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ORIGINAL ARTICLE
Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 65-68  

Assessing the adherence to insulin therapy and the effect of injection pain on insulin adherence among type 2 diabetes mellitus patients


Department of Clinical Pharmacy, College of Pharmacy, University of Baghdad, Baghdad, Iraq

Date of Submission17-Apr-2019
Date of Decision15-Jun-2019
Date of Acceptance14-Aug-2019
Date of Web Publication20-Jul-2020

Correspondence Address:
Dr. Ehab Mudher Mikhael
Department of Clinical Pharmacy, College of Pharmacy, Baghdad University, Baghdad
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpnr.JPNR_8_19

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   Abstract 


Background: Nearly all type 2 Diabetes Mellitus (DM) patients need eventual treatment with insulin at some point in their life. One of the major problems that lead to failure of insulin therapy is lacking medication adherence, which is common among type 2 DM patients. Therefore, this study aimed to assess adherence to insulin therapy and the effect of insulin injection pain on insulin adherence among type 2 DM patients. Methodology: A cross-sectional pilot study was conducted on a convenient sample of 63 type 2 DM patients at the National Diabetes Center, Baghdad, Iraq, from November 2018 till March 2019. A direct interview with each patient was conducted to assess the pain of injecting insulin through the use of a visual analog scale and to assess medication adherence using Medication Adherence Questionnaire, besides assessing patient's techniques to reduce the pain of injecting insulin. Results: The majority (81%) of the participants adhere to their insulin therapy; however, only a few (22.2%) of them adhere completely to their insulin therapy. There was a significant inverse correlation (R = −0.253; P = 0.045) between the degree of pain for injecting insulin with insulin adherence. In addition, the degree of pain reduced statistically significantly (R = −0.346; P = 0.005) by practicing proper injecting techniques; however, the practice of these techniques can only modestly improve patient adherence to insulin therapy (R = 0.214; P = 0.092). Conclusion: Improper practice of insulin-injecting techniques can lead to a greater degree of pain and eventually reduce adherence to insulin therapy.

Keywords: Adherence, injection pain, insulin, Iraq, type 2 diabetes mellitus


How to cite this article:
Mikhael EM, Al-Rubaye MH. Assessing the adherence to insulin therapy and the effect of injection pain on insulin adherence among type 2 diabetes mellitus patients. J Pharm Negative Results 2020;11:65-8

How to cite this URL:
Mikhael EM, Al-Rubaye MH. Assessing the adherence to insulin therapy and the effect of injection pain on insulin adherence among type 2 diabetes mellitus patients. J Pharm Negative Results [serial online] 2020 [cited 2020 Aug 4];11:65-8. Available from: http://www.pnrjournal.com/text.asp?2020/11/1/65/290210




   Introduction Top


Diabetes mellitus (DM) is a highly prevalent metabolic disease, and its incidence has increased substantially in the Middle East region, especially in Iraq during the last decades.[1] Although there are many types of DM, type 2 DM is the most common one.[2] Type 2 DM occurs mainly due to resistance to insulin action and is characterized by hyperglycemia.[2] If left untreated, diabetes can cause many complications;[3] some of the acute complications include hyperosmolar hyperglycemic state and less commonly diabetic ketoacidosis, whereas long-term complications include cardiovascular disease, stroke, chronic kidney disease, foot ulcers, and retinopathy.[4] Thus, managing diabetes is essential to reduce morbidity and mortality through controlling blood glucose level.[5] Although many oral and injectable medications are available for the initial treatment of type 2 DM, nearly all of these patients need eventual treatment with insulin at some point in their life.[6] One of the major problems that lead to failure of insulin therapy is lacking medication adherence, which is common among type 2 DM patients.[7] There are many factors that reduce medication adherence, but it seems that injection pain is the major factor in reducing adherence to insulin therapy.[8] Some techniques such as modifying specific needle features (e.g., reducing the needle diameter) and choosing an optimum injection angle are effective methods to minimize the pain of injection.[9] To the best of our knowledge, till now, no study has been conducted in Iraq to assess the adherence to insulin therapy among type 2 DM patients and thus, this study aimed to assess adherence to insulin therapy and the effect of insulin injection pain on insulin adherence among type 2 DM patients.


   Methodology Top


A cross-sectional pilot study was conducted on a convenient sample of type 2 DM patients at the National Diabetes Center, Baghdad, Iraq, from November 2018 till March 2019. Patients who had lipohypertrophy at multiple injection sites, cognitive impairment, and depression were excluded from the study. All recruited patients were informed about the aim of the study, and only those who provided their verbal informed consent were included in this study.

The sample size for this study was set at 68 to ensure a margin of error at 10% and the confidence level was set at 90%; the sample size was calculated using an online calculator “http://www.raosoft.com/samplesize.html.” However, only 63 patients completed this study [Figure 1].
Figure 1: The recruited sample

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Ethical approval for this study was obtained from the local ethical committee at both University of Baghdad – College of Pharmacy – and the National Diabetes Center. The main author of this study performed a direct interview with each patient to collect information about patients' demographics and to assess pain of injecting insulin through the use of a visual analog scale (VAS) (0–10)[10] and to assess medication adherence using the Medication Adherence Questionnaire,[11] besides assessing patient's techniques to reduce pain of injecting insulin through filling a special checklist that was developed based on the American Association of Diabetes Educators recommendations.[12] Patients who achieved 100% of points were considered to have an optimum practice while those with less than 50% of points were considered to have a poor technique. All other scores were considered as fair technique.

Statistical analysis

Data input and analysis was done using Statistical Package for Social Sciences (SPSS), version 17, Chicago). Categorical variables were presented as number and frequencies, whereas continuous variables were presented as mean ± standard deviation. Kolmogorov–Smirnov test was used to evaluate the normality of distribution for continuous variables. Spearman's rho test was used to test the correlation between abnormally distributed continuous variables. Chi-square test was used to measure the difference among categorical variables. P < 0.05 was considered statistically significant.


   Results Top


[Table 1] shows that the average age of the participants was 57.56 years, with an average of 13.85 years of being with diabetes and 4.47 years on insulin therapy. The mean score for the pain of injecting insulin was 4.37.
Table 1: Demographic and clinical data of the participants

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[Table 2] shows that there was a statistically significant inverse correlation (R = −0.253; P = 0.045) between the degree of pain for injecting insulin with insulin adherence. In addition, degree of pain reduced statistically significantly by practicing specific injecting techniques (R = −0.346; P = 0.005); however, the practice of these techniques can only modestly improve patient adherence to insulin therapy (R = 0.214; P = 0.092).
Table 2: Correlation between insulin-injecting pain and medication adherence and the effect of practicing techniques to reduce injection pain and medication adherence

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[Table 3] shows that 79.4% of the participants poorly practice the required techniques to reduce the pain of injecting insulin. In this regard, there was a non-significant difference in practicing these techniques among patients with different gender and educational level or even those with different duration of DM and use of insulin.
Table 3: Degree of practicing technique for reducing pain of injecting insulin according to different patient demographics

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[Table 4] shows that 81% of the participants adhere to their insulin therapy; however, only a few (22.2%) of them adhere completely to their insulin therapy. In this regard, there was a non-significant difference in insulin adherence among patients with different gender and educational level or even those with different duration of DM and use of insulin.
Table 4: Medication adherence according to different clinical and demographic data

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   Discussion Top


The current study showed that the majority (81%) of the participants were adherent to their insulin therapy. This finding was nearly similar to what was obtained in a Saudi (79%) study [13] and higher than that in an Ethiopian (59%) study.[14] The difference in insulin adherence between Ethiopian and Iraqi patients may be due to the difference in the used methods for assessing adherence in that study.

This study showed that there was a non-significant difference in the degree of insulin adherence among patients with different gender and educational level or even those with different duration of DM and use of insulin. A similar finding was obtained in a recent study that assessed adherence to oral antidiabetic therapy among Saudi type 2 DM patients.[15] The lack of difference by patient demographics may be reasonable especially among insulin users due to the lack in reinforcing factors such as the support to patients from health-care providers, community, and family members.[16],[17]

The present study showed that the mean score of pain while injecting insulin (using VAS score) was 4.37, which was higher than the score (1.9) among young patients with type 1 DM.[10] This finding was paradoxical because it is well known that pain scores are inversely correlated with patient age.[10] This paradoxical finding may be reasonable because most of the participants in this study failed to use the necessary techniques for injecting insulin in a less painful way, which was a common problem for all participants without regard to their age, gender, or educational level; in the same regard, as the patient's injecting technique improved, the degree of injecting pain significantly reduced. This finding was consistent with the finding of the Indian study in which most Indian patients did not inject insulin properly and thus nearly half of them suffer from pain while injecting insulin.[18] In addition, this study showed that insulin injection technique is not statistically different among participants with different educational level, this finding was in contrast to another study that showed significantly better insulin-injecting technique among highly educated patients.[19] This difference can be explained in that nearly all Iraqi patients did not receive sufficient education and counseling about the injecting technique of insulin therapy.[17],[20]

On the other hand, this study showed that there was a significant inverse correlation between the degree of pain and insulin adherence. A similar finding was obtained in other studies that were conducted in Iran [21] and Mexico.[22] In this regard, the current study failed to prove that injecting insulin properly can improve adherence to insulin therapy significantly despite its ability to significantly reduce injecting pain; this can be explained in that adherence can be reduced by many factors other than injection pain such as forgetfulness and insulin side effects such as hypoglycemia and weight gain.[23]

The main limitations of this study were the small sample size and the cross-sectional study design which preclude patients' follow-up to determine whether educating patients about the proper insulin injecting technique can really reduce injecting pain and improve adherence and eventually glycemic control.


   Conclusion Top


Improper practice of insulin-injecting techniques can lead to greater degree of pain and reduction in patient adherence to insulin therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mansour A, Al Douri F. Diabetes in Iraq: Facing the epidemic. A systematic review. Wulfinea 2015;22:258.  Back to cited text no. 1
    
2.
Kharroubi AT, Darwish HM. Diabetes mellitus: The epidemic of the century. World J Diabetes 2015;6:850-67.  Back to cited text no. 2
    
3.
Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care 2009;32:1335-43.  Back to cited text no. 3
    
4.
Abejew AA, Belay AZ, Kerie MW. Diabetic complications among adult diabetic patients of a tertiary hospital in Northeast Ethiopia. Adv Public Health 2015;2015:1-7.  Back to cited text no. 4
    
5.
Mannucci E, Dicembrini I, Lauria A, Pozzilli P. Is glucose control important for prevention of cardiovascular disease in diabetes? Diabetes Care 2013;36 Suppl 2:S259-63.  Back to cited text no. 5
    
6.
Chaudhury A, Duvoor C, Reddy Dendi VS, Kraleti S, Chada A, Ravilla R, et al. Clinical review of antidiabetic drugs: Implications for type 2 diabetes mellitus management. Front Endocrinol (Lausanne) 2017;8:6.  Back to cited text no. 6
    
7.
Donnelly LA, Morris AD, Evans JM; DARTS/MEMO collaboration. Adherence to insulin and its association with glycaemic control in patients with type 2 diabetes. QJM 2007;100:345-50.  Back to cited text no. 7
    
8.
Peyrot M, Rubin RR, Kruger DF, Travis LB. Correlates of insulin injection omission. Diabetes Care 2010;33:240-5.  Back to cited text no. 8
    
9.
Arendt-Nielsen L, Egekvist H, Bjerring P. Pain following controlled cutaneous insertion of needles with different diameters. Somatosens Mot Res 2006;23:37-43.  Back to cited text no. 9
    
10.
Hanas R, Ludvigsson J. Experience of pain from insulin injections and needle-phobia in young patients with IDDM. Pract diabetes Int 1997;14:95-9.  Back to cited text no. 10
    
11.
Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986;24:67-74.  Back to cited text no. 11
    
12.
American Association of Diabetes Educators. Insulin Injection know-how: Pro Tips (and tricks) for Easier and Better Insulin Injections. American Association of Diabetes Educators; 2017. Available from: https://www.diabeteseducator.org/docs/default-source/patient-resources/tip-sheets/insulin_injection_pro_tips_aade.pdf?sfvrsn=2. [Last retrieved on 2018 Feb 10].  Back to cited text no. 12
    
13.
Alqarni AM, Alrahbeni T, Qarni AA, Qarni HM. Adherence to diabetes medication among diabetic patients in the Bisha governorate of Saudi Arabia – A cross-sectional survey. Patient Prefer Adherence 2019;13:63-71.  Back to cited text no. 13
    
14.
Tewabe T, Kindie S. Level of insulin adherence among diabetes mellitus patients in Felege Hiwot Referral Hospital, Bahir Dar, Northwest Ethiopia, 2017: A cross-sectional study. BMC Res Notes 2018;11:295.  Back to cited text no. 14
    
15.
Aloudah NM, Scott NW, Aljadhey HS, Araujo-Soares V, Alrubeaan KA, Watson MC, et al. Medication adherence among patients with type 2 diabetes: A mixed methods study. PLoS One 2018;13:e0207583.  Back to cited text no. 15
    
16.
Inamdar SZ, Kulkarni RV, Karajgi SR, Manvi FV, Ganachari MS, Kumar BM. Medication adherence in diabetes mellitus: An overview on pharmacist role. Open J Adv Drug Deliv 2013;1:238-50.  Back to cited text no. 16
    
17.
Mikhael EM, Hassali MA, Hussain SA, Shawky N. Self-management knowledge and practice of type 2 diabetes mellitus patients in Baghdad, Iraq: A qualitative study. Diabetes Metab Syndr Obes 2019;12:1-7.  Back to cited text no. 17
    
18.
Kalra S, Mithal A, Sahay R, John M, Unnikrishnan AG, Saboo B. Indian injection technique study: Injecting complications, education, and the health care professional. Diabetes Ther 2017;8:659-72.  Back to cited text no. 18
    
19.
Basazn Mekuria A, Melaku Gebresillassie B, Asfaw Erku D, Taye Haile K, Melese Birru E. Knowledge and self-reported practice of insulin injection device disposal among diabetes patients in Gondar town, Ethiopia: A Cross-sectional study. J Diabetes Res 2016;2016:1897517.  Back to cited text no. 19
    
20.
Mikhael EM, Hassali MA, Hussain SA, Mustafa MY. Assessment of pharmacist's role in counselling and educating diabetic patients about insulin therapy. Int Res J Pharm 2018;9:65-8.  Back to cited text no. 20
    
21.
Aazami S, Mozafari M, Poorabdollah H. Insulin-related outcomes (satisfaction, pain, and adherence) among type II diabetes patients switched from syringe to insulin pen. Bali Med J 2018;7:678-81.  Back to cited text no. 21
    
22.
Bermeo-Cabrera J, Almeda-Valdes P, Riofrios-Palacios J, Aguilar-Salinas CA, Mehta R. Insulin adherence in type 2 diabetes in Mexico: Behaviors and barriers. J Diabetes Res 2018;2018:3190849.  Back to cited text no. 22
    
23.
Almaghaslah D, Abdelrhman AK, AL-Masdaf SK, Majrashi LM, Matary BM, Asiri WM, et al. Factors contributing to non-adherence to insulin therapy among type 1 and type 2 diabetes mellitus patients in Asser region, Saudi Arabia. Biomed Res 2018;29:2090-5.  Back to cited text no. 23
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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