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”).
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.
2Because 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).
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 algorithm
3). 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.
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