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06-13-2017 | Hypoglycemia | Editorial | Article

Is it harder to treat diabetes today?

Author:
Jay Shubrook

Disclosures

This has been an exciting time in the world of diabetes. In the last 15 years there has been an explosion in the number of new medications that address many of the ominous octet associated with the pathophysiology of type 2 diabetes. This must have made it easier to treat diabetes? Unfortunately this is not the case, as treating type 2 diabetes has become so complicated. Why is this so?

Diabetes is consuming our practices

Diabetes is becoming an increasingly frequent chronic disease, affecting one in nine adults in the USA. It is projected that diabetes will affect one in three adults in 2050 [1]. This means that we will need to shift our care from acute symptom-based care to chronic disease management, a paradigm shift in practice. To survive in this environment we need to change the way we provide care. This shift must occur in patients as well as healthcare teams. 

Why is it so complicated to treat diabetes?

When I was trained, we believed that type 2 diabetes was caused by a combination of insulin resistance and inadequate insulin secretion. With this in mind, we merely had to find a way to improve the body’s sensitivity to insulin or to help it secrete more. While these treatments clearly improved glucose levels we now know that it did not change the progression of the disease. There is now widespread support for the ominous octet, first described by DeFronzo et al. [2, 3], to explain the pathophysiology of type 2 diabetes (inadequate insulin secretion, excessive glucagon production, abnormal incretin effect, excessive hepatic glucose production, abnormal lipolysis, abnormal renal glucose reabsorption, decreased insulin sensitivity in the periphery, and abnormal satiety signals), but even this may be expanded [4]. As our understanding of the pathophysiology of diabetes has expanded, we find ourselves unsure which aspect is the most important to treat and if this differs between individuals.

To match our expanded understanding of pathophysiology, we have new medication classes to address each of these defects. In my tool box I had three sulfonylureas, two thiazolidinediones, a couple of formulations of metformin, and human insulin. Most people ended up on all three oral medications, so order was less important. However, we now have more than 50 medication choices in diabetes among the 12 classes of medications. While this may be manageable for a doctor who only treats diabetes, this is completely overwhelming for physicians that treat many diseases.

Guidelines and formularies do not match

The good news is that we have recommended treatment guidelines from major medical organizations. The American Diabetes Association [5], American Association of Clinical Endocrinologists [6], American Family Physicians [7], and the American College of Physicians [8], and the Canadian diabetes guidelines [9] all have recommended treatment algorithms to help us navigate the maze of medications. Unfortunately, these guidelines are different from each other, which adds confusion, and medication formularies have become more restrictive so we may not be able to follow a guideline if the medications are not available.

We need more time not less

Office visits have become so complicated. In addition to taking the patient-centered history, we are expected to meet the preventive guidelines, have a continually expanding number of "vital signs", and there are often multiple agendas for any given visit. Most patients have some cost sharing in a visit and they want to get their money’s worth whilst getting their problems addressed. Rarely do patients come in to get their diabetes under better control, and so we need to make the shift from symptom management to disease management, and at least to complication prevention if not disease prevention.

Ways to make diabetes less overwhelming 
1. Diabetes needs at least four visits per year.
2. Stagger your diabetes visit focus.
3. Install a glucose meter download station in your office.
4. Let glucose logs help you decide on treatments.
5. Pick one guideline to follow.

1. Diabetes needs at least four visits per year

Let your patients know that managing diabetes is important and it requires special attention. If a patient is coming for a diabetes recheck and they have an acute complaint that they want addressed you can change the focus to their acute problem and reschedule the appointment to follow soon after. 

There are so many things to address with diabetes: healthy lifestyles (eg, eating healthy, staying active, getting enough sleep), monitoring glucose, problem solving for high and low blood glucose, healthy coping, taking medications, and risk reduction [10].

2. Stagger your diabetes visit focus

By having staggered themed visits it is easier to remember all of the diabetes treatment components. For example, in the spring, I focus on cardiovascular risk reduction (statin, aspirin, etc.) as many people are emerging from winter and want to pick up their activity. In the summer, I might also focus on hypoglycemia and adherence to medication regimens as many people have different schedules in the summer and, with more activity, are at greater risk for dropping low. In the fall, I focus on preventive screening (retinopathy, nephropathy, and neuropathy) and vaccines as these sometimes require an appointment for a specialist or an additional lab test. In the winter, I focus on healthy adjusting to diabetes, including screening and treating depression, diabetes distress, and major adjustments in life situations. This, of course, is rather simplistic and not comprehensive but if there are items that are harder for you to include in your patients' care then it is possible that a schedule will help.

3. Install a glucose meter download station in your office

A written log of people's home blood glucose monitoring can take a while to identify treatable patterns. A download station can allow the office to take a large amount of information and have it organized quickly into discernible patterns. Most of the meter companies would be happy to provide you with a cable and the software to enable you to download information in your office. The meter can be downloaded by a medical assistant so that when you walk into the room you have already obtained information about the number of times the person is checking their glucose, what the range of their glucose readings is, and if they are having any hypoglycemic episodes. Even better, some clinicians have patients download their meters at home and bring the printout with them to the office. In my experience this saves me 5–10 minutes per patient. In a day full of diabetes this saves me a couple hours per day.

4. Let glucose logs help you decide on treatments

Once you have the glucose readings you can discuss the patterns with the patient and discuss how these readings help them to make adjustments. Further, the patterns can help you to know whether you need to address fasting or post-prandial hyperglycemia or hypoglycemia. This allows you to target your approach specifically to the problems you see, including lifestyle and medication changes.

5. Pick one guideline to follow

When you select a treatment, pick one preferred guideline and get to know one main medication in each class. Each of the guidelines are helpful and will provide you with a structure to help make treatment decisions. I prefer to group my medications together in terms of glucose effect and in terms of risk of hypoglycemia: insulin sensitizers (metformin and thiazolidinediones), glucose-independent insulin secretagogues (sulfonylureas and meglitinides), glucose-dependent insulin secretagogues (incretin agents such as dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists), glucoretics (sodium-glucose co-transporter-2 inhibitors), all other agents which I and many others use less of (alpha-glucosidase inhibitors, dopamine agonist, amylin mimetic, colesevelam), and finally insulin.

While helping people manage diabetes will still be challenging I hope that taking these steps may make this process just a little bit easier.

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