Question of the week
Managing a chronic condition can be difficult, especially when juggling daily injections or complex medication routines. For patients with Type 2 Diabetes, it’s crucial to make treatment plans manageable to help them stay on track and reduce the risk of long-term complications.
In this case, a practitioner is seeking guidance on how to help a patient who frequently misses basal insulin doses, exploring strategies to simplify her regimen and reduce injection burden while maintaining optimal glycemic control.
What would your next steps be? Log in or sign up to leave a comment and see the consensus.
Patient:
• 67-year-old female
• Type 2 diabetes, diagnosed 15 years ago
Treatment History:
• Initially managed with metformin + sulfonylurea
• Transitioned to daily basal insulin 5 years ago
• Added SGLT2 inhibitor (dapagliflozin) 2 years ago
• Currently: insulin glargine 22 units daily + dapagliflozin + metformin
Recent Clinical Course:
• A1C: 8.2%
• Fasting glucose: 150–170 mg/dL
• Weight stable, BMI 29
• eGFR: 68 mL/min/1.73 m²
• No recent severe hypoglycemia, but occasional mild episodes when she doubles doses after forgetting.
Status:
• Frequently forgets daily insulin doses; admits missing ~2–3 per week.
• Finds daily injections burdensome, says it makes her “feel like a sick person.”
• Very motivated to simplify her regimen where possible.
Questions
1. For a patient already on daily basal insulin but missing several doses per week, what treatment adjustments would you consider? Why?
2. How would her challenges with adherence and burden of daily injections influence your recommendation?
Comments
Key takeaways on improving adherence in type 2 diabetes:
- Simplify the regimen
Weekly GLP-1 agonists or oral options can reduce injection burden and improve adherence, sometimes decreasing the need for multiple daily meds. - Tailor therapy to the patient
Consider lifestyle, preferences, and tools like CGM to guide titration. Shared decision-making ensures patients stay invested in their care. - Support adherence through education and reminders
Engage family or caregivers, provide clear guidance on risks, and encourage sustainable lifestyle habits to reinforce treatment success.
Family Practice
"1. This patient will benefit from weekly injections. Daily injections are too much for her to handle. A trial of a GLP1 agonist is most logical in this case. And, she does not have contraindications. Most likely, she will be able to decrease the number of her medications for diabetes because her DM control will improve on GLP1A.
2. Very much. Once a week injection is a good option for her. Oral GLP1, like Rybelsus, continues to be an option as well because it is oral. It looks like she does well with oral meds. It is only daily injections that bother her."
Endocrinology/Diabetes
"1. Add GLP-1 weekly and titrate as tolerated. Insulin can be stopped as her sugars improve.
2. If fewer injections can get her to the desired control, no problem. But the patient needs to be educated on the burden of complications so she understands the value of optimal control regardless of what regimens are followed."
Endocrinology/Diabetes
"1. Make sure she is on a therapeutic dose. It would be frustrating to take shots daily and still have an elevated fasting glucose. A CGM could help her, and a GLP-1RA, if it is not contraindicated, could be a good option, especially if it is once weekly and could help her reduce or stop insulin.
2. I think we should chat with her first. Make sure she is taking it at a time convenient for her. We would not want to blindly increase her insulin without knowing what her bedtime to am glucose delta is. Again, a CGM would help."
Internal Medicine
"1. I would recruit family members to see if they can help in reminding the patient or administering the basal insulin. Another option is to start a GLP-1 agonist once a week, but again, get the family involved to ensure the patient takes this.
2. I think if the issue is daily injections, the once-a-week GLP-1 agonist will help reduce the discomfort. After having a frank discussion with the patient regarding what she is able to do and risks/benefits, I would proceed with a change in regimen with close monitoring."
Family Practice
"1. Explain gently that she actually IS a "sick person," and thankfully her sickness can be managed very well...but she will not improve unless she is invested in the process. Start Mounjaro, titrate upwards, and explain the importance of not skipping doses. Find an exercise habit she enjoys and can stick with.
2. Hoping she can commit to once weekly injections rather than daily. Encourage her to know that she does have the power and ability to prevent/delay diabetes from ruining her heart, kidneys, vision, etc."
How would you suggest improving treatment adherence for patients with Type 2 diabetes? Review the full case on Healthcasts and leave a comment to help your peers.
