Chapter 74: Diabetes Mellitus

Patient Care Process for the Management of Diabetes

Collect

• Patient characteristics (e.g., age, race, sex, pregnant)

• Characteristics of diabetes (e.g., type, age of onset, initial presentation)

• Microvascular and macrovascular complications

• Hypoglycemia episodes, symptoms, frequency, and suspected cause(s)

• History of diabetic ketoacidosis frequency, severity, and suspected cause

• Patient history (past medical, family, social—dietary habits, weight history, sleep behaviors, physical activity habits)

• Current medications (including complementary and alternative therapies) and medication taking behaviors (e.g., adherence, injection technique)

• Past diabetes treatments, response to therapy, reason for discontinuation

• Diabetes and nutritional education (currently enrolled and completed)

• Self-monitorng of blood glucose (SMBG) results and self-management behaviors

• Social and cultural Issues: preferences, values, and beliefs; health literacy

• Physical exam: height, weight, BMI, blood pressure, heart rate, comprehensive foot exam

• Labs (e.g. Glucose, A1C, Scr, BUN, eGFR, fasting lipid panel, urinary albumin/Cr ratio, serum electrolytes)

Assess

• Diagnosis and classification (See Tables 74-1 and 74-3)

• Microvascular and macrovascular complications and potential comorbid conditions

• Achievement of A1C and glucose goals (see Table 74-6)

• Appropriateness, effectiveness, safety/tolerability, treatment burden, cost and adherence of current antihyperglycemic regimen and additional treatment options being considered

• Achievement of weight, lifestyle or other behavioral goals

• Achievement of goals for comorbidities (e.g., blood pressure, lipids, neuropathic pain)

• Screen for depression, anxiety, disordered eating

• Screen for psychosocial problems and barriers to diabetes self-management

Plan^*

• Set appropriate A1C and glucose goals based on age, comorbidities, and other factors (See Table 74-6)

• Tailored lifestyle modifications (e.g., diet, exercise, weight management)

• Drug therapy regimen including specific antihyperglycemic agent(s), dose, route, frequency, and duration; specify continuation and discontinuation of existing therapies (see Figure 74-4 and Tables 74-7, 74-10, and 74-11)

• Monitoring parameters including efficacy (e.g., A1C, SMBG), safety (medication-specific adverse effects, hypoglycemia), and timeframe (see Tables 74-5 and 74-14)

• Patient education (e.g., purpose of treatment, drug administration, dietary and lifestyle modification)

• Referrals to other providers when appropriate (e.g., diabetes educator, registered dietician, eye care professional, podiatrist, mental health professional)

Implement^*

• Provide patient education regarding all elements of treatment plan

• Use motivational interviewing and coaching strategies to maximize adherence

• Schedule follow-up including follow-up phone calls to adjust treatment

Follow-up: Monitor and Evaluate

• Determine A1C and glucose goal attainment

• Presence of adverse effects

• Occurrence/development/progression of diabetes-related complications

• Patient adherence to treatment plan using multiple sources of information

Content Update

November 15, 2019

Semaglutide: The First Oral GLP-1 Receptor Agonist: In September 2019, the U.S. Food and Drug Administration (FDA) approved semaglutide (Rybelsus, Novo Nordisk) for treatment of type 2 diabetes mellitus (T2DM). The glucacon-like-peptide-1 (GLP-1) receptor agonists are a recommended second-line, add-on therapy to metformin for patients with T2DM who are at high-risk of ...