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Supporting insulin initiation in type 2 diabetes in primary care

The global epidemic of type 2 diabetes demands innovation in care delivery, and supporting and embedding insulin initiation in routine primary care practice is an important first step in achieving glycaemic targets.

The global epidemic of type 2 diabetes demands innovation in care delivery. Guidelines recommend early adoption of insulin as part of a stepwise treatment to bring glycated haemoglobin (HbA1c) below the target of 7% (53mmol/mol) to reduce long-term complications.


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Supporting and embedding insulin initiation in routine primary care practice is an important first step in achieving glycaemic targets and reducing referrals to costly secondary care. Insulin use is often delayed, particularly in primary care. This delay can be related to professional factors, such as fear of hypoglycaemia or concern about lack of time, or to a patient’s psychological resistance to starting insulin.

Delaying insulin use when clinically indicated is neither ethical nor effective, but health systems will not cope with demand if initiation of insulin remains anchored in specialist centres rather than with nurses in primary care. The Stepping Up model of care trains nurses to improve their knowledge, skills and confidence in initiating use of insulin as part of routine care.

This study randomised primary care practices that had at least one patient with HbA1c levels above 7.5% on maximal oral treatment. Providing education and support to nurses in the intervention group saw an increase in the number of patients starting insulin when compared with the control group. This resulted in improvements in HbA1c with no reports of hypoglycaemic events or worsening of emotional well-being.

The researchers conclude that, with appropriate support, insulin initiation can become part of routine diabetes management in primary care, reducing the need to refer to costly specialist services and the risk of long-term complications.


Furler J, O’Neal D, Speight J et al (2017) Supporting insulin initiation in type 2 diabetes in primary care: results of the Stepping Up pragmatic cluster randomised controlled clinical trial. BMJ. 356:j783. doi:10.1136/bmj.j783.

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