of the first oral, non-insulin drugs to treat type 2 diabetes, including metformin and the sulfonylurea class of drugs.
Today, metformin is the first drug doctors usually recommend for people with type 2 diabetes who need to take medication. Researchers have still been on the hunt for other diabetes treatment options because metformin doesn't work for everyone who has diabetes. Some people who take this drug still have trouble controlling their blood sugar and A1C number.
In recent years, new drugs have been introduced that offer more options for people with type 1 and type 2 diabetes. In 2005, the U.S. Food and Drug Administration approved two injectable non-insulin medications -- pramlintide (Symlin) and exenatide (Byetta). Then in 2010, the FDA also approved the drug liraglutide (Victoza).
Unlike insulin, which lowers blood sugar by pulling glucose from the bloodstream into cells, these drugs cause the body to release insulin, or work with insulin to control blood sugar levels.
Here's a rundown of the three non-insulin injections your doctor might recommend for controlling your blood sugar levels -- how they work, who they help, and what side effects they can have.
Pramlintide (Symlin)
What it is: Symlin is a man-made version of a hormone called amylin, which is produced along with insulin by the pancreas when blood glucose levels rise.
Who can take it: Symlin is designed for people who aren't able to get their A1C number down to the recommended less than 7.0% using other medications. It's approved for people with type 1 diabetes who are taking insulin, and people with type 2 diabetes who are taking insulin, a sulfonylurea drug, and/or metformin.
What it does: You take Symlin with insulin after a meal. The two drugs work together to lower your blood sugar. Symlin also slows your body's digestion of food, which puts less sugar into your bloodstream. In addition to controlling your A1C levels, Symlin helps reduce your appetite, so you eat less.
Side effects: The most common side effects of Symlin are nausea, stomach pain, diarrhea, and vomiting. Starting this drug at a low dose and increasing it slowly can help combat the nausea. Symlin can also cause a drop in blood sugar (hypoglycemia) if you don't adjust the amount of insulin you're taking.

Exenatide (Byetta)
What it is: This diabetes drug’s discovery comes from an unlikely source -- the saliva of the Gila monster, a huge desert-dwelling lizard. Byetta is actually a man-made version of a hormone called glucagon-like peptide-1 (GLP-1), which is found in Gila monster spit. Your intestines normally release this hormone when you eat.