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Diabetes in the modern age

How many of you are initiating insulin in primary care now? How many of you would like to do that if you had the right training and skills? Those of you who have already trained, was the training sufficient and did you get the support you need in order to gain confidence in your new competencies?

I trained six or seven years ago, with the support of Sanofi Aventis, who sponsored the Warwick-based 'Insulin for Life' course in our locality. As I was working in a very large practice and had a large number of patients with diabetes, I readily gained plenty of experience. However, I now realise how limited that training was, and for some time I only ever felt able to use the long-acting insulin analogues for my patients.

Following a second part to this training a year later, I grew in confidence, and I felt able to initiate a wider variety of insulins. Of course now, we are being constantly pressured to use the older human variety of insulin, because they are much cheaper.

How do you manage this aspect of diabetes care? When do you think is the appropriate time to start a patient on insulin therapy? When I was starting out after that training, most of my patients had an Hba1c above 9.5%, and this makes it hard work to get the insulin dose to be sufficient to being that down to a more normal range of 6.5%-7.5%. Now I do not wait so long, as I know that the higher the Hba1c when you start with insulin the harder the work to bring it down.

What do patients feel when we suggest it is time for them to start insulin therapy? From my experience, many of them will feel they have failed when they reach the point of commencing insulin therapy.

How many are wary of giving themselves injections? Something I learnt at 'Insulin for Life' is that when training a person to give insulin injections, it is absolutely vital, to get them to give themselves a dummy injection (two units approx) while in the surgery. It is amazing how many are extremely surprised at how painless the procedure is. I have always done this, and know that having taught them about all aspects of insulin management, they will feel far more confident in continuing to do this at home, having actually experienced giving themselves that first injection.

How do you think your patients would react, if soon after diagnosis, they were advised to go on insulin therapy for approximately three months? As part of a study I am doing, I have been learning about the use of  insulin for three months, and how this preserves beta cell function, and not just in the short term. There have been a few studies looking into this. Would any of your patients be willing to try this do you think?

Out of interest, how are your patients able to contact you, for advice, particularly when titrating insulin doses? Do you have regular phone consultations with them? I have encouraged patients at my current surgery to always phone me at the practice if they are concerned about their diabetes or some aspect of their treatment. If I am busy at the time they call, I endeavor to phone them back later during my work time.

I am now hoping to enable them to contact me via email, through our surgery website which will have a diabetes page, so that I can respond that way. We live in an electronic age, and we need to provide our patients with the means to access support by those means.