Saudi Pharmaceutical Journal, Volume 26, Issue 4, May 2018, Pages 487-495. https://doi.org/10.1016/j.jsps.2018.02.010

A qualitative study exploring patients’ experiences regarding insulin pump use

Zahra Alsairafi1, Felicity Smith2, Kevin Taylor2, Fatemah Alsaleh1 and Abdulnabi Al Attar3

1From the Department of Pharmacy Practice, Kuwait University, Hawalli, Kuwait

2From The Department of Pharmacy Practice, UCL, Brunswick Square, London

3From the Ministry of Health, Al Amiri Hospital, Kuwait

Correspondence should be addressed to Zahra Alsairafi, Department of Pharmacy Practice, Kuwait University, Hawalli, Kuwait, Email: Zahra.alsairafi@hsc.edu.kw

 

Abstract

Here, we studied the views and experiences of adults with type 2 diabetes regarding the use of insulin pumps, and compared their use with traditional methods of insulin delivery such as vials and syringes or insulin pens. Also, there was a special interest to understand whether insulin pumps helped patients to improve their adherence to doses or they introduced new difficulties towards medicine-taking behaviour. Insulin pump is a medical device that is used to administer insulin for the management of type 1 diabetes; also known as continuous subcutaneous insulin therapy. Recently, insulin pumps’ use has been expanded to include patients with type 2 diabetes. However, studies regarding their effectiveness, safety, advantages and disadvantages, particularly for this type is lacking. Understanding patients’ perspectives and experiences about their use would assist in addressing the disadvantages and improving delivery of care to patients. Also, it would help new patients to interpret the challenges in using such therapy. However, due to the small number of adults who use insulin pumps for the management of type 2 diabetes, there were only eight participants in this study. Six females and two males with a mean age of 38 years, participated and shared their experiences surrounding insulin pump use. The method used to obtain patients’ views was semi-structured interviews, which allowed to gain the most valuable data by asking patients open questions that allowed them to explain their perceptions and enabled the researcher to explore further the responses. Data analysis was performed by using MAXQDA-11 software and revealed different codes and sub-codes [Figure 1]. Results revealed that insulin pumps are effective in improving patients’ quality of life and glycaemic control as a result to improved satisfaction and adherence to doses.  Studies on larger samples are needed; such studies could potentially reveal the significance of expanding such therapy to this group of patients.

PMID: 29844719

 

Supplement

Insulin pumps are mostly recommended for patients with type 1 diabetes in several countries around the world, supported by the extensive evidence on their effectiveness particularly for this type (Reznik et al., 2014). The National Diabetes Information Service Insulin Pump Audit reported 35 patients with type 2 diabetes using insulin pumps in England in 2009 versus 5,667 patients with type 1 diabetes. In Turkey, 99.5% of pump users have type 1 diabetes. Findings of this study suggest that insulin pump therapy for adults with type 2 diabetes, who were poorly controlled on insulin injections and pens, can be effective overall. In the current study, all the participants who had valid clinical data achieved good glycaemic control, manifested by HbA1c readings of 7.5% or less. In addition, the participants reported that the achievement of target blood glucose levels was easier with the pump compared to injections and pens, and that control was maintained longer. When Reznik and colleagues (2014) examined outcomes for HbA1c in patients with poor glycaemic control randomised to either insulin pump or MDI, significant reductions in HbA1c levels for the insulin pump group (55%) compared with the MDI group (28%) were reported. Because insulin resistance is a major component of type 2 diabetes, especially in obese patients, the achievement of target levels with insulin pumps could be attributed to the enhancement of insulin absorption and sensitivity. In light of data provided by that study, insulin pumps should particularly be considered in patients with type 2 diabetes, who have consistently experienced challenges in achieving glycaemic targets. However, some researchers showed conflicting results, where both therapies, insulin pump and MDI, found to be equally effective in improving HbA1c levels (Herman et al., 2005). In addition, those researchers indicated that the safety profile was similar for both therapies, and that insulin pumps were not superior to MDI, especially in patients who were able to control their glycaemic level well with daily injections. This indicates that insulin pumps may not be required in some patient groups.

However, in the current study, there were cases of delayed achievement of glycaemic control. Also, there were cases in which the participants experienced hypo-/hyperglycaemic episodes during the pump therapy. Based on reports from the participants, the episodes were fewer in frequency and severity compared to those that occurred with injections and pens. In addition, the majority of participants noticed improvements in their awareness of hypoglycaemic episodes on insulin pumps. Results of this study are consistent with Berthe and colleagues’ study (2007), where reduced rates of hyperglycaemia were reported with insulin pump. Experiencing less hyperglycaemia on insulin pumps could be attributed to the easier access to insulin due to being attached all the time, so that doses are less likely to be omitted. The results on reduced hypoglycaemic episodes on insulin pumps might be predictable because the continuous delivery of insulin with the pump simulates the work of pancreas of normal persons who do not have diabetes (Berthe et al., 2007). Traditional delivery of insulin with injections or pens cannot simulate the body in the same way, and larger doses are injected daily over periods of time, in which probability of hypoglycaemia increased (Barnard and Dixon, 2010). This was supported in this study by reports of some participants who identified reasons for experiencing poor glycaemic control on insulin injections and pens, which were related to lack of awareness in calculating doses according to meals and body requirements, in which the participants were injecting either less or more insulin than what did they actually need. However, results found by other researchers reported less hyperglycaemic episodes on insulin pumps, but no significant differences in the occurrence of hypoglycaemia between insulin pump and MDI groups (Raskin et al., 2003; Herman et al., 2005; Reznik et al., 2014). Exploring why glycaemic control was not achieved promptly, and at all times, in the current study revealed different reasons that are related to the pump technology, insulin basal rates, non-adherence to diet, and pregnancy.

The most prevalent clinical problem associated with insulin pumps among the participants was weight gain (n=5) followed by bruising, and inflammation at the administration site (n=4 and 1, respectively). Barnard and Skinner (2007) reported a small possibility of marking and scaring at cannula insertion sites with insulin pumps. However, based on reports from the participants in the current study, bruising and inflammation resulted from administering injections or pens were worse than those caused by the pump, also, they could resolve it by changing the infusion site. Similarly, Raskin et al. (2003) reported episodes of skin reactions, such as redness or soreness with insulin pumps, which were mild and resolved spontaneously by patients. Regarding the findings of weight gain in this study, these were consistent with the results of Wolff-McDonagh et al. (2010), who noticed significant increase in BMI of patients with type 2 diabetes after the initiation of insulin pump therapy. Use of insulin in general leads to hyperinsulinemia and weight gain due to increased appetite and low thermogenesis (Russell-Jones & Khan, 2007). However, continuous delivery of insulin could result in better control using less insulin, and thus, causing less weight-gain (Wainstein et al., 2005). Examining factors that contributed to weight gain in most participants of the current study revealed that lack of nutritional awareness, health beliefs and lifestyle were major reasons for gaining weight on insulin pumps. To further explain and validate these factors, a comparison between the affected group and the non-affected one was performed, and the following results were obtained. Participants who gained weight on the pump lacked the awareness of carbohydrate counting. Participants were misunderstanding the importance of this task, and were either not counting carbohydrate or counting calories instead. Not counting carbohydrate could lead to consuming more carb from food, and consequently increases bodyweight (Johnson, 2000). In addition, some participants believed that cutting down sugar is enough to maintain glycaemic control and bodyweight, and they were consuming the other elements of nutrition, such as carbohydrate, fat and protein as usual. Other kind of belief, which was raised by some participants, was the belief in the efficacy of the pump, and the accuracy of its insulin dosing. Having this belief in mind along with achieving improved glycaemic control with less complications encouraged patients to enjoy eating as normal persons, who do not have diabetes. Non-adherence to diet and exercise was prevalent among the participants who gained weight. Consumption of calories more than burning them increases bodyweight, while regular and moderate physical activity helps in losing weight (Lee et al., 2010).

Moreover, this study suggested that insulin pumps were almost convenient during sleeping and exercising, and caused no problems. However, in half of the cases, insulin pumps were found inconvenient in wearing particular clothes. The participants provided conflicting point of views; some participants found the pump more suitable with traditional dresses (Dishdasha for men and Abaya for women), as it would be well covered, in which the sense of self-consciousness would be reduced. Others found it uncomfortable to wear the pump with traditional dresses, as they preferred to clip it in a trouser or a skirt rather than using its belt. However, the public image of being noticed due to wearing the pump was raised in three cases. Those participants explained that the pump was visible, annoying, and looked unacceptable in wearing particular clothing, e.g. dresses for women and jeans and t-shirt for men. In this study, women were more concerned about body image than men (2 women versus a man). This could be because females are more concerned about body esteem and fashion inconveniences than males. Conflicting results were equally obtained regarding the suitability of the pump for travelling. Some participants found insulin pump more suitable for travelling due to achievement of good glycaemic control, improvement of general health, and the convenience of the pump for transport. In contrast, insulin pumps were disadvantageous during travelling due to the difficulties experienced in some airports, and the unsuitability of the pump in wearing casual clothes. Use of insulin pumps had no impact on family members [Figure 2]; most families were neither worrying about the patient nor involved in the management responsibilities. In some cases, worrying and helping of family members were even reduced compared to insulin injections and pens. Achieving good glycaemic control, improving general health, and causing less hypoglycaemic events were all contributed to reduce anxiety and help of some families, in terms of reminding the patient about doses administration, and taking care of the patient when experiencing hypoglycaemia.

Although use of insulin pump was associated with many tasks, participants in this study showed better adherence to doses compared to insulin injections and pens. The improved adherence of most participants was attributed to the improvement in their satisfaction. Reduced burden of dose tracking and scheduling, and enhanced flexibility leaded to improved adherence. Researchers reported the advantages of insulin pumps as having more flexibility, better freedom, ease with meals, and consequently better quality of life (Didangelos and Iliadis, 2011). In addition, reduced side effects with insulin pumps relieved patients from fear of needles, and contributed to better satisfaction and adherence as well. In this study, most cases found the pump more convenient, and consistent with daily routines than injections and pens, which were associated with greater workload and side effects. These results are consistent with Reznik et al.’s study (2014), which concluded that insulin pumps were more convenient and flexible than injections. However, Herman et al. (2005) in their study, which compared the satisfaction of older patients with type 2 diabetes using insulin pumps with those using MDI, revealed a high level of satisfaction in both groups.

However, although there were some caveats involved in utilising insulin pump therapy, this study reported an overall better glycaemic control, quality of life, satisfaction and consequently adherence of patients who were poorly controlled on insulin injections and pens. The main alert raised in this study was weight gain. Weight gain may consequently lead to obesity, which can exacerbate the ability of patients to achieve good glycaemic control. However, the health benefits of insulin pumps, which perceived in this study, outweigh the potential of weight gain. Because glycaemic control is a crucial issue for maintaining health and preventing development of serious complications, there is an impetus to ensure that those having difficulties achieving target HbA1c levels are provided with the resources needed to better accomplish these goals. In patients experiencing difficulty controlling their blood glucose targets, insulin pump therapy may provide the most effective tool for achieving these goals. In addition, glycaemic control is associated with better quality of life, which is an important health outcome, measured by perceived physical and mental well-being (Rubin, 2000). Complications of diabetes and adherence to treatment are essential for achieving and maintaining glycaemic control.

 

 

Figure 1: Codes and sub-codes emerged from the interviews

 

 

Figure 2: Impact of insulin pump use on family members, the reasons of that impact and their frequencies

 

References 

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