Download Introducing and adjusting injectable insulin therapy for patients with

Introducing and adjusting
injectable insulin therapy
for patients with type 2
diabetes mellitus
Joseph M. Tibaldi, MD, FACP
D
iabetes mellitus affects more than 26 million
people in the United States,1 and the Centers for
Disease Control and Prevention projects that
more than 48 million people will have this disease
in the United States by 2050.2 Diabetes mellitus is the
leading cause of kidney failure, cardiovascular disease,
nontraumatic lower-limb amputations, and new cases of
blindness among U.S. adults.1 Despite numerous
therapeutic options, glycemic control in the United States
has not improved in recent years.3,4
Dialogue and Diagnosis // September 2012
1
One of the reasons for
this lack of metabolic
control in patients with
type 2 diabetes mellitus
(T2DM) is a continued
clinical inertia regarding
treatment intensification
and adjustment5 and an
underuse of insulin in
T2DM patients.6
Poor glycemic control may be
reflected in the failure of self-management by patients with diabetes mellitus, and inadequate intervention
strategies by clinicians.7-11 Attaining
target glucose levels under various
daily conditions—while avoiding
hypoglycemia, dramatic excursions
in blood glucose, and weight gain—
can be difficult to achieve. Physicians
need to overcome clinical inertia and
intensify therapy in an appropriate
and timely manner.7 Because T2DM
is a progressive disease, many
patients will ultimately need insulin
therapy to achieve and maintain adequate glycemic control. Insulin
remains essential treatment for
patients with T2DM after oral
therapy alone becomes inadequate.
The present article offers a case
report to highlight the need for
intensification and adjustment of
insulin therapy in patients with
T2DM. It also reviews factors that can
impact achievement of treatment
goals, challenges in adding
medications to therapeutic regimens,
and special challenges related to
ethnic minorities and patient
education.
came at the urging of his wife who
helped him realize that disease
control is important for staying
healthy. His experience with diabetes
has not been good. He had vivid
memories from early childhood of his
grandmother receiving insulin injections from his mother. His
grandmother lost her vision soon
after starting insulin. She could not
fill the syringe by herself and
required help with her therapy.
As Sam aged, he remained slim
and active. Nevertheless, diabetes
mellitus still developed in Sam. Three
years ago, when his glycosylated
hemoglobin (HbA1c) level was found
to be 7.3%, he grudgingly agreed to
begin self-monitoring of his blood
glucose levels and to take metformin
twice daily. Much to his surprise, his
glucose control improved, and his
HbA1c level was 6.3%. A year later,
despite following his nutritionist’s
suggestions and exercising even
more, Sam’s fasting plasma glucose
level (FPG) level increased, and his
HbA1c level rose to 7.7%. He initially
refused additional medications, but
he later agreed to use glipizide (a sulfonylurea), noting that he preferred a
medication that had been “tried and
true” for many years and he did not
want to take injections.
The addition of glipizide to Sam’s
therapy worked only transiently. At
the time of his follow-up to his
primary care physician, he had not
seen the doctor for 9 months because
his FPG values had remained between
220 and 250 mg/dL and he did not
want to know the next steps. He said
he did not want to “take shots” and
suffer as his grandmother had.
His physician was empathetic.
Sam’s weight was stable and his body
mass index was 24. His blood
pressure was 118/76 mm Hg, despite
Report of case
Sam is a 46-year-old Hispanic man
who presented to his primary care
physician for follow-up treatment for
his T2DM. He went unwillingly but
2
Dialogue and Diagnosis // September 2012
the fact that he was obviously upset
at the time it was measured. His
HbA1c level was 9.1%. As his phenotype was not typical for T2DM, and
his treatment had little durability
despite his significant lifestyle efforts
the consideration for atypical types
of diabetes was entertained. These
patients may be the “thin diabetics”
and often have family history of
other autoimmune diseases. Nearly
10% of adults (>35 y/o) who think
they have T2DM actually have a
slowly progressive form of T1DM.
Autoimmune antibodies (GAD65)
were ordered as was the test for
endogenous glucose production
(c-peptide in conjunction with serum
glucose). Alternatively, people from
ethnic minorities, especially men of
African descent can have a form of
T2DM that is prone to go to diabetic
ketoacidosis. This has been termed
ketosis prone T2DM or “Flatbush diabetes”—named after a street in the
Bronx in which this pattern was first
described.
Islet-cell cytoplasm autoantibodies
and glutamic acid decarboxylase
autoantibodies (GADAs) can occur in
patients with apparently typical
T2DM. Data from the United
Kingdom Prospective Diabetes Study
25, or UKPDS 2512 showed that
among patients older than 45 years,
the presence of GADAs was highly
predictive of the likelihood of insulin
requirements. In the ADOPT trial,
10% of the T2DM study population
had GAD antibodies.13
The (GAD65) antibody was negative and his c-peptide was normal
despite mild hyperglycemia (FSG
140 mg/dl).
Sam’s physician explained that in
light of his significant hyperglycemia
and the fact he has contributed so
significantly to his control that
insulin would be the safest and most
effective therapy. The physician also
Dialogue and Diagnosis // September 2012
Figure 1. Site selection
for insulin injection.
The most common injection site is
the abdomen or stomach. Other sites
that can be used include the back of
the upper arms, the upper buttocks
or hips, and the outer side of the
thighs. These sites are recommended
because they have a layer of fat just
below the skin to absorb the insulin
but not many nerves, which means
that injection at the site will be more
comfortable to the patient than
injection in other parts of the body.
Injection at these sites also make it
easier for the patient to inject into the
subcutaneous tissue.
explained that insulin has been a
“tried and true” life-saving therapy
for almost a century. Also as a
hormone replacement it may have
less side effects and drug interactions
than most oral medications.
As a side note, if Sam were not
slim and if he had a preponderance
of postprandial hyperglycemia
without an elevated fasting blood
glucose level, then the short-acting
glucagon-like peptide-1 (GLP-1)
receptor agonist exenatide would be a
treatment option. Because the longeracting GLP-1 receptor agonists lower
both fasting and postprandial blood
glucose levels, they would also be
options in this type of case, especially
if weight loss is a consideration.
However, because Sam was relatively
slim with high FPG and HbA1c levels,
insulin was his best option for therapeutic addition.
Sam was instructed regarding how
to use an insulin pen, including the
appropriate injection sites (ie,
abdomen, outer arms, and thighs).
See Figure 1. Upon placing the needle
on the pen, he was shown how to do
a 2-unit “air-shot” (ie, dialing up the
pen to 2 units and ejecting a drop of
insulin into the air to ensure that the
injection would deliver the correct
amount of insulin with no air
bubbles). When administering the
injection, he was advised to count to
6 to ensure that the full dose of
insulin was delivered prior to
withdrawing the needle from the
injection site. The needle for the pen
was short and 32 gauge. Sam was
amazed how small and thin the
needles were and was pleasantly surprised that he did not feel pain with
the injection. Part of the education
provided to Sam was to stress that the
needle should be changed with each
injection.
Sam began injecting 10 units of a
basal insulin analog every night at
bedtime. The PREDICTIVE 303 algorithm was given to Sam to enable
him to self-titrate his insulin
(Table 1).14 He had always checked
his fasting blood glucose levels daily
and was amenable to being even
more involved with his therapy, with
the assurance that he would receive
guidance from his physician.
Increased self-monitoring of blood
glucose levels gave him further feedback and a sense of empowerment.
His fasting blood sugar (FBS) goal was
between 80 and 130 mg/dL, which
was individualized to his situation
and which is a bit more lenient than
3
FPG (mg/dL)
Response
⬍80
80-110
⬎110
Reduce dose by 3 units
No Change
Increase dose by 3 units
⫺3
⫹0
⫹3
Table 1. Change in glycosylated hemoglobin levels
Patient self-titration of basal insulin analog, with dose adjustment every 3 days on basis of
fasting plasma glucose level.14,31
the clinical trial goal of 80-110 mg/dL
in the PREDICTIVE trial (see below
for discussion of American
Association of Clinical Endocrinologists and the American Diabetes Association guidelines). He was advised to
increase the insulin dose by 3 units in
his insulin dose every 3 days until his
mean FBS was in that range. Sam was
also told to continue using his oral
diabetes medications (eg, sulfonylurea) but was advised to call his
physician should he experience
hypoglycemia. Any blood glucose
level ⬍80 mg/dL necessitated a reduction of 3 units in dose. However, if
the total insulin dose exceeded 30
units, a 10% drop was recommended.
Sam returned 6 weeks later. He was
found to have achieved his FBS goal
with 36 units of insulin. He told his
physician, “Shots aren’t bad after all.”
At his next visit, 14 weeks after beginning insulin therapy, a repeat HbA1c
measurement yielded a result of
6.9%.
Unfortunately, with the first ice
storm of the winter Sam fell and
broke his leg. Without his exercise
routine, Sam’s FPG level began to rise.
On the basis of guidance from the
PREDICTIVE 303 algorithm, Sam
added another 6 units of basal insulin
to regain control over his FBS. After
the cast was removed from his leg, his
activity level increased and he was
able to reduce the basal insulin dose
to 36 units. Although Sam
experienced many changes and challenges with his medications, he
expressed confidence that he had the
4
tools to control his diabetes mellitus
as he had the flexibility to match his
medication with his life circumstances.
Sam did well for the next 2 years.
He then received a promotion at
work, and his mealtimes became
more erratic. He continued his exercise routine and followed his dietary
recommendations, but he noted that
his bedtime plasma glucose levels had
risen to more than 200 mg/dL. He
continued up-titration of the insulin
dose to lower his evening glucose
levels. The dose increased to 55 units
of basal insulin. He began noting
occasional morning (fasting) plasma
glucose values of approximately
60 mg/dL. Most upsetting to him was
that if his lunch was delayed because
of his job, hypoglycemia would
occur. He began carrying candy in his
jacket for such occasions.
On Sam’s return to his physician,
it was determined that the basal
insulin dose was excessive. Sam
agreed to add a second type of
insulin, prandial or meal time
insulin, to better cover his meal time
insulin needs and to alleviate the
hypoglycemia caused by excessive
basal insulin and to allow him to
regain control of his diabetes mellitus. The sulfonylurea was stopped. He
was given a second pen with a rapidacting insulin to take within 15
minutes of starting dinner, and he
was asked to test his blood glucose
levels before and 2 hours after dinner.
The starting dose of prandial
insulin was 6 units. Instruction was
given on how to titrate the dinner
dose every 3 days by 1 unit—until his
2-hour postprandial glucose level was
less than 180 mg/dL. If Sam were to
eat a larger meal, perhaps at a restaurant, he would take an additional 2
units to compensate for the extra
food. He would also continue during
the next 3 days to titrate the basal
insulin dose to achieve a FPG level
between 80 and 130 mg/dL. The
basal insulin dose was decreased to 45
units. Only 1 type of insulin was to
be titrated on a given day.
After these adjustments in therapy,
life quickly returned to normal for
Sam. His hypoglycemia abated, and
his glucose goals were achieved.
Considerations for
insulin therapy
Insulin should be considered for any
patient undergoing triple therapy if
his or her HbA1c levels are not at goal
for more than a few (no more than
2 to 3) months.15 The AACE
recommends insulin for patients
with HbA1c levels ⬎10%, regardless
of whether the patients are symptomatic. The AACE also recommends
insulin for patients with HbA1c levels
more than 9% above normal if the
patients are symptomatic.15
Introducing insulin
Patients’ fear, discomfort, and lack of
adherence with insulin therapy, as
well as certain societal factors, can
impact achievement of treatment
goals.16 Patients failing to initiate prescribed insulin therapy commonly
have misconceptions regarding
insulin risk. One study indicated that
35% of such patients believe that
insulin causes blindness, renal failure,
amputations, heart attacks, strokes, or
early death. Many patients see the
need for insulin as personal failure in
self-care. Common characteristics
among patients who fail to initiate
Dialogue and Diagnosis // September 2012
insulin therapy include a sense of
personal failure, low self-efficacy,
injection phobia, hypoglycemia concerns, inadequate health literacy, and
limited insulin self-management
training, as well as having health care
providers who inadequately explain
risks and benefits.17
Recent data show that patients
who are non-adherent with clinic
visits and insulin therapy are more
likely to have higher HbA1c levels and
face an increased risk for all-cause
mortality compared to adherent compliant patients.18 These data demonstrate the importance of ensuring
that patients with diabetes mellitus
are knowledgeable and comfortable
with insulin therapy.
To facilitate psychological
receptiveness to injectable treatments
among patients, physicians can
encourage patients to self-monitor
their blood glucose, they can educate
patients about acceptable ranges for
blood glucose readings, and they can
discuss HbA1c results with patients.
Providing patients with injectable
pen delivery devices and establishing
a structured program of support
during insulin initiation may also
help patients overcome their
anxieties about treatment.19 Other
factors to consider for facilitating
insulin therapy include the
following:
Basal insulin analogs
Long-acting insulin analogs (eg,
insulin glargine and insulin detemir)
are now firmly established as key
tools in the battle against diabetes
mellitus, and ongoing clinical
research is focused on treatment
strategies to maximize the benefits of
these agents. Basal insulin analogs
provide relatively uniform insulin
coverage throughout the day and
night, primarily by controlling blood
glucose levels through the
suppression of hepatic glucose
production between meals and
during sleep.20 These agents are traditionally dosed once daily, at the same
time each day. Recent data from the
Outcome Reduction with Initial
Glargine Intervention (ORIGIN) trial
showed that insulin glargine had no
positive or negative effect on cardiovascular outcomes and no association
with cancer in patients with type 2
diabetes.21
Although basal insulin analogs are
associated with a lower risk of hypoglycemia than human neutral protamine Hagedorn (NPH) insulin,
hypoglycemia is a dose-limiting
adverse effect of these agents.22
Patients using basal insulin therapy
are more likely to adhere to treatment
if they are prescribed a long-acting
basal analog (eg, detemir or glargine
vs NPH)23 and if they are able to
administer insulin using a pre-filled
pen (compared to the use of a vial
and syringe).24
Continuation of oral medications
along with basal insulin is a common
clinical practice. The use of
metformin mitigates insulinassociated weight gain and provides
another mechanism of action by
which to control hyperglycemia.
Sulfonylureas may or may not be
continued, depending on the patient
and the physician’s clinical
experience. Sulfonylureas are insulin
secretagogues, and their use with
insulin may increase the risk of
hypoglycemia in some patients.
Physicians are more likely to stop the
use of sulfonylureas as the number of
insulin doses increase; they should
certainly consider discontinuing
them regardless of the number of
insulin doses if unacceptable
hypoglycemia occurs, because the
䡲 Address the patient’s beliefs about
insulin.
䡲 Assess the patient’s insulin
experiences.
䡲 Determine the best insulin regimen
for the patient.
䡲 Determine the best delivery device
for the patient.
䡲 Educate the patient about dose
adjustment.
䡲 Adjust the insulin regimen as
necessary.
Dialogue and Diagnosis // September 2012
5
sulfonylureas are most likely the
culprits.
Patients should be counseled
about the signs and symptoms of
hypoglycemia, including hypoglycemia prevention and treatment.
Patients expressing concern about the
possibility of insulin-related
hypoglycemia should be reassured
that the risk of this condition is low
for patients with T2DM who are
treated with basal insulin analogs,24,25
even among older adults.26 This risk
is low despite the fact that patients
with T2DM, because of an innate
insulin resistance, tend to require
higher doses of insulin than patients
better tolerability than NPH insulin.27
Once-daily dosing with long-acting
insulin analogs is adequate in many
patients.13,28 Basal insulin doses
should be titrated to reduce FPG
levels to between 80 and 110 mg/dL
(according to AACE guidelines)29 or
between 70 and 130 mg/dL (according to ADA guidelines) depending on
patient characteristics.30
Results of clinical trials suggest
that patients, even those previously
naïve to injectable insulin therapy,
can safely and effectively manage
their blood glucose levels themselves
if empowered and educated to do
so.31,32 Offering patients the option
with type 1 diabetes mellitus. In the
case of Sam, if hypoglycemia were to
occur, discontinuation of the sulfonylurea would be advisable.
of a once-daily basal insulin analog
with a simple-to-use titration
algorithm is a safe and effective intervention that may address some of the
concerns of physicians related to the
complexity of initiating insulin
therapy.31,32
Regarding glucose self-monitoring,
physicians should consider urging
measurements of fasting levels and
“bracketing” 1 meal with preprandial
and postprandial measurements daily
on a repetitive basis. In addition, it
should be kept in mind that Medicare
Patient self-titration
Basal insulin is most often initially
used in patients with T2DM who fail
to achieve optimal glycemic control
with oral antidiabetic drugs. Clinical
trials have shown that addition of a
basal insulin analog to an oral regimen is capable of lowering the HbA1c
level by approximately 1.6%, with
6
allows 3 insulin measurements per
day. Patients can get more if needed
with additional documentation.
Intensification of insulin
therapy
Titration of the patient’s existing
insulin regimen is the first step in
intensification efforts to maintain
HbA1c goals. However, as T2DM takes
its natural course of progression,
treatment regimens need to be monitored and, when necessary, further
intensified to maintain acceptable
glycemic control. Physicians should
consider intensifying therapy beyond
titration of basal insulin when a
patient using basal insulin has an
HbA1c level above goal despite having
achieved the FPG target. The addition
of a sulfonylurea or an increase in sulfonylurea dose will not correct this
glycemic problem and may actually
increase the risk of hypoglycemia.
Sulfonylureas first lower FPG, then
lower PPG. Furthermore, simply
increasing the dose of basal insulin in
such a scenario is likely to expose the
patient to the risk of between-meal
hypoglycemia and persistent
postprandial hyperglycemia.
Clinical experience suggests that
the total daily insulin dose—on the
basis of unit per kilogram of body
weight—typically ranges from 0.5 to
2 units per kilogram per 24 hours for
patients with T2DM. Approximately
50% of a patient’s total daily insulin
dose is basal insulin, with the balance
allocated across mealtime glucose
spikes (ie, postprandial insulin). Thus,
if the patient has not achieved HbA1c
goals, attention to postprandial
hyperglycemia is warranted. Adding
prandial insulin to basal insulin regimens provides physiologic coverage
of insulin requirements by means of
switching to a premixed insulin
analog or addition of a rapid-acting
analog at mealtimes, as indicted in
Dialogue and Diagnosis // September 2012
Basal insulin alone
Often with oral agents
continued
Premixed insulin
once a day
Sequential addition of
prandial insulin before
meals with high PPG levels
Provides basal
and prandial insulin
in a single injection
Simple way to start
increasing number
of injections
Premixed insulin
twice a day
Basal Bolus insulin
(multiple daily injections
Consider gold standard;
allows customization
to food activity
Figure 2. Sequential insulin strategies
for patients with type 2 diabetes
mellitus.
Adapted with permission from Inzucchi SE,
Bergenstal RM, Buse JB, et al; American
Diabetes Association (ADA); European
Association for the Study of Diabetes (EASD).
Management of hyperglycemia in type 2
diabetes: a patient-centered approach: position
statement of the American Diabetes Association
(ADA) and the European Association for the
Study of Diabetes (EASD). Diabetes Care.
2012;35(6):1364-1379.
Premixed insulin
three times a day
Requires some
consistency in food
intake/exercise
Figure 2 and Table 2, provides considerations regarding which type of
prandial coverage may be most suitable for a given patient. While basalbolus insulin therapy required more
injections, it tends to increase day-today life flexibility.
Given Sam’s erratic schedule, premixed insulin is not a desirable treatment option for him. Because he will
likely need to titrate prandial insulin
doses according to meal times and
sizes, the addition of a prandial
insulin at the largest meal is the most
attractive option. Data from the Orals
Plus Apidra and LANTUS (OPAL)
trial33 showed that a single bolus of
prandial insulin analog improved
HbA1c levels when added to a basal
insulin analog and oral antidiabetic
agents (Figure 3).
Challenges in adding
medications to
therapeutic regimens
Recent data suggest that most
patients with diabetes mellitus have
negative perceptions of the initiation
of additional medications, viewing it
as evidence of personal failure and
increased burden.34 Patients equate
medication intensification with
Dialogue and Diagnosis // September 2012
increased risk for diabetes-related
complications rather than a step in
reducing risk. They view de-escalation of medication as their primary
goal. However, patients respond
favorably to an individualized medication plan outlining future contingencies.34 According to the international Diabetes Attitudes, Wishes,
and Needs (DAWN) study,35 more
than half (57%) of all patients with
T2DM are very worried about starting
insulin therapy.
Many factors contribute to this
worry. As previously noted, feelings
of failure or depression (regarding following lifestyle changes and
adherence to therapy), as well as the
sense that using insulin means that
their diabetes has worsened, may lead
to resistance to insulin therapy. Many
patients who are resistant to insulin
therapy may also be reluctant to
accept the responsibilities of everyday
management of insulin therapy.36
Insulin should be offered to patients
in a positive light—as a means to
improve their health. Reminding
them early in the disease that there
may be times insulin is needed in a
pinch, such as a critical illness or hospitalization, may help. This approach
might facilitate their acceptance of
insulin therapy. Physicians can help
patients at the time of diagnosis by
explaining that diabetes mellitus is a
progressive disease, and that changes
in therapy over the course of a
lifetime in no way reflect badly on
the patient.
Premixed Insulin
(1, 2, or 3 injections of same insulin)
Basal-Bolus Insulin
(4 injections; 2 types of insulin)
— Preference for few injections
— Fixed daily routine
— Unwilling to monitor blood glucose*
— Limited cognitive function*
— Limited healthcare support system*
— Variable meal pattern
— Variable daily routine
— Postprandial control an issue
— Able to comply with complicated
regimen (eg, willing and good
cognitive function)
— Support system available
*the last 3 apply when relaxed glucose
targets are applied
Table 2. Criteria for choosing between premixed vs basal-bolus insulin.
7
Glycosylated Hemoglobin Level, %
7.4
P = ⬍.0001
7.2
7.0
6.8
6.6
6.4
6.2
6.0
Baseline
7.32
Endpoint
6.99
Figure 3. Change in glycosylated hemoglobin levels
Change in glycosylated hemoglobin levels with addition of a single prandial dose of a
rapid-acting insulin in patients with type 2 diabetes mellitus who were treated with a
basal insulin analog and oral antidiabetic medications.33
Many patients have misconceptions about insulin therapy. Some of
these misconceptions relate to the
fact that insulin therapy was formerly
delayed until the patient had
advanced disease, often with complications. Thus, physicians may hear
that the patient’s grandmother
started insulin therapy and shortly
thereafter was on dialysis or had an
amputation as a result of peripheral
neuropathy—family experiences that
cause the patient to associate the start
of insulin therapy with a bad outcome. In Sam’s case, he associated
insulin therapy with his grandmother’s diabetic complication of
blindness.
It is important to ask patients
what they think they know about
insulin therapy. They should be
informed about advances in insulin
therapy−such as the availability of
insulin analogs that reduce hypoglycemia risks (a valid concern) and
that are convenient to dose (so as
not to pose a lifestyle constraint),
as well as the availability of insulin
pen delivery devices (which should
allay concerns about pain,
embarrassment, and worries
regarding correct dosing). All
8
patients need to understand that
in T2DM, the ability of the body to
make insulin decreases over time.
Helping patients understand the
role of insulin in the management
of T2DM and in the context of the
disease process may go a long way
to avoiding patient resistance to
insulin use.
Challenges in ethnic
minorities
to diabetes medications than are
African Americans or non-Hispanic
whites.39 Hispanics are also much
more likely to be resistant to the idea
of insulin therapy.40,41
Ultimately, minority patients with
diabetes mellitus are more likely than
white patients with this condition to
have poor long-term outcomes,
leading to such complications as diabetic retinopathy, lower extremity
amputations, and chronic kidney
disease. Increasing clinicians’ awareness of such racial and ethnic disparities and improving communication
between clinicians and minority
patients may enhance care among
these patients.39,42,43 Language
barriers may hinder adequate care by
limiting or preventing communication (including the exchange of
important cultural information) and
by leading to misunderstanding of
physicians’ instructions, poor shared
decision-making, and ethical
compromises (eg, not obtaining full
informed consent). In the Translating
Research Into Action for Diabetes
(TRIAD) study,44 23% of Spanish-
Type 2 diabetes mellitus is more
common among African Americans
and Mexican Americans than among
non-Hispanic whites, which necessitates that primary care physicians
consider culturally competent
approaches to care. Mexican Americans and non-Hispanic blacks are less
likely to achieve good glycemic
control compared with non-Hispanic
whites.37 Data from the National
Health and Nutrition Examination
Survey reveal that the disparity in
diabetes-related mortality across education levels widened from the late
1980s to 2005−both overall and in
the subgroups of men, women,
blacks, whites, and Hispanics.38 Hispanics are generally much more concerned about adverse effects related
Dialogue and Diagnosis // September 2012
speaking Hispanic patients reported
language to be a barrier in communicating with health care professionals.
Poor adherence to treatment, missed
appointments, and patient
dissatisfaction can all be attributed to
miscommunication.
Patient education and
support
The use of support groups for patients
with diabetes mellitus that focus on
management and education, creative
ways to adopt healthy foods that
complement ethnic diets, exercise
opportunities, and other advice is an
additional way to enhance self-management.45,46 Encouraging patients to
use social networks of family
members, peer support groups, community health workers, and one-onone interactive education can
improve patient resilience to
stressors. Diabetes self-management
education programs for Hispanics
and Latinos, led by community
health workers, have been implemented in a number of community
settings. These programs may
effectively improve behavioral skills,
such as physical activity and healthy
eating.47
Key learning points
䡲 Effectively educate patients with
diabetes mellitus about the progression of and treatment for the
disease.
䡲 Achieving good glycemic control
early prevents diabetic complications. The lowest possible HbA1c
level, without unacceptable hypoglycemia and untoward complications, should be attained.
䡲 Optimal glycemic control should be
maintained to minimize the risk of
diabetic complications. When
choosing the treatment option for
each patient, consider the duration
of T2DM, stage of the disease,
Dialogue and Diagnosis // September 2012
current level of control, lifestyle
habits, and attitude toward disease
management.
䡲 Intensification of treatment
requires glucose monitoring and
medication adjustment every 2 to 3
months.
䡲 Lifestyle intervention remains the
foundation of care for all patients
with diabetes mellitus, and healthy
lifestyle choices should be
addressed at every office visit.
䡲 Most patients who have HbA1c
levels greater than 7.5% will require
combination therapy with complementary mechanisms of action.
䡲 Insulin should be prescribed for all
patients with HbA1c levels greater
than 10% and for all symptomatic
patients with HbA1c levels greater
than 9%.
References
1. Centers for Disease Control and Prevention.
National Diabetes Fact Sheet: National Estimates and
General Information on Diabetes and Prediabetes in
the United States, 2011. Atlanta, GA: US Department
of Health and Human Services, Centers for Disease
Control and Prevention; 2011.
2. Boyle JP, Thompson TJ, Gregg EW, Barker LE,
Williamson DF. Projection of the year 2050 burden
of diabetes in the US adult population: dynamic
modeling of incidence, mortality, and prediabetes
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Joseph M. Tibaldi, MD, FACP, is an assistant
clinical professor of medicine at Weill Cornell
Medical College in New York, New York. Dr.
Tibaldi can be reached at [email protected].
Dialogue and Diagnosis // September 2012