Diabetes Dilemmas: Potential Interventions

Pharmacy Times, October 2014 Diabetes, Volume 80, Issue 10

A practical approach to daily life with the support of a pharmacist can make a difference.

A practical approach to daily life with the support of a pharmacist can make a difference.

Meet Denise and Devin. Denise is 42 years of age and has type 2 diabetes mellitus (T2DM), which was diagnosed at 39 years of age. Her 18-year-old son Devin has had type 1 diabetes mellitus (T1DM) since he was 10 years of age. Besides their diagnoses and their genes, they have several things in common. They both weigh 200 lb, although Denise is 5 ft 2 inches tall and Devin is 6 ft tall, resulting in body mass indexes (BMIs) of 36.6 and 27.1 kg/m2, respectively. They are both addicted to television and have the same hobby—going to movies. Both have dyslipidemia, of which they are aware, and depression, which is undiagnosed. As you consider the following diabetes dilemmas, what would you do to help?

Dilemma 1

If you ask Denise and Devin—either independently or together—how they’re doing with their diabetes, you’ll see the strong family resemblance in their similar shrugs. Both of them test their blood glucose often (and complain about the cost). Devin’s glycated hemoglobin (A1C) level is around 8%, and Denise’s hovers at or above 10%. The consistency of their test results suggests that whatever they’re doing is being done consistently, acting more out of habit than making an effort to change.

Devin’s primary issue is adolescence and peer pressure.1 Denise fixes a good breakfast for Devin each morning, but his pediatric treatment team has encouraged him to take responsibility for snacks and lunch as he moves toward adulthood. He often selects high-carbohydrate vending machine and cafeteria foods—tasty items such as pizza and hamburgers. He thinks, I’ll increase my insulin a bit. He knows approximately how to adjust his insulin for his favorite foods, and uses this as a justification of sorts. Unfortunately, he sometimes can’t find a private place to inject his insulin, and consequently, it’s not tightly controlled and he already has dyslipidemia.

Denise is a mindless eater. She eats a healthy breakfast with her children. After everyone goes to school, she often eats any leftovers, thinking, I shouldn’t waste food. She lacks energy most of the time and breezes through the doughnut shop drive-through to pick up a large coffee on the way to work. Often, she also picks up a few doughnut holes, not realizing each one has 70 calories, 4 grams of fat, and 7 grams of carbohydrate. She’s exhausted after a day of answering telephones at a busy garage, so she often makes dinner using convenience foods.

It doesn’t look like their test results are motivating the changes needed to move them toward tight insulin control. Their A1C levels, while stable, are inadequate to slow or prevent the complications of hyperglycemia.2

Dilemma 2

For both Denise and Devin, a sedentary lifestyle is a problem. Cardiovascular disease is the primary complication for T2DM patients; it ultimately kills about half of them.3,4 Sedentary behavior contributes to poor cardiovascular outcomes, and it is not only the total amount of sedentary time but also the pattern of its accumulation that are important. People who sit for long periods of time for many years are at higher risk than those who break up periods of sitting and also exercise moderately to intensely 5 or more times a week.3

Dilemma 3

Devin and Denise both have concerns about recommendations from their treatment teams.

Like 750,000 other American children every year,5 Devin will soon transition from his familiar pediatric care team, and he’s worried. He interprets his physician’s comments about transitioning to adult care as abandonment and finds the prospect deeply disturbing. Many young adults lose diabetic control during the transition.5

Denise battles with her treatment team in a passive-aggressive way. Unable to tolerate metformin’s gastrointestinal side effects, she switched to a sulfonylurea and a dipeptidyl peptidase—4 inhibitor. Her response was noticeable but inadequate: her A1C level fell from 11% to around 10%. Her treatment team tells her that many (if not most) T2DM patients need insulin to attain an A1C level <7.0%.6,7 Although administering basal insulin glargine and detemir is associated with an increased incidence of hypoglycemia and a modest increase in weight, it corrects hyperglycemia better than most oral agents.8-10 Denise shudders at the thought of self-injecting, but instead of telling her treatment team, she says she’d prefer to add a sodium-glucose linked transporter—2 inhibitor she saw advertised on television. Denise and her treatment team are at an impasse.

Dilemma 4

Neither Denise nor Devin have age-appropriate energy, enthusiasm, or engagement. Devin goes through the motions at school but has a limited social circle and is not a joiner. Denise finds basic activities of daily living exhausting. Around 10% of young adults with T1DM are clinically depressed,11 and around 15% of patients with T2DM are as well.12 Depression may be related to lifestyle adjustments, stressful and time-consuming self-care, or dietary restrictions. Or it may simply be a confounding condition of unknown cause. The benefits of antidepressants may outweigh their risks.

These important dilemmas require attention, and the Table1,5,13,14 offers some solutions.

Endnote

Until recently, Denise and Devin didn’t think of their pharmacist, Alec, as an active member of their treatment team. When Alec reached out 4 months ago and asked how they were feeling, it opened a door. Alec helped them identify small changes that helped improve their A1C levels. He compared adding a third oral drug with starting insulin, in terms of the potential side effects, costs, and changes in A1C level, and he was able to help Denise make a decision to try insulin. She did, and when she reported an A1C level of 7.2% recently, Alec beamed and said, “Funny how that works, isn’t it?” Denise and Devin now walk for 30 minutes at the end of each day. As Devin transitions to adult care, he is relying on Alec as a constant. Denise and Devin’s joint goals include normal BMIs and better glycemic control.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy.

References

1. Wang YL, Brown SA, Horner SD. The school-based lived experiences of adolescents with type 1 diabetes. J Nurs Res. 2013;21:235-243.

2. Le Floch JP. Critical appraisal of the safety and efficacy of insulin detemir in glycemic control and cardiovascular risk management in diabetics. Diabetes Metab Syndr Obes. 2010;3:197-213.

3. Dempsey PC, Owen N, Biddle SJ, Dunstan DW. Managing sedentary behavior to reduce the risk of diabetes and cardiovascular disease. Curr Diab Rep. 2014;14:522.

4. Diabetes Atlas. 6th ed. Brussels, Belgium: International Diabetes Foundation; 2013.

5. McPheeters M, Davis AM, Taylor JL, Brown RF, Potter SA, Epstein RA. Transition care for children with special health needs. Agency for Healthcare Research and Quality website. www.ncbi.nlm.nih.gov/books/NBK222123. Accessed August 10, 2014.

6. Turner RC, Cull CA, Frighi V, Holman RR; UK Prospective Diabetes Study (UKPDS) Group. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). JAMA. 1999;281:2005-2012.

7. UK Prospective Diabetes Study Group. UKPDS 28: a randomized trial of efficacy of early addition of metformin in sulfonylurea-treated type 2 diabetes. Diabetes Care. 1998;21:87-92.

8. Gerstein HC, Bosch J, Dagenais GR, et al. ORIGIN Trial Investigators Basal insulin and cardiovascular and other outcomes in dysglycemia. N Engl J Med. 2012;367:319-328.

9. Mellbin LG, Rydén L, Riddle MC, et al; ORIGIN Trial Investigators. Does hypoglycaemia increase the risk of cardiovascular events? a report from the ORIGIN trial. Eur Heart J. 2013;34:3137-3144.

10. 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;35:1364-1379.

11. Trief PM, Xing D, Foster NC, et al; T1D Exchange Clinic Network. Depression in adults in the T1D Exchange Clinic Registry. Diabetes Care. 2014;37:1563-1572.

12. Tabák AG, Akbaraly TN, Batty GD, Kivimäki M. Depression and type 2 diabetes: a causal association? Lancet Diabetes Endocrinol. 2014;2:236-245.

13. Sorli C, Heile MK. Identifying and meeting the challenges of insulin therapy in type 2 diabetes. J Multidiscip Healthc. 2014;7:267-282.

14. Looney SM, Raynor HA. Behavioral lifestyle intervention in the treatment of obesity. Health Serv Insights. 2013;6:15-31.