Receiving a diagnosis of diabetes is life changing and usually overwhelming. Helping patients get off to a strong start and establishing a treatment plan for success can make all the difference for both the patient and the clinician. This chapter explores how to initiate treatment plans for adults and children diagnosed with diabetes, with special attention to key aspects of education, early intensive treatments, and the benefits of a team-based approach.
Case 1. Type 2 Adult
“Step-down therapy is better than step-up therapy.”
A 62-year-old man presents for a diabetes follow-up. He has type 2 diabetes (10 years), hypertension (12 years), and dyslipidemia (10 years). Unfortunately, he missed his last two scheduled appointments. You recall he was previously actively involved in managing his diabetes, and it had been well-controlled. He tells you today that his diabetes medications are no longer working. His blood sugars are always above 200 mg/dL and at times, after meals his meter just reads “high.” He stopped doing fingerstick glucose readings because he got frustrated by how high his readings were.
He has been using the same diabetes medications for the past 2 years. He acknowledges feeling more depressed and anxious because his readings are so high. He does not understand why diabetes is different from hypertension. He has been on the same blood pressure medications for a long time, and his blood pressure has always been controlled.
Past Medical History: hypertension, type 2 diabetes, dyslipidemia, knee osteoarthritis (OA)
Family Medical History: parents deceased: mom—old age, dad—myocardial infarction (MI); two older brothers with similar health problems
Social History: lives alone (divorced 6 months ago); two adult children; breakfast is often coffee and a pastry; lunch is fast food 50% of time; dinner is preprepared meals; prior to his divorce, his wife cooked meals at home. He works for the public utilities service and is active on his job; no other regular physical activity. No tobacco, rarely alcohol.
Physical Exam
Vitals: HR 72, R 14, BP 136/82, Ht. 66 inches, Wt. 204 lb, BMI 32.9
General: truncal obesity
CV: normal
Resp: normal
EXT: pulses intact, monofilament, and vibration sensation intact. Skin and nails normal
1. What this patient is describing is a very common scenario. Type 2 diabetes is a chronic, progressive condition. The medications we use are intended to improve glycemia and reduce the risk of complications. However, current approaches to care do little to address the natural history and underlying pathophysiology of the disease state. As a result, patients often require modifications to their medication regimen over time (see box “Adding Diabetes Medications”).
The demands of successfully living with diabetes can be extremely challenging. Not uncommonly patients become frustrated and depressed when, despite their best efforts, their blood sugar readings are higher than desired. Often, in response patients will stop trying to manage their diabetes. They no longer perform fingerstick glucose readings and may stray from their diet. Many people find that the work of taking care of their diabetes has become too overwhelming.
For this patient, the first step is to normalize his experience. We can acknowledge the patient’s frustration that he continues to take his medication but does not necessarily see the benefit. Most diabetes medications (including the ones he is taking) will lose their efficacy over time. In addition, his diet has changed considerably since his divorce. Therefore, it is not surprising that his glucose levels have been climbing.
The next step is to help him gain a better understanding of what is going on with his diabetes while not overwhelming him with too much information. There is some good news that could be shared with this patient. Despite having had diabetes for more than 10 years, he does not appear to have any diabetes-related complications. This can likely be attributed to his prior excellent self-management behaviors. Bringing attention to these factors is a good way to start the visit, reminding the patient that he can still prevent complications by effectively managing his diabetes.
This might also be a good time to speak with the patient about what his goals are and what is most important to him. This allows for greater patient engagement; having him identify his treatment priorities promotes ownership over aspects directly affecting his care. Establishing a locus of control with shared decision making enhances the likelihood that the patient will adhere to his treatment plan. One approach to accomplish this is to use a patient handout with itemized goals and a checklist of “to do” items that can help him understand the overall treatment strategy. Below are examples of checklists (see boxes “How Often Should I Check My Blood Sugar?” “Blood Sugar Goals,” and “Other Treatment Goals”).
How Often Should I Check My Blood Sugar?________ times per day
__X_ First thing in the morning before you eat or drink and at bedtime
____ Before lunch or dinner
__X_ Whenever you feel that your blood sugar is low (experiencing symptoms)
__X_ Always check before you take a shot of insulin
My basal insulin is ________________. My dose is ______units at _____ time.
My mealtime and correction scale insulin is _________________. I take _______ units for my food 15 or 30 minutes BEFORE breakfast, lunch, dinner (circle time before and meals).
My correction scale is:
__0_ units if less than 150
____ units if glucose 151-200
____ units if glucose 201-250
____ units if glucose 251-300
____ units if glucose 301-350
____ units if glucose greater than 351
I also take: _____________________________________________________________ _.
Blood Sugar Goals
A1C blood sugar average over 3 mo
Less than 6.5% 7% 7.5% 8%
Blood sugar before eating
80-130 mg/dL or _______________mg/dL
Blood sugar 2 h after a meal
Less than 180 mg/dL or _______________mg/dL
Other Treatment Goals
Blood pressure
Less than 130/80 mm Hg or 140/90 mm Hg
Aspirin
All people at 50 years or older with cardiovascular disease (CVD) and low risk of bleeding
Statin (based on age and risk of heart attack and stroke in the next 10 years and LDL level)
High intensity
Moderate intensity
None
Screenings
Annual “Comprehensive” Foot Exam
Yes
No
Date:
Foot should be assessed at each diabetes care visit
Annual Eye Exam
Yes
No
Date:
Subsequent examinations for type 1 and type 2 patients with diabetes should be repeated annually by an ophthalmologist or optometrist
Annual Lipid Screening
Yes
No
Date:
Annual Liver (Liver Function Test) Screening
Yes
No
Date:
Annual Test for Kidney Function
Yes
No
Date:
Urine albumin and eGFR in type 1 patients with diabetes duration of ≥5 years, in all type 2 patients with diabetes, and in all patients with comorbid hypertension starting at diagnosis
How often should I get my A1C checked?
6 mo
3 mo
A1C well controlled, then check every 6 mo
A1C not at goal or ≥ 7%, then check every 3 mo
Routine Blood Pressure Readings
Yes
No
Blood pressure should be measured at every routine diabetes visit. Patients found to have systolic blood pressure ≥140 or diastolic blood pressure ≥90 mm Hg.
Medications
Should I be on aspirin therapy?
Yes
No
Consider aspirin therapy (75-162 mg/d) as a primary prevention strategy in those with type 1 or type 2 diabetes
Increased cardiovascular risk (10-year risk >10%)
Men or women aged 50 years or older
At least one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria)
Should I be on statin therapy?
Yes
No
≥ 40 years of age, CVD, or CVD risk factors include LDL cholesterol ≥100 mg/dL, high blood pressure, smoking, and overweight, and obesity; <40 years of age with additional ASCVD risk factors.
Vaccinations
Annual Flu Vaccine
Yes
No
Date:
≥6 months of age
Pneumococcal Vaccine
Yes
No
Date:
Administer pneumococcal polysaccharide vaccine 23 (PPSV23) to all patients with diabetes ≥2 years of age.
Adults ≥ 65 years of age, if not previously vaccinated, should receive pneumococcal conjugate vaccine 13 (PCV13), followed by PPSV23 6 to 12 months after initial vaccination.
Adults ≥ 65 years of age, if previously vaccinated with PPSV23, should receive a follow-up ≥ 12 mo with PCV13.
Hepatitis B Vaccination
Yes
No
Administer hepatitis B vaccination to unvaccinated adults with diabetes who are aged 19 to 59 years.
It is important to give this patient hope so that he can regain a sense of control. Type 2 diabetes is largely self-managed. One study estimated that 95% of all diabetes-related management is completed by the patient.1 Another study surveyed certified diabetic educators to estimate the amount of time needed daily to complete diabetes self-care tasks. The results showed that comprehensive diabetes self-care can take more than 3 h/d for type 2 diabetes, and up to 5 h/d for type 1 diabetes.2
Because diabetes is largely self-managed, it is important that patients are well versed in the skills necessary to complete their self-care tasks. Prior to his divorce, it is possible that his spouse may have had a role in managing some of his diabetes care. Now he will need to assume responsibility for those tasks. Clearly this patient is no longer confident in his ability to effectively manage his diabetes. Because he is struggling, it may be beneficial to help him set small goals at first to help build his confidence and regain his self-efficacy. For example, by reinforcing effective self-management skills we can help him move from viewing his glucose monitoring as a threat to a tool he can use to promote positive behaviors.
The American Diabetes Association (ADA), in its Standards of Care, recommends an assessment every 3 to 6 months of the patient’s achievement toward shared glucose targets and, if they are not at goal, consideration of further intensification of treatment.3 While this may sound simple, it is anything but. Visits with a health care professional are typically rather short. Too often, providers forget to acknowledge the work of managing diabetes as opposed to focusing on just the metrics.
Diabetes self-management education and support are critical components to help our patients acquire the necessary skills to successfully manage their diabetes. This is often best accomplished via support from other members of the patient’s medical team. This might include a dietician, diabetes educator, or pharmacist. The ADA currently recommends people receive diabetes education at the time of diagnosis; at the time of any major change in their health, including diabetes-related complications; anytime a change in life occurs such as divorce, death, or change in self-care responsibilities; and at any change in treatment such as the initiation of injectable therapies.
Similarly, diabetes care guidelines recommend screening for psychosocial issues (ie, diabetes distress, depression, anxiety, eating disorders) at the time of these major changes in health and/or life. For this particular patient, screening for diabetes distress and depression makes the most sense. During his diabetes recheck, he said that he thought his meds were no longer working. He stopped checking his sugars because he was upset when he saw the high numbers. He also mentioned that he did not understand the difference between managing his hypertension and his diabetes. His comments suggest frustration with self-management, which can be a major contributor to moderate to severe levels of diabetes distress. Additionally, screening for depression is recommended given that he lives alone, was divorced 2 years ago, and is 62 years old. Older adults are two to four times more likely to have depression than the general population, and they account for nearly one-fifth of suicides (18%) in the United States. The most common risk factors for suicide in older adults include loss of a loved one, social isolation and loneliness, major life changes (eg, divorce, retirement), physical illness (eg, diabetes, chronic pain), and poor perceived health. This patient shows signs that he is at risk for depression and suicide.
Importantly, screening does not need to take a lot of time. There are brief, validated measures for diabetes distress and depression (see Table 2.1).
TABLE 2.1 Brief, Validated Measures of Diabetes Distress and Depression
Measure
Items
Time to Complete
Scoring
Cost
Citation
Problem Areas in Diabetes 5 (PAID-5)
5
1-2 minutes
Scores are summed, generating a total score between 0 and 20. A score ≥8 is indicative of high distress.
Individual items rated as “serious problem” are worthy of clinical attention even if score is <8.
No cost; available online
McGuire BE, Morrison TG, Hermanns N, et al. Short-form measures of diabetes-related emotional distress: the Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia. 2010;53(1):66-9. doi:10.1007/s00125-009-1559-5.4
Problem Areas in Diabetes 1 (PAID-1)
1
1 minute
A score ≥3 is indicative of high distress.
No cost; available online
McGuire BE, Morrison TG, Hermanns N, et al. Short-form measures of diabetes-related emotional distress: the Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia. 2010;53(1):66-9. doi:10.1007/s00125-009-1559-5.4
Diabetes Distress Scale 2 (DDS-2)
2
1 minute
Items are averaged or summed. An average ≥ 3 or sum ≥6 indicates moderate to high diabetes distress.
No cost; available online
Fisher L, Glasgow RE, Mullan JT, Skaff MM, Polonsky WH. Development of a brief diabetes distress screening instrument. Ann Fam Med. 2008;6(3):246-52. doi:10.1370/afm.842.5
Patient Health Questionnaire-2 (PHQ-2)
2
1 minute
A score ≥ 3 is the recommended cut point.
No cost; available online
2. What to suggest in terms of glycemic management?
2. The current ADA treatment algorithm provides recommendations for the use of medication in the treatment of type 2 diabetes (see the table in the ADA Standards of Medical Care 2022 hyperglycemia treatment algorithm3). While it looks rather complicated, breaking this algorithm into small sections can make it much more straightforward.
Let us start with the blue box on the very top left in the ADA Standards of Medical Care 2022 hyperglycemia treatment algorithm.3 The most important thing to take from this is that every patient should have comprehensive diabetes self-management education and support at the time of diagnosis. Health care professionals often do not have the time or expertise to take a deep dive into therapeutic lifestyle changes for their patients. With short visits, patients often will not have the opportunity to ask all their questions of their health care providers. Dedicated time is necessary to cover the key aspects of diabetes self-care. Therefore, an early referral for diabetes education is critically important to help patients get their questions answered with meaningful information, so they can succeed in diabetes self-management.
The next step on the ADA algorithm is the red box on the left. Most patients will be initiated on metformin. It is important to determine whether a patient has a compelling indication(s), for example, atherosclerotic cardiovascular disease (ASCVD), heart failure, and kidney disease, for very specific therapies. If the patient has one or more of these conditions, treatment will coincide with the left side of the algorithm. Our patient in this case presentation does not have any of these conditions. The next step is to consult the right side of the algorithm.
Then we can ask the patient about their priorities in terms of treatment goals and concerns they may have with their current medications. Typically, issues such as undesired side effects, weight gain, hypoglycemia, and expense take precedent. This approach gives the patient the opportunity to express their priorities and enables the provider to make suggestions that will match those priorities.
The patient’s A1c = 9.2%; his diabetes is no longer on target on his current regimen. He has been using metformin, a DPP4 inhibitor, and a sulfonylurea (SU).
It is important to recognize that metformin and SUs will lose efficacy over time. Metformin has a 40% failure rate at 5 years—this failure rate is higher if metformin is not started at diagnosis.7 With SUs, about 20% of people will not respond to them due to a lack of functioning beta cells. Further, about 5% of people on SUs will stop responding to them—leaving a 50% nonresponder rate at 6 years8 and most will not respond to a SU at 10 years.
The options at this point include a basal insulin, a GLP-1 receptor agonist, or a SGLT-2 inhibitor. Since the patient does not have a compelling indication, each option is reasonable. Shared decision making is important at this step. The patient may have strong preferences about performing injections versus taking more oral medications. Other considerations may be side-effect profiles, whether the medication may promote weight gain or weight loss, and how quickly the treatment will work, medication expense, and insurance coverage.
Adding Diabetes Medications
Class
Agent
Instructions
GLP-1 (glucagon-like peptide 1) receptor agonists
Victoza (liraglutide)
Week 1: 0.6 mg daily
Week 2: 1.2 mg daily
Week 3 and thereafter: 1.8 mg daily
Trulicity (dulaglutide)
Weeks 1 and 2: 0.75 mg weekly
Week 3 and thereafter: 1.5 mg weekly
*Can increase to 3.0 and 4.5 mg if needed
Ozempic (semaglutide)
Weeks 1-4: 0.25 mg weekly
Weeks 5-8 (or longer): 0.5 mg weekly
Rybelsus (oral semaglutide)
*Can increase to 1 or 2 mg weekly if needed
3 mg daily on empty stomach and 4 oz of water for 30 days, then 7 mg daily
*Can increase to 14 mg daily if needed (after 30 days of 7 mg)
Bydureon (exenatide—weekly)
2 mg once weekly at any time of day
Byetta (exenatide—twice daily)
5 mcg twice daily before meals within 60 minutes
*Can increase to 10 µg twice daily after 1 month of 5 µg
*Pay attention to urinary tract infection symptoms and keep yourself hydrated
Invokana (canagliflozin)
Farxiga (dapagliflozin)
Steglatro (ertugliflozin)
DPP-4 (dipeptidyl peptidase 4) inhibitors
Nesina (alogliptin)
Once daily
*Not recommended to be used with GLP-1 RA
Onglyza (saxagliptin)
Tradjenta (linagliptin)
Januvia (sitagliptin)
Insulin
Insulin N (NPH)
Basal/background insulin ______ units
Can be taken at bedtime OR in the morning
Toujeo (glargine)
Tresiba (degludec)
Basaglar (glargine)
Lantus (glargine)
Semglee (glargine-yfgn)
Levemir (detemir)
Insulin R (regular)
Bolus/mealtime insulin ____ units
Inject 15 or 30 minutes before a meal (1 to 3 times daily)
Novolog (aspart)
Humalog (lispro)
Apidra (glulisine)
Fiasp (aspart)
Bolus/mealtime insulin ____ units
Inject right before OR within 20 minutes of a meal (1 to 3 times daily)
Lyumjev (lispro-aabc)
Fixed ratio injections
Soliqua (glargine + lixisenatide)
Xultophy (degludec + liraglutide)
Start 16 units daily
Start 15 units daily
Basal insulin is the most potent medication, but it can increase the risk of hypoglycemia and weight gain. GLP-1RAs have good fasting and postprandial coverage and will likely result in significant weight loss. They are currently formulated as once-weekly injections, once- or twice-daily injections, or a single daily oral tablet. For many patients that are reluctant to perform injections, a once-weekly administration may be an acceptable option. Our patient would need to discontinue his DPP4i if he were to start a GLP1a as they have similar mechanisms of action. The SGLT-2 inhibitors are less potent than the other agents, but are taken orally, are less expensive than the GLP-1RAs, and have the added potential to improve blood pressure levels. Even though the SU is no longer effective, it is prudent to add a treatment before reducing or stopping the SU.
When starting a new diabetes agent, it is important to share with patients what they can expect in terms of changes in blood glucose. For example, if the patient is started on basal insulin, they should know they will need to monitor their morning glucose for its effect and to help adjust their insulin dose.
At this visit, the clinician can discuss the utility of fingerstick glucose monitoring or use of a continuous glucose monitoring (CGM) system to test the efficacy of the new treatment. Some providers may have the ability to offer an office-based CGM system for short-term use. A CGM system can be a very powerful tool to help the patient see “how their life affects their diabetes.”
Once a treatment plan has been agreed on and implemented, it is important to bring the patient back within 2 to 4 weeks for follow-up. He will be making major regimen changes including new medication, resumption of glucose monitoring, dietary modification, and will have received diabetes self-management education and support. Close follow-up provides an opportunity to evaluate the effectiveness of the regimen change, problem-solve if necessary, and provide encouragement. This is particularly relevant when the work of change is great.
No matter what treatment is recommended, it is key to bring the patient back at least every 3 months to reassess progress made toward reaching goals and to identify any barriers that get in the way. It has been shown that the more visits a person has specific to their diabetes the better the control they have.9
Another important thing to remember is to ask patients open-ended questions at these follow-up visits. This allows the patient to verbalize feelings and provide information in their own words. Next, employ active listening skills via reflection, or repeating statements back to the patient in the tone of a question, and summarizing, or recapping the patient’s conversation, to show the patient that you have been listening. It also presents an opportunity to correct any misunderstandings between the two of you. Perhaps most importantly, reflecting and summarizing communicate empathy to your patient, and patients with type 2 diabetes who experience higher levels of empathy from their physician show a 40%-50% lower risk of all-cause mortality 10 years later.
3. How to prevent this scenario in the first place?
3. Historically, when people were diagnosed with type 2 diabetes, they were initially advised to make lifestyle changes and then return in 3 months to see if they required medication. The great majority of these people needed to make substantial lifestyle changes and did not have the tools or guidance to understand what changes were essential. Typically, most people would be prescribed medications when they returned in 3 months. One can only imagine the frustration of those people who did make significant efforts still being told they would need to start medication, leading them to assume that lifestyle changes are not effective in the management of diabetes.
The 2022 ADA guidelines recommend starting BOTH therapeutic lifestyle changes and pharmacotherapy at diagnosis. As mentioned earlier, delaying metformin initiation even 3 months after diagnosis reduces the benefit of this medication. In fact, one study showed that starting metformin 3 months after diagnosis reduced the durability by 56%.8
Ralph DeFronzo, MD, labeled typical diabetes care as “treat to fail” practices.10 Following the conventional treatment guidelines of the times, providers waited until a patient’s glucose was out of control before adding medication. This approach created a situation where glucose regulation was never maintained for any length of time. Consequently, providers continually added more medication to catch up with the glucose levels without ever establishing long-term control.
Rather than following this “step-up therapy,” it may be prudent to aggressively treat the condition at diagnosis, establish glycemic control with multiple modalities, and then use “step-down therapy.” Despite several studies having shown this approach to be successful, it still has not become common practice. By using “step-down therapy” to achieve euglycemia, we are more likely to increase patient confidence that they can get control of their condition. This is especially true when there is a “legacy effect” of early intensive treatment with a reduction in numbers and dosages of medications used over time, versus increasing medication which is the more typical patient experience.
Research has shown that some of these early intensive initial therapies have helped put diabetes into “remission.” Remission is defined as a minimum of 6 months of normal glycemic control with a HbA1c less than 6.5% with no pharmacologic therapy. One meta-analysis found that after 2 to 4 weeks of intensive therapy, 59% of people were in remission at 6 months and 46% were in remission at 1 year.8 There is growing evidence that the timing and approach to early intensive therapy is critically important. For example, numerous studies have shown that early intensive insulin therapy can induce diabetes remission.8,9,10,11,12,13,14,15,16,17,18,19,20,21,22 Another study by this team found that providing this intervention in the first 2 years of diagnosis is the best predictor of diabetes remission for 1 year.12
4. What are the options for early intensive therapy?
4. There have been several early intensive therapy trials that have shown success in managing diabetes. Some effective strategies for people NEWLY diagnosed with type 2 diabetes include a very-low-calorie (800 kcal/daily) diet,13,14 triple med therapy,15 intensive insulin therapy,16,17,18,19,20,21,22,23 and metabolic surgery.24,25
ANSWERS AND EXPLANATIONS
1. What this patient is describing is a very common scenario. Type 2 diabetes is a chronic, progressive condition. The medications we use are intended to improve glycemia and reduce the risk of complications. However, current approaches to care do little to address the natural history and underlying pathophysiology of the disease state. As a result, patients often require modifications to their medication regimen over time (see box “Adding Diabetes Medications”).
The demands of successfully living with diabetes can be extremely challenging. Not uncommonly patients become frustrated and depressed when, despite their best efforts, their blood sugar readings are higher than desired. Often, in response patients will stop trying to manage their diabetes. They no longer perform fingerstick glucose readings and may stray from their diet. Many people find that the work of taking care of their diabetes has become too overwhelming.
For this patient, the first step is to normalize his experience. We can acknowledge the patient’s frustration that he continues to take his medication but does not necessarily see the benefit. Most diabetes medications (including the ones he is taking) will lose their efficacy over time. In addition, his diet has changed considerably since his divorce. Therefore, it is not surprising that his glucose levels have been climbing.
The next step is to help him gain a better understanding of what is going on with his diabetes while not overwhelming him with too much information. There is some good news that could be shared with this patient. Despite having had diabetes for more than 10 years, he does not appear to have any diabetes-related complications. This can likely be attributed to his prior excellent self-management behaviors. Bringing attention to these factors is a good way to start the visit, reminding the patient that he can still prevent complications by effectively managing his diabetes.
This might also be a good time to speak with the patient about what his goals are and what is most important to him. This allows for greater patient engagement; having him identify his treatment priorities promotes ownership over aspects directly affecting his care. Establishing a locus of control with shared decision making enhances the likelihood that the patient will adhere to his treatment plan. One approach to accomplish this is to use a patient handout with itemized goals and a checklist of “to do” items that can help him understand the overall treatment strategy. Below are examples of checklists (see boxes “How Often Should I Check My Blood Sugar?” “Blood Sugar Goals,” and “Other Treatment Goals”).
How Often Should I Check My Blood Sugar?________ times per day
__X_ First thing in the morning before you eat or drink and at bedtime
____ Before lunch or dinner
__X_ Whenever you feel that your blood sugar is low (experiencing symptoms)
__X_ Always check before you take a shot of insulin
My basal insulin is ________________. My dose is ______units at _____ time.
My mealtime and correction scale insulin is _________________. I take _______ units for my food 15 or 30 minutes BEFORE breakfast, lunch, dinner (circle time before and meals).
My correction scale is:
__0_ units if less than 150
____ units if glucose 151-200
____ units if glucose 201-250
____ units if glucose 251-300
____ units if glucose 301-350
____ units if glucose greater than 351
I also take: _____________________________________________________________ _.
Blood Sugar Goals
A1C blood sugar average over 3 mo
Less than 6.5% 7% 7.5% 8%
Blood sugar before eating
80-130 mg/dL or _______________mg/dL
Blood sugar 2 h after a meal
Less than 180 mg/dL or _______________mg/dL
Other Treatment Goals
Blood pressure
Less than 130/80 mm Hg or 140/90 mm Hg
Aspirin
All people at 50 years or older with cardiovascular disease (CVD) and low risk of bleeding
Statin (based on age and risk of heart attack and stroke in the next 10 years and LDL level)
High intensity
Moderate intensity
None
Screenings
Annual “Comprehensive” Foot Exam
Yes
No
Date:
Foot should be assessed at each diabetes care visit
Annual Eye Exam
Yes
No
Date:
Subsequent examinations for type 1 and type 2 patients with diabetes should be repeated annually by an ophthalmologist or optometrist
Annual Lipid Screening
Yes
No
Date:
Annual Liver (Liver Function Test) Screening
Yes
No
Date:
Annual Test for Kidney Function
Yes
No
Date:
Urine albumin and eGFR in type 1 patients with diabetes duration of ≥5 years, in all type 2 patients with diabetes, and in all patients with comorbid hypertension starting at diagnosis
How often should I get my A1C checked?
6 mo
3 mo
A1C well controlled, then check every 6 mo
A1C not at goal or ≥ 7%, then check every 3 mo
Routine Blood Pressure Readings
Yes
No
Blood pressure should be measured at every routine diabetes visit. Patients found to have systolic blood pressure ≥140 or diastolic blood pressure ≥90 mm Hg.
Medications
Should I be on aspirin therapy?
Yes
No
Consider aspirin therapy (75-162 mg/d) as a primary prevention strategy in those with type 1 or type 2 diabetes
Increased cardiovascular risk (10-year risk >10%)
Men or women aged 50 years or older
At least one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria)
Should I be on statin therapy?
Yes
No
≥ 40 years of age, CVD, or CVD risk factors include LDL cholesterol ≥100 mg/dL, high blood pressure, smoking, and overweight, and obesity; <40 years of age with additional ASCVD risk factors.
Vaccinations
Annual Flu Vaccine
Yes
No
Date:
≥6 months of age
Pneumococcal Vaccine
Yes
No
Date:
Administer pneumococcal polysaccharide vaccine 23 (PPSV23) to all patients with diabetes ≥2 years of age.
Adults ≥ 65 years of age, if not previously vaccinated, should receive pneumococcal conjugate vaccine 13 (PCV13), followed by PPSV23 6 to 12 months after initial vaccination.
Adults ≥ 65 years of age, if previously vaccinated with PPSV23, should receive a follow-up ≥ 12 mo with PCV13.
Hepatitis B Vaccination
Yes
No
Administer hepatitis B vaccination to unvaccinated adults with diabetes who are aged 19 to 59 years.
It is important to give this patient hope so that he can regain a sense of control. Type 2 diabetes is largely self-managed. One study estimated that 95% of all diabetes-related management is completed by the patient.1 Another study surveyed certified diabetic educators to estimate the amount of time needed daily to complete diabetes self-care tasks. The results showed that comprehensive diabetes self-care can take more than 3 h/d for type 2 diabetes, and up to 5 h/d for type 1 diabetes.2
Because diabetes is largely self-managed, it is important that patients are well versed in the skills necessary to complete their self-care tasks. Prior to his divorce, it is possible that his spouse may have had a role in managing some of his diabetes care. Now he will need to assume responsibility for those tasks. Clearly this patient is no longer confident in his ability to effectively manage his diabetes. Because he is struggling, it may be beneficial to help him set small goals at first to help build his confidence and regain his self-efficacy. For example, by reinforcing effective self-management skills we can help him move from viewing his glucose monitoring as a threat to a tool he can use to promote positive behaviors.
The American Diabetes Association (ADA), in its Standards of Care, recommends an assessment every 3 to 6 months of the patient’s achievement toward shared glucose targets and, if they are not at goal, consideration of further intensification of treatment.3 While this may sound simple, it is anything but. Visits with a health care professional are typically rather short. Too often, providers forget to acknowledge the work of managing diabetes as opposed to focusing on just the metrics.
Diabetes self-management education and support are critical components to help our patients acquire the necessary skills to successfully manage their diabetes. This is often best accomplished via support from other members of the patient’s medical team. This might include a dietician, diabetes educator, or pharmacist. The ADA currently recommends people receive diabetes education at the time of diagnosis; at the time of any major change in their health, including diabetes-related complications; anytime a change in life occurs such as divorce, death, or change in self-care responsibilities; and at any change in treatment such as the initiation of injectable therapies.
Similarly, diabetes care guidelines recommend screening for psychosocial issues (ie, diabetes distress, depression, anxiety, eating disorders) at the time of these major changes in health and/or life. For this particular patient, screening for diabetes distress and depression makes the most sense. During his diabetes recheck, he said that he thought his meds were no longer working. He stopped checking his sugars because he was upset when he saw the high numbers. He also mentioned that he did not understand the difference between managing his hypertension and his diabetes. His comments suggest frustration with self-management, which can be a major contributor to moderate to severe levels of diabetes distress. Additionally, screening for depression is recommended given that he lives alone, was divorced 2 years ago, and is 62 years old. Older adults are two to four times more likely to have depression than the general population, and they account for nearly one-fifth of suicides (18%) in the United States. The most common risk factors for suicide in older adults include loss of a loved one, social isolation and loneliness, major life changes (eg, divorce, retirement), physical illness (eg, diabetes, chronic pain), and poor perceived health. This patient shows signs that he is at risk for depression and suicide.
Importantly, screening does not need to take a lot of time. There are brief, validated measures for diabetes distress and depression (see Table 2.1).
TABLE 2.1 Brief, Validated Measures of Diabetes Distress and Depression
Measure
Items
Time to Complete
Scoring
Cost
Citation
Problem Areas in Diabetes 5 (PAID-5)
5
1-2 minutes
Scores are summed, generating a total score between 0 and 20. A score ≥8 is indicative of high distress.
Individual items rated as “serious problem” are worthy of clinical attention even if score is <8.
No cost; available online
McGuire BE, Morrison TG, Hermanns N, et al. Short-form measures of diabetes-related emotional distress: the Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia. 2010;53(1):66-9. doi:10.1007/s00125-009-1559-5.4
Problem Areas in Diabetes 1 (PAID-1)
1
1 minute
A score ≥3 is indicative of high distress.
No cost; available online
McGuire BE, Morrison TG, Hermanns N, et al. Short-form measures of diabetes-related emotional distress: the Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia. 2010;53(1):66-9. doi:10.1007/s00125-009-1559-5.4
Diabetes Distress Scale 2 (DDS-2)
2
1 minute
Items are averaged or summed. An average ≥ 3 or sum ≥6 indicates moderate to high diabetes distress.
No cost; available online
Fisher L, Glasgow RE, Mullan JT, Skaff MM, Polonsky WH. Development of a brief diabetes distress screening instrument. Ann Fam Med. 2008;6(3):246-52. doi:10.1370/afm.842.5
Patient Health Questionnaire-2 (PHQ-2)
2
1 minute
A score ≥ 3 is the recommended cut point.
No cost; available online
2. The current ADA treatment algorithm provides recommendations for the use of medication in the treatment of type 2 diabetes (see the table in the ADA Standards of Medical Care 2022 hyperglycemia treatment algorithm3). While it looks rather complicated, breaking this algorithm into small sections can make it much more straightforward.
Let us start with the blue box on the very top left in the ADA Standards of Medical Care 2022 hyperglycemia treatment algorithm.3 The most important thing to take from this is that every patient should have comprehensive diabetes self-management education and support at the time of diagnosis. Health care professionals often do not have the time or expertise to take a deep dive into therapeutic lifestyle changes for their patients. With short visits, patients often will not have the opportunity to ask all their questions of their health care providers. Dedicated time is necessary to cover the key aspects of diabetes self-care. Therefore, an early referral for diabetes education is critically important to help patients get their questions answered with meaningful information, so they can succeed in diabetes self-management.
The next step on the ADA algorithm is the red box on the left. Most patients will be initiated on metformin. It is important to determine whether a patient has a compelling indication(s), for example, atherosclerotic cardiovascular disease (ASCVD), heart failure, and kidney disease, for very specific therapies. If the patient has one or more of these conditions, treatment will coincide with the left side of the algorithm. Our patient in this case presentation does not have any of these conditions. The next step is to consult the right side of the algorithm.
Then we can ask the patient about their priorities in terms of treatment goals and concerns they may have with their current medications. Typically, issues such as undesired side effects, weight gain, hypoglycemia, and expense take precedent. This approach gives the patient the opportunity to express their priorities and enables the provider to make suggestions that will match those priorities.
The patient’s A1c = 9.2%; his diabetes is no longer on target on his current regimen. He has been using metformin, a DPP4 inhibitor, and a sulfonylurea (SU).
It is important to recognize that metformin and SUs will lose efficacy over time. Metformin has a 40% failure rate at 5 years—this failure rate is higher if metformin is not started at diagnosis.7 With SUs, about 20% of people will not respond to them due to a lack of functioning beta cells. Further, about 5% of people on SUs will stop responding to them—leaving a 50% nonresponder rate at 6 years8 and most will not respond to a SU at 10 years.
The options at this point include a basal insulin, a GLP-1 receptor agonist, or a SGLT-2 inhibitor. Since the patient does not have a compelling indication, each option is reasonable. Shared decision making is important at this step. The patient may have strong preferences about performing injections versus taking more oral medications. Other considerations may be side-effect profiles, whether the medication may promote weight gain or weight loss, and how quickly the treatment will work, medication expense, and insurance coverage.
Adding Diabetes Medications
Class
Agent
Instructions
GLP-1 (glucagon-like peptide 1) receptor agonists
Victoza (liraglutide)
Week 1: 0.6 mg daily
Week 2: 1.2 mg daily
Week 3 and thereafter: 1.8 mg daily
Trulicity (dulaglutide)
Weeks 1 and 2: 0.75 mg weekly
Week 3 and thereafter: 1.5 mg weekly
*Can increase to 3.0 and 4.5 mg if needed
Ozempic (semaglutide)
Weeks 1-4: 0.25 mg weekly
Weeks 5-8 (or longer): 0.5 mg weekly
Rybelsus (oral semaglutide)
*Can increase to 1 or 2 mg weekly if needed
3 mg daily on empty stomach and 4 oz of water for 30 days, then 7 mg daily
*Can increase to 14 mg daily if needed (after 30 days of 7 mg)
Bydureon (exenatide—weekly)
2 mg once weekly at any time of day
Byetta (exenatide—twice daily)
5 mcg twice daily before meals within 60 minutes
*Can increase to 10 µg twice daily after 1 month of 5 µg
CASE QUESTIONS
ANSWERS AND EXPLANATIONS
