Editorial Diabetes

Insulin—Five ‘M’s that Matter

Sanjay Kalra
Department of Endocrinology, Bharti Hospital, Karnal, India

DOI: https://doi.org/10.17925/USE.2017.13.01.14

T
his editorial describes a simple and useful checklist that facilitates timely and appropriate insulin initiation and usage in type 2 diabetes.
The ‘five Ms’ (5Ms) mnemonic list facilitates timely insulin use by breaking the process down into five ‘M’s: match, motivate, method,
monitor, and modify. The 5Ms approach conveys the need to match the patient to the appropriate insulin regime, preparation, and delivery
device; to motivate the patient to accept insulin through a process of informed, shared decision making; to ensure the correct method of insulin
delivery by teaching injection technique; to monitor therapy by both biomedical (glycemic control, metabolic benefit) and patient reported
outcomes (quality of life); and to modify therapeutic strategy, as and when needed. This concept can be used as a teaching tool, a clinical aid,
and a practice audit.

Keywords Insulin, over its 95 years of existence, has revolutionized the management of diabetes. Previously
Clinical inertia, glucose monitoring, insulin limited to use in type 1 diabetes, extensive evidence supports its benefit in type 2 diabetes as well.1
initiation, insulin intensification, Type 2 diabetes In spite of this, insulin is not used as often as it should be. Multiple factors, both biomedical and
psychosocial, discourage the timely initiation of insulin in real-world practice.2 This inertia delays insulin
Disclosure: Sanjay Kalra has nothing to disclose in relation
to this paper. No funding was received for the publication prescription, insulin acceptance, and adherence to insulin therapy. This, in turn, exposes patients to a
of this article. This article is a short opinion piece and long duration of uncontrolled glycemia, and leads to development of vascular complications.3
has not been submitted to external peer reviewers.
Authorship: All named authors meet the International
Committee of Medical Journal Editors (ICMJE) criteria Extensive research and evidence describe the barriers to insulin initiation and intensification.4 These
for authorship of this manuscript, take responsibility barriers have been classified as patient- and physician-related, as biomedical and psychosocial, and
for the integrity of the work as a whole, and have
given final approval to the version to be published. in terms of social marketing.5 Relatively less discussion, however, informs practice, which can be used
Open Access: This article is published under the to bridge these barriers.6
Creative Commons Attribution Noncommercial License,
which permits any noncommercial use, distribution,
adaptation, and reproduction provided the original We describe the facilitators of timely insulin use as a matter of five ‘M’s (5Ms):
author(s) and source are given appropriate credit.
Received: February 6, 2017 • match;
Published Online: April 14, 2017
• motivate;
Citation: US Endocrinology, 2017;13(1):Epub ahead of print
• method
Corresponding Author: Sanjay Kalra,
Department of Endocrinology, Bharti Hospital, • monitor; and
Karnal, India. E: [email protected] • modify.

The 5Ms approach conveys the need to match the patient to the appropriate insulin regime, preparation
and delivery device; to motivate the patient to accept insulin through a process of informed, shared
decision making; to ensure the correct method of insulin delivery by teaching injection technique;
to monitor therapy by both biomedical (glycemic control, metabolic benefit) and patient reported
outcomes (quality of life); and to modify therapeutic strategy, as and when needed (see Table 1).

Patient–insulin matching
The crux of patient-centered care is to understand and respect the attitudes, wishes, and needs of the
patient, while planning management. This approach, however, needs to be accompanied by respect,
from the patient’s side, for biomedical issues and challenges, which the physician is better equipped
to appreciate.7 Based upon a comprehensive, reciprocal understanding of each other’s viewpoints,
the patient and physician can (usually) easily find an insulin regime, preparation and delivery device
which suits the patient’s lifestyle, and fulfils biomedical needs as well (see Table 2).

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Editorial Diabetes

Table 1: The five ‘M’s of Insulin therapy Table 4: Insulin technique—seven messages

1. Match: insulin to patient 1. Ensure clean injection site and hands

2. Motivate: patient to accept insulin 2. Prefer abdomen, upper thighs, and upper arms for injection
3. Prefer 4 mm pen needles, and 6 mm syringe needles
3. Method: of injection technique
4. Encourage self-inspection of injection sites and screen for lipohypertrophy (LH)
4. Monitor: glycemic and other parameters
self insulin site examination (Self IE).
5. Modify: dose, preparation, and regime as indicated 5. Inspect, palpate injection sites at least once a year, more often if LH is detected
6. Do not reuse needles, or share insulin pens, cartridges, and vials
Table 2: Matching insulin to the patient 7. Ensure safe disposal of needles and ancillary supplies

Regime Basal Premixed or basal Basal-bolus Table 5: Monitoring of insulin therapy

plus
Frequency Once daily 1–3 times daily 4–5 times daily Glucose monitoring
Glucophenotype Fasting Fasting and Fasting and • Laboratory-based blood glucose
hyperglycemia postprandial postprandial • Self-monitoring blood glucose
hyperglycemia hyperglycemia • Ambulatory glucose monitoring
Risk of Low Low-moderate High • Continuous glucose monitoring system (CGMS)
hypoglycemia • Fructosamine
Ability/willingness Low Low-moderate High • 1,25-anhydroglucitol
to monitor • HbA1c (glycosylated hemoglobin)
Patient-reported outcomes
Table 3: Motivational interviewing—the WATER approach • Quality of life
• Treatment satisfaction

W: welcome with warmth

A: ask and assess complaints, medical status Table 6: Modification of insulin
T: tell the truth, while counselling
E: explain, with empathy, the need for insulin
Modification Indication
R: reassure and ensure return
Dose titration • Mild deviation from glycemic target
• Newly begun regime
Motivation
Change of preparation, e.g.,
The process of finding a suitable match is not an easy or a short one. This
• Human to analogue • Mild deviation from glycemic target
requires a detailed two-way conversation. The physician should aim to
• Long-acting to ultra-long acting • Patient unwilling to increase dose
achieve information equipoise with the patient, regarding insulin use, its
• Premixed to dual action co-formulation frequency
benefits, risks, and costs. Simultaneously, motivation for insulin acceptance,
• Low dose premix to high mix • Glycemic variability
through effective motivational interviewing, is required (see Table 3).8
Change of injection frequency, e.g.,
This aspect of insulin prescription is also termed ‘diabetes therapy by
• Basal plus 1 to basal plus 2 • Gross deviation from glycemic target
the ear’.9 Diabetes therapy by the ear is a triptych of concepts, actions,
• Isolated postprandial hyperglycemia
or responsibilities. It involves listening to the patient in an empathetic
Change of regime, e.g.,
manner, and responding to her or his concerns in language that is easily
comprehensible. It also includes filtering of unwanted, or inappropriate • Basal to basal plus • Gross deviation from glycemic target
• Basal to premixed • Postprandial hyperglycemia
information, which may reach the patient’s ears through a variety of sources
• Premixed to basal plus
and communication channels. Therapy by ear, therefore, represents use of
the physician’s ears as a diagnostic tool, use of the patient’s ears as a route
of administration of therapy, and enhancement of the patient’s ability to site reactions quickly, and take appropriate corrective measures, while
distinguish between useful and harmful health-related information that enhancing patient confidence and satisfaction.
may reach her or his ears.
Monitoring
Method of injection It must be noted that treatment with insulin is usually a long-term affair.
Motivation needs to be accompanied by explanation and practical A single prescription cannot (and should not) be followed indefinitely. The
demonstration of method of injection technique. Use of inappropriate or physician should ensure regular monitoring of glycemic parameters, listed
wrong technique may create unwanted complications, which hamper as the glycemic pentad.11 Monitoring strategies should be decided on an
acceptance of insulin therapy (see Table 4). Comprehensive evidence- individual basis (see Table 5). Monitoring techniques and frequency may
based guidelines are available to inform the correct injection technique.10 vary according to the insulin regime being used, risk of hypoglycemia and
Insulin technique counseling needs to be incorporated in every clinic visit. glycemic variability, glycemic target, and ability of the patient to act upon
Regular audits of injection sites and insulin technique helps detect local monitoring data.

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 Insulin—Five 'M's that Matter

Modification of therapy considered if one is unable to achieve targets within six to 12 weeks, or
Diabetes management is a dynamic exercise, which needs regular re- earlier if clinical circumstances indicate.
evaluation. Dose titration—based upon results of symptoms, glucose
monitoring, and other investigations—is needed frequently. Revision of Summary
insulin regimes, and review of choice of preparations or delivery devices, The 5Ms represent a useful pedagogic tool, which will help students of
may be necessary at intervals.12 Modification of dose and regime thus diabetology improve their skills in insulin usage. The 5Ms that matter also
becomes an integral part of insulin treatment (see Table 6). Dose titration form a useful checklist for diabetes care professionals. This list can be used
frequency is based upon patient and drug-related factors. Baseline glucose at each clinic visit to ensure that one has followed the cardinal rules of
level, glycemic targets, and risk of hypoglycemia/glycemic variability matching insulin to the patient, motivating and informing the patient about
influence frequency of dose titration, as does the ability of the patient or planned therapy, explaining the method of administration, monitoring
care giver to self-titrate. Drug-related factors, such as the pharmacokinetic health, and making appropriate modifications to treatment. In the long
properties of insulin preparations also impact the frequency of titration. run, this should help encourage timely insulin prescription, acceptance,
An ultra-long-acting insulin such as degludec, for example, does not adherence and persistence. This, in turn, will improve glycemic control and
require titration before a week.13 Modification of insulin regime should be prevent avoidable complications in people living with diabetes.

1. UK Prospective Diabetes Study (UKPDS) Group, Intensive blood- Attitudes of Patients and Physicians in Insulin Therapy study, Metab, 2013;17:376–95.
glucose control with sulphonylureas or insulin compared with Diabet Med, 2012;29:682–9. 9. Kalra S, Baruah MP, Das AK, Diabetes therapy by the ear: A bi-
conventional treatment and risk of complications in patients with 5. Kalra S, Sahay R, Timely insulin use: Need for social marketing, directional process, Indian J Endocr Metab, 2015;19:S4.
type 2 diabetes (UKPDS 33), Lancet, 1998;352:837. Indian J Endocr Metab, 2016;20:586. 10. Frid AH, Kreugel G, Grassi G, et al., New insulin delivery
2. Khunti K, Millar-Jones D, Clinical inertia to insulin initiation and 6. Kalra S, Ghosal S, Barriers and bridges to insulin therapy: bio recommendations, Mayo Clinic Proceedings, 2016;91:1231–55.
intensification in the UK: A focused literature review, Prim Care psychosocial classification, J Pak Med Assoc, 2017;67:320–21. 11. Kalra S, Hypoglycaemia in diabetes, J Pak Med Assoc,
Diabetes, 2017;11:3–12. 7. Tandon N, Kalra S, Balhara YS, et al., Forum for Injection Technique 2014;64:1090–3.
3. Thomas MC, Glycemic exposure, glycemic control, and metabolic (FIT), India: The Indian recommendations 2.0, for best practice 12. Kalra S, Gupta Y, Insulin initiation: bringing objectivity to choice,
karma in diabetic complications, Adv Chronic Kidney Dis, in Insulin Injection Technique, 2015, Indian J Endocr Metab, Journal of Diabetes & Metabolic Disorders, 2015;14:7.
2014;21:311–7. 2015;19:317–31. 13. Kalra S, Gupta Y, Clinical use of insulin degludec: Practical
4. Peyrot M, Barnett AH, Meneghini LF, Schumm‐Draeger PM, Insulin 8. Kalra S, Sridhar GR, Singh BY, et al., National recommendations: experience and pragmatic suggestions, North Am J Med Sci,
adherence behaviours and barriers in the multinational Global Psychosocial management of diabetes in India, Indian J Endocr 2015;7:81.

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