|Year : 2020 | Volume
| 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
Ehab Mudher Mikhael, Mohammed Hayder Al-Rubaye
Department of Clinical Pharmacy, College of Pharmacy, University of Baghdad, Baghdad, Iraq
|Date of Submission||17-Apr-2019|
|Date of Decision||15-Jun-2019|
|Date of Acceptance||14-Aug-2019|
|Date of Web Publication||20-Jul-2020|
Dr. Ehab Mudher Mikhael
Department of Clinical Pharmacy, College of Pharmacy, Baghdad University, Baghdad
Source of Support: None, Conflict of Interest: None
| 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|| |
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. Although there are many types of DM, type 2 DM is the most common one. Type 2 DM occurs mainly due to resistance to insulin action and is characterized by hyperglycemia. If left untreated, diabetes can cause many complications; 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. Thus, managing diabetes is essential to reduce morbidity and mortality through controlling blood glucose level. 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. One of the major problems that lead to failure of insulin therapy is lacking medication adherence, which is common among type 2 DM patients. There are many factors that reduce medication adherence, but it seems that injection pain is the major factor in reducing adherence to insulin therapy. 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. 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|| |
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].
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) and to assess medication adherence using the Medication Adherence Questionnaire, 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. 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.
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|| |
[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 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|| |
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  and higher than that in an Ethiopian (59%) study. 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. 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.,
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. This finding was paradoxical because it is well known that pain scores are inversely correlated with patient age. 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. 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. 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.,
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  and Mexico. 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.
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|| |
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
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]