Overcoming objections to injectable GLP-1 RAs

Type 2 diabetes is a disease caused by a progressive loss of β-cell insulin secretion against a background of underlying insulin resistance.¹ Maintaining near-normal blood glucose levels reduces the risk of complications^2,3 but many patients do not achieve glycaemic targets.⁴ Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) and insulin are recommended in treatment guidelines as effective options for intensifying therapy but injected therapies often face resistance from patients and clinicians.⁵

COMMON PATIENT OBJECTIONS

Anxiety about, and fear of injection-related pain is thought to affect 30–50% of patients. Patients are also concerned about:

• Their ability to manage injectable therapy
• Possible side effects of treatment, and
• How their new treatment will affect their quality of life.⁶

Other concerns include:

• Fear of hypoglycaemia
• Fear of weight gain
• Complexity of regimens
• Restrictions on daily living
• Feelings of failure
• Perceptions that their diabetes is getting worse.⁷

OVERCOMING PATIENT OBJECTIONS

Reassure patients that needles used for GLP-1 RA therapies are smaller and thinner than needles used for vaccinations or intramuscular injections.⁶

Have a trial run, using a dummy injection, so the patient can see how easy and painless it can be.⁷

Consider the use of a pen-injector that hides the needle from view.⁶

Strategies for overcoming injection-related pain⁶

• Discuss past experience of injections
• Identify perceptions about injectable therapy
• Select needle designs for syringes and pens that are smaller and thinner or improve ease of insertion
• Allow supervised injection rehearsals
• Suggest breathing techniques – deep breathing before the injection, forceful exhalation during injection
• Provide follow-up education and counselling as needed

Think about the frequency of administration – patients may prefer once-weekly injections to daily injections.⁸

Tell patients what to expect from treatment, including potential side effects and tips for mitigating them if they occur:9

• Gastrointestinal (GI) side effects are common but usually lessen over time.¹⁰
  • GI effects can be reduced by gradual dose titration (depending on the preparation).¹⁰
  • If you are full, stop eating! Patients should reduce their food intake if they experience nausea or vomiting,⁹ and eat smaller meals more frequently
• Injection site reactions are not uncommon. Pea-sized nodules may occur with exenatide once-weekly, but should resolve spontaneously after approximately 6 weeks.⁷
• Expectations about weight loss should be realistic – 2.75 – 3.6kgs – although greater weight loss may occur if patients eat less and exercise more.⁹

If a patient is reluctant to start an injectable treatment, suggest a 3-month trial – experience suggests that few people want to stop a treatment once they have started but the idea of using it for life can be daunting.⁷

PATIENT EDUCATION: BEFORE YOU START

• Explain the potential benefits of GLP-1 RAs – blood glucose lowering, weight loss, low risk of hypoglycaemia
• Discuss potential side effects – nausea/vomiting, diarrhoea, worsening of gastro-oesophageal reflux disease
• Warn about symptoms of pancreatitis (persistent abdominal pain) and what to do (stop injections and contact the practice)
• Demonstrate the device
• Advise about injection site rotation
• Discuss changes in other medications
• Explain sick day rules (see box)
• Follow up¹⁰

GETTING STARTED

• Allow 30 – 60 minutes for a first appointment (which may be a remote consultation) when initiating injectable therapy. Agree a date for the first injection, taking into consideration patients’ wishes.⁷
• Avoid making the appointment at the end of the week – appropriate support for a patient who needs help initially is more difficult to find over a weekend.⁷
• Demonstrate the range of devices to provide patient choice.⁷
• A simple device that does not require mixing or a separate needle (See Table) may be easier to initiate when the appointment is online or over the phone
• Assess patient’s understanding and ability to use the chosen device.⁷
• Discuss injection sites and site rotation.¹⁰
• Explain needle safety and disposal.¹⁰
• Arrange appropriate monitoring and review
  • Advise about dose titration if required¹⁰
  • Discuss blood glucose monitoring (if used with gliclazide or insulin)¹⁰
  • Suggest targets for continuation of treatment.⁷
• Follow up (by phone) after their first injection.¹⁰

SICK DAY RULES

Blood glucose levels may rise during periods of illness, even if the patient is eating less than usual. The TREND UK¹² sick day rules advise:

• Continue medication even if not eating
• If injecting a GLP-1 RA and develop acute abdominal pain, nausea and vomiting, stop the injections immediately and seek urgent medical attention
• Rest – avoid strenuous exercise
• Prevent dehydration – drink 2.5 – 3.5 litres of sugar-free fluids in 24 hours
• Treat symptoms such as high temperature with over-the-counter medicines – speak to your pharmacist
• Contact the practice if you think you have an infection – you may need antibiotics
• If possible, monitor blood glucose levels (≥4 times daily)
• You may need to adjust diabetes medication while you are ill
• Seek medical help if blood glucose levels remain higher than usual, you feel very unwell and you are not sure what to do.

References

1. American Diabetes Association. Clinical Diabetes 2020;38(1):10-38

2. International Diabetes Federation. Global Guidelines for Type 2 diabetes; 2017. https://www.idf.org/our-activities/advocacy-awareness/resources-and-tools/79:global-guideline-for-type-2-diabetes.html

3. Stratton IM, et al. BMJ 2000;321:405 https://www.bmj.com/content/321/7258/405

4. Fernandez G, et al. Curr Med Res Opin 2020;36(5):741-748

5. Santos Caviola T, et al. Clin Therapeut 2019;41(2):352-367

6. Kruger DF, et al. Diabetes Metab Syndr Obes 2015;8:49–56

7. RCN. Starting injectable treatments in adults with type 2 diabetes; 2019. https://www.rcn.org.uk/professional-development/publications/pub-007758

8. Hauber AB, et al. Value Health 2014;17(3):A255

9. Hinnen D. Diabetes Spectr 2017;30(3):202-210

10. Morris D. J Diabetes Nursing 2021;25(1):1-13

11. Milne N. Diabetes and Primary Care 2019;21:45-46

12. Trend UK. Type 2 diabetes: what to do when you are ill; 2020. https://trenddiabetes.online/trend-uk-releases-updated-sick-day-rules-leaflets/