Table 3.

Patient barriers [39–43]

Concern	Panel recommendations
Fear of needles or apprehension toward injections Feeling that insulin is too complicated [3, 11, 16, 33, 44]	Demonstrate injection technique: show the insulin pen and small needle tips. Apply the principles of systematic desensitization (self-controlled exposure) Highlight that the injection is into subcutaneous tissue, not a vein Invite patient to try these without insulin, in your office (i.e., dry injection); give first injection together with patient to observe, support and ensure correct administration of insulin Educating on injections: see http://www.fit4diabetes.com/canada-english/fit-recommendations/
Feeling that this is a personal failure [3, 11, 16, 33, 45]	Pro-action. Do not wait to talk about insulin once the patient needs insulin. Explain from the time of diagnosis that insulin is a likely treatment option in the course of T2D [46] Discuss with the patient, using decisional balance analysis (pros and cons), that need to advance therapy is due to the progressive nature of diabetes, not because the patient has done something wrong
Belief that insulin causes diabetes complications [3, 11, 16, 33]	Insulin is a natural hormone and a replacement therapy [42] Explain why insulin becomes necessary for most patients with diabetes eventually; it is not a punishment [46] Explain that use of insulin will help achieve glycemic target and minimize the risk of complications [47, 48]
Concerns over hypoglycemia (BG < 4.0 mmol/L) [3, 11, 16, 33, 49–52]	Reassure the patient that most hypoglycemic episodes are mild. Severe hypoglycemia (defined as requiring assistance by another person) is relatively rarea [52] http://guidelines.diabetes.ca/browse/chapter14; [53] http://guidelines.diabetes.ca/browse/chapter13; [20, 29, 42, 47, 54] Educate the patient on how to recognize and respond to symptoms [52] http://guidelines.diabetes.ca/browse/chapter14 Make sure the patient and partner/family (if applicable) know how to recognize, treat, and avoid hypoglycemia, and how to self-adjust insulin [34] Choose insulins and regimens with lower rates of hypoglycemia [14, 29] Use systematic desensitization to allow the patient to work from a psychologically safe zone to a medically safe zone
Concerns over weight gain [3, 11, 16, 33]	Encourage healthy diet and moderate exercise. Monitor weight. http://guidelines.diabetes.ca/fullguidelines Combine insulin with metformin or other NIAHA with weight benefit. http://guidelines.diabetes.ca/cdacpg_resources/CPG_Quick_Reference_Guide_WEB.pdf [14, 29] Explain that weight gain with basal insulin regimens is small especially with newer basal insulin analogues (1–2 kg) [14, 20, 26–29, 32]
Belief that insulin can never be stopped and will restrict lifestyle [3, 4, 16, 33, 42]	Offer a 3-month trial period with subsequent reassessment. http://guidelines.diabetes.ca/fullguidelines Recall that engaging the patient in the decision empowers them and leads to better outcomes [3, 4] Prescribe once-daily basal insulin that minimizes inconvenience and is easy to use. http://guidelines.diabetes.ca/bloodglucoselowering/insulinprescriptiontool

NIAHA non-insulin anti-hyperglycemic agent, BG blood glucose

^aIn UKPDS, the annual incidence of severe hypoglycemia in insulin-treated patients was < 3%. With the newer long-acting basal insulins this is even lower (2.3%) [47]