Managing Type 2 Diabetes

Patient and NP as Partners In Care

By Jane Jeffrie Seley, NP, CDE, and Esther Wei, NP, CDE

Continuing Education Offering: The goal of this article is to educate nurse practitioners about type 2 diabetes. Nurse practitioners may obtain 3 contact hours by reading this article and earning a passing score on the test that follows. For immediate test results, take the quiz online at www.advanceweb.com/np.

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Instructions: Nurse practitioners may receive 3 contact hours by reading the article noted below and successfully answering the questions in the accompanying quiz. To obtain contact hours

1. Read the article "Managing Type 2 Diabetes. Patient and NP as Partners in Care," carefully noting the tables and other illustrative materials provided to enhance your knowledge and understanding of the content.

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Objectives: The purpose of this article is to educate nurse practitioners about type 2 diabetes. After reading this article, the nurse practitioner should be able to:

• Discuss specific characteristics of type 2 diabetes.

• Discuss nonpharmacologic treatment strategies for type 2 diabetes.

• Discuss pharmacologic treatment strategies for type 2 diabetes.

• List several complications of diabetes and a prevention strategy for each.

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Type 2 diabetes is on the rise in the United States. National statistics show that 6.3% of the population has diabetes today, and approximately 5 million of these 18.2 million cases have not been diagnosed.¹ Regardless of practice setting or population served, nurse practitioners are and will continue to feel the growing impact of diabetes and its complications.

Since diabetes is a chronic and progressive condition, its management requires an ongoing process that involves the patient and provider as partners in care. Nurse practitioners can be instrumental in coaching and educating patients in the skills and knowledge needed to manage diabetes successfully. Every health care visit is an opportunity to review current diabetes self-management and to offer suggestions for improvement in glycemic control and quality of life. Quality outpatient care that promotes diabetes self-management helps prevent or reduce amputation, cardiovascular disease and hospitalizations.²

This article encapsulates in practical form the most up-to-date diabetes management strategies. Since time limitations are a reality for all of us, we recommend incorporating one or two of these approaches at each visit. In our experience, behavior change is most successful when you build relationships with your patients and suggest a few changes at a time.

To Screen or Not to Screen

Screening is necessary to identify the many undiagnosed cases of diabetes. In the United States, most people diagnosed with diabetes have had the disease for 5 to 10 years by the time they are diagnosed. To improve screening efforts, risk factors for developing diabetes were recently expanded. Patients 45 years and older should be screened for prediabetes and diabetes, especially if their body mass index (BMI) is higher than 25 and they have a family history of diabetes. Asian-Americans have an increased diabetes risk, and experts believe it may be associated with their generally lower BMI (23).3 The American Diabetes Association recommends screening younger and overweight patients (BMI >25) who have any of the identified risk factors:⁴

• sedentary lifestyle

• first-degree relative with diabetes

• African, Asian, Latino, Native American or Pacific Islander descent

• history of gestational diabetes or delivery of a baby weighing >9 lbs

• blood pressure >140/90 mm Hg

• HDL cholesterol <35 mg/dL or total cholesterol >250 mg/dL

• history of polycystic ovarian syndrome (PCOS) or suggestive of it

• history of vascular disease

• acanthosis nigricans.

How Should We Screen Patients?

The diagnostic criterion for diabetes mellitus is a fasting plasma glucose level of ³126 mg/dL or a 2-hour glucose challenge result of ³200 mg/dL on 2 separate days. A fasting plasma glucose test requires no caloric intake for 8 hours prior to sampling. The glucose challenge is drawn after a 75-gram anhydrous glucose load. The diagnosis of diabetes can also be made with a single random glucose level of ³200 mg/dL with symptoms of polydipsia, polyuria and polyphagia.

If the fasting plasma glucose is between 100 mg/dL and 125 mg/dL (impaired fasting glucose or IFG) or the 2-hour glucose challenge is between 140 mg/dL and 199 mg/dL (impaired glucose tolerance or IGT), the patient has prediabetes. If untreated, the patient with prediabetes has an increased and almost inevitable risk of developing type 2 diabetes. An estimated 41 million U.S. residents between the ages of 40 and 74 have prediabetes, which carries an increased risk of heart disease and stroke.¹

Can Diabetes Be Prevented?

In the past 10 years, studies have identified protocols that prevent or delay the onset of type 2 diabetes in high-risk patients. The Diabetes Prevention Program was a large, multicenter trial that randomized 3,324 high-risk adults with IFG and IGT to intensive lifestyle changes or 850 mg of metformin twice daily. The lifestyle interventions included nutrition counseling and behavior modification with a goal of a 7% weight loss and moderate physical activity for about 150 minutes per week. Over the 3 years of the study, participants achieved a weight loss of about 10 pounds or 5%. Although the weight loss was modest, the payoff was a 58% reduction in the development of diabetes in the lifestyle change group compared with a 31% reduction in the metformin group.^5,6 Share these findings with high-risk patients and guide them to lower their risk through lifestyle changes such as losing weight.

Meal Planning

Interventions to manage type 2 diabetes include meal planning, physical activity, blood glucose monitoring and pharmacologic or insulin therapy.

Meal planning should focus on strategies that improve glycemic control as well as lipids and blood pressure. Although weight loss is an important goal to decrease insulin resistance and improve blood glucose levels, patients are often fearful that they will fail. We must devote time and attention to individualizing the meal plan, making every effort to incorporate foods the patient enjoys.

A great way to begin this dialogue is to ask the patient to tell you everything he or she has eaten for the past 24 hours and whether the selection is typical. This 24-hour recall provides guidance for making specific suggestions, examples of which are listed in Table 1.

Consistent carbohydrate counting is a simple method of meal planning in which the patient identifies foods high in carbohydrate (fruit, milk, yogurt, bread, cereal and starchy vegetables) and limits the portion sizes at each meal or snack.⁷ Both simple and complex carbohydrates rapidly convert to glucose during digestion. A patient's total caloric intake should be about 55% to 60% carbohydrate.⁸ To help blunt the rise in glucose, patients should choose foods high in fiber and always consume a carbohydrate with some protein or fat.

Blood glucose monitoring before and 2 hours after the start of meals can determine whether the amount of carbohydrate and medication are appropriate for that meal. Using the 2002 American Association of Clinical Endocrinologists (AACE) recommendations as a guide, we set target blood glucose goals at <120 mg/dL before meals and <140 mg/dL 2 hours after the start of each meal. Remind your patient that although these targets will help achieve A_1C levels of less than 6.5% — greatly reducing the risk of serious complications — any reduction in A1C will lower their risk.

To be successful at carbohydrate counting, patients should measure portion sizes of commonly eaten foods and read nutrition facts labels (Table 2). One carbohydrate serving is approximately 15 grams, and each meal should be limited to about 45 grams. When reading a nutrition label, the most important items to consider are serving size and total carbohydrate. Grams of sugar are already included in the amount of total carbohydrates. Also consider the amount of fat (one serving is 5 grams), fiber and sodium. Although we do not focus on these nutrients, we encourage more fiber and less fat and salt. To help estimate serving sizes, we recommend The Doctor's Pocket Calorie, Fat & Carbohydrate Counter (Family Health Network, 2005 ed.), available in bookstores and at www.calorieking.com.

Once you discuss consistent carbohydrate counting, help the patient calculate a sample breakfast, lunch and dinner using this new skill. At subsequent visits, continue to review 24-hour food recalls to evaluate progress. Use this information to provide further guidance to the patient.

Physical Activity

Regular physical activity helps patients improve glycemic control and hyperlipidemia, decrease insulin resistance, and lose weight.⁸ The increased insulin sensitivity induced by regular physical activity lasts well beyond the exercise, for up to 48 hours. Before recommending a physical activity program, consider the need for a stress test if the patient is older than 40 or you suspect cardiovascular disease.

Patients with diabetes should use perceived exertion rather than pulse to evaluate the intensity of exercise, since medication or neuropathy can interfere with pulse rate. Exercise recommendations should be specific and based on considerations such as the patient's schedule, access, health status and enjoyment. To promote success, help patients choose the type, time and place of exercise. Optimally, the patient should build slowly to at least 20 minutes of continuous activity every other day. Daily exercise promotes greater weight loss. If the patient is on diabetes medication such as insulin or an insulin secretogogue, advise against exercise when those medications are peaking. In addition, patients should test their blood sugar before exercise (and snack if needed) and carry a fast-acting carbohydrate such as glucose tablets, along with medical alert identification.

One simple way to encourage physical activity is to recommend wearing a pedometer. Patients should determine their baseline by wearing the pedometer for a typical day to find out the number of steps they take. They should gradually increase the number of steps to build up to 8,000 to 10,000 per day. Two helpful resources are ClubPed, available at the American Diabetes Association Web site (www.diabetes.org), and the Steps-to-Health Program (www.steps-to-health.org).

Blood Glucose Monitoring

Blood glucose meters come in various sizes and shapes with a variety of features. Some relevant points are listed in Table 3. For a comprehensive list of meters and their features, go to the product resources section at the Diabetes Health magazine Web site (www.diabeteshealth.com) and download the blood glucose meter chart.

Familiarizing yourself with several blood glucose meters will allow you to help patients choose an appropriate meter and learn how to correctly and comfortably test themselves. Patients must know how to obtain an accurate test result as well as what to do with the result.

We recommend working to lower A1C as much as possible, with a target of below 6.5%. To achieve this goal, the premeal glucose checks should be less than 120 mg/dL. Two hours after the start of the meal, the glucose level should be less than 140 mg/dL. These goals are based on AACE guidelines, and are stricter than American Diabetes Association (ADA) guidelines.⁹ For a comparison of glycemic targets, see Table 4. Both organizations would agree that the lower the A1C, the lower the risk of complications.

A common reason patients stop testing or test less often is because nothing is done with the results. When looking at a patient's log book of glucose readings, ask questions to help interpret and prevent highs and lows. Use these real examples to offer suggestions and treatment adjustments. If you treat test results as valuable, patients will view blood glucose monitoring as worthwhile. Don't judge dietary indiscretions. Instead, talk about ways to handle difficult situations appropriately the next time.

Oral Agents

For patients with type 2 diabetes who are unable to achieve target A1C through lifestyle modification alone, a variety of oral agents can be used alone or in combination. Monother-apy results in a 0.5% to 2% reduction in A1C.¹⁰ Combination therapy (two or more oral agents or oral agents and insulin) can result in a further decrease in A1C. The efficacy of treatment depends on matching the patient's underlying defects of insulin deficiency and insulin resistance with the appropriate pharmacologic agent. Patients who would benefit most from insulin sensitizers (thiazolidinediones [TZDs], metformin [Glucophage]) are generally overweight and have dyslipidemia and other characteristics of insulin resistance (central obesity, acanthosis nigricans). Consider insulin secretogogues (sulfonylureas [SUs] and meglitinides) for lean or normal weight patients, patients with no characteristics of insulin resistance, and patients who are relatively insulinopenic. Consider checking C-peptide blood levels, which indicate the amount of endogenous insulin production, to determine whether patients are insulin deficient.¹¹ A low C-peptide would establish the lack of efficacy of an insulin secretogogue.

Medication therapy must be individualized. Consider many factors when choosing an oral agent, including the degree of hyperglycemia, potential side effects, risk for adverse effects, patient preference and cost.

The second-generation SUs are insulin secretogogues; they act on the pancreas to increase insulin production. SUs are metabolized in the liver and cleared by the kidneys, so prescribe them with caution for patients with advanced liver or kidney disease. They are contraindicated in patients with sulfa allergy. An advantage of SUs is their relatively quick response with little or no lag time. We often initiate an SU with a biguanide or TZD, then taper down the SU dose once glucose levels start to improve. Other advantages to SUs are the flexible dosing and relatively low cost (especially for generics). Two potential disadvantages are hypoglycemia and weight gain. Because of the potential for decreased kidney function and hypoglycemia in the elderly, the dose should be carefully adjusted in this age group.

Meglitinides are short-acting insulin secretagogues used to increase insulin release in response to food. They have a rapid onset and should be taken with the first bite at each meal.¹² If the patient skips a meal or eats a meal very low in carbohydrates, the dose should be held. Repaglinide (Prandin) is available in several strengths, and the dose can be adjusted depending on the premeal glucose and the size and carbohydrate content of the meal. Because of their short duration of action, meglitinides tend to cause less hypoglycemia than long-acting SUs. Patient adherence is a concern, since the drug must be taken before every meal and can be very expensive.

Metformin is a biguanide that decreases hepatic glucose output and, to a lesser degree, increases peripheral glucose uptake. In addition to its use as an oral antihyperglycemic, metformin is prescribed to improve ovulation in insulin-resistant women with PCOS and can slow the progression from IGT to type 2 diabetes.^5,13 Metformin suppresses appetite and can produce modest weight loss in some patients. This makes metformin an excellent choice as initial therapy for type 2 patients who are overweight or obese. GI symptoms are the most common side effect, and can often be relieved by taking the medication with food and slowly titrating the dose. Some patients who have difficulty tolerating or remembering to take the generic metformin have success with the once-daily extended release (XR) formulation. For patients who find metformin tablets large and difficult to swallow, a liquid formulation, Riomet, is now available.

In addition to potential weight loss, advantages of metformin include a high initial response rate and no significant risk for hypoglycemia. Metformin is metabolized in the kidneys and should not be used in patients with renal insufficiency (creatinine >1.4 in women, >1.5 in men). Metformin should be used cautiously in patients older than 80 years and should be avoided in patients at risk for lactic acidosis (impaired renal or liver function, heart failure, chronic obstructive pulmonary disease, alcoholism). Patients should skip metformin doses when they have protracted nausea, vomiting, diarrhea or any other risk for dehydration. Metformin should be temporarily stopped before any iodinated contrast dye studies, and should not be resumed until 48 hours later and once normal renal function is established.¹²

TZDs decrease insulin resistance and increase peripheral glucose uptake, with possible preservation of beta cell function.¹⁴ Pioglitazone (Actos) increases HDL and lowers triglycerides.^15,16 In addition, the drug may have protective vascular effects by reducing inflammation and levels of C-reactive protein.¹⁷ A recent study documented that rosiglitazone prevented restenosis after coronary stenting in patients with type 2 diabetes.¹⁸ The effects of TZDs are generally not evident for at least 3 to 4 weeks after initiating therapy. These agents do not cause hypoglycemia. TZDs are contraindicated if alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels are >2.5 times the upper limits of normal. We check ALT and AST at baseline and every 3 months — along with A1C for the first year — and then periodically. TZDs can cause weight gain and fluid retention, especially when used in combination with insulin. New York Heart Association Class III or IV heart failure is an absolute contraindication to TZD use. TZDs may cause resumption of ovulation in premenopausal women, with an increased risk of pregnancy.⁷

The alpha-glucosidase inhibitors, acarbose (Precose) and miglitol (Glyset), work by delaying the absorption of carbohydrate in the small intestine, thereby decreasing postprandial blood glucose. These agents are often prescribed for overweight and obese patients since they do not promote weight gain. GI side effects (gas, bloating) are common. Since carbohydrate breakdown is delayed, hypoglycemia should be treated with glucose and not sucrose or complex carbohydrates. This drug class also is not appropriate for patients with chronic intestinal disorders or cirrhosis (acarbose).¹² The efficacy of these agents is modest.

The United Kingdom Prospective Diabetes Study Group (UKPDS) illustrated the progressive nature of type 2 diabetes and the waning efficacy of monotherapy. After 3 years, only 50% of patients were controlled with monotherapy, and after 9 years, this dropped to 25%.¹⁹ As the disease progresses, most patients require combination therapy to achieve target A1C levels.²⁰ Combining medications with distinct mechanisms of action to target different defects (insulin deficiency and insulin resistance) often improves glycemic control.

Several combination oral medications are available, including Glucovance (glyburide plus metformin), Avandamet (rosiglitazone plus metformin) and Metaglip (glipizide plus metformin). Advantages include convenience, improved adherence and cost (combination pills may require only one co-pay). You may want to initiate the two pills separately at the same time while titrating the dosages, then switch to the combination once the patient is stabilized. For a visual overview of oral agents, see Table 5.

Incretin Mimetic Agents

In April, the FDA approved exenatide (Byetta) as adjunct therapy for type 2 diabetes. This drug is a synthetic version of a polypeptide (exendin-4) found in the saliva of the gila monster lizard. Byetta is known as an incretin mimetic agent. It has glucose regulating properties similar to glucagon-like peptide (GLP-1). By activating the GLP-1 receptor, exenatide increases insulin release in the beta cells as glucose levels rise. It decreases inappropriate glucagon production (often impaired in type 2 diabetes) and delays gastric emptying, which blunts postprandial glucose excursions. In studies of the drug, patients treated with 5-mcg and 10-mcg doses twice daily experienced a significant decrease in A1c without increased hypoglycemia and experienced sustained weight loss.²¹

Exenatide is indicated as adjunctive therapy for type 2 diabetes patients taking metformin or a sulfonylurea to improve glycemic control. It is not recommended for patients with end-stage renal disease or severe gastrointestinal disease. Side effects are mostly gastrointestinal, with mild to moderate nausea being the most common.²² The nausea often dissipates with time.

Exenatide is administered subcutaneously in the upper arm, abdomen or thigh and is available in prefilled 5-mcg or 10-mcg disposable pens. The best time to administer the drug is within 60 minutes before breakfast and before dinner. The drug must be refrigerated or kept cold (36 degrees to 46 degrees F) at all times. For more information, visit www.byetta.com or call (800) 868-1190.

Initiating Insulin Therapy

When A1C targets can no longer be achieved with a combination of oral agents, the next step is initiating insulin therapy. Insulin therapy may also be used intermittently in times of acute illness, chronic hyperglycemia (glucose toxicity), surgery, infection, corticosteroid therapy and pregnancy. The risk of hypoglycemia in intensive insulin therapy can be minimized with adequate patient education and self-management training. The hardest part of initiating insulin therapy is to convince the patient that it is the best treatment for him or her. To avoid it, they may vow to strictly follow their meal plan, physical activity and oral medication regime. If you truly believe the patient will do this, give them a 3-month opportunity to improve their A1C. If no improvement occurs, further delay in insulin therapy will continue to expose the patient to an increased risk of developing complications.²³

Insulin replacement therapy strives to mimic normal physiology. Rapid-acting insulin analogs (Lispro, Aspart, Apidra) can be given up to 15 minutes before a meal to blunt rapid postmeal glucose excursion. Since regular insulin does not start working immediately and can last as long as 5 to 8 hours, rapid-acting analogs provide better coverage.

To mimic normal physiology, a basal or background insulin should be absorbed slowly over a long period of time with little or no peak. Intermediate-acting insulins (NPH and Lente) have an early peak and a long duration but are prone to variable rates of absorption. Ultralente, which takes several hours to start working and peaks anywhere from 6 to 12 hours later, is even more unpredictable than NPH and Lente.²⁴ Glargine is the closest to a basal insulin given its long duration of action and no peak. Table 6 reviews basal and bolus insulins.

When deciding the best way to initiate insulin therapy in the type 2 patient, consider whether the main concern is fasting blood glucose levels, postprandial levels or both. If it is just the fasting plasma glucose (FPG), the use of glargine once a day at any time or NPH at bedtime might be enough to improve glycemic control. If the hyperglycemia only occurs postprandially, consider a premeal rapid-acting analog. If the hyperglycemia is both pre- and postmeal, try 70/30 or 75/25 premixed analog (two shots daily) or glargine and rapid-acting analog (four shots daily). Include the patient in this decision-making process. The 70/30 or 75/25 regimen is certainly more convenient but may provide less flexibility with mealtimes and more hypoglycemia.²⁵

A regimen of basal/bolus glargine and rapid-acting analog produces less hypoglycemia, especially at night, and less weight gain than NPH.⁷ We recommend adding insulin to the oral agents to facilitate improved glycemic control and limited weight gain. Although weight-based insulin regimens can be effective, starting with a modest dose of insulin and titrating up slowly is a safer plan. Rapidly increasing dosages leads to unnecessary hypoglycemia and patient panic.

Insulin therapy should not replace lifestyle modifications. All patients should follow a meal plan and a program of physical activity. When titrating the basal insulin dose, use the FPG as your guide. Determine whether the bedtime FPG reading the night before was elevated because the nighttime reading was high and not treated. In most cases, the glargine or NPH dose should be titrated to an FPG of less than 120 mg/dL.

When titrating the premeal insulin dose, ask the patient to test before and 2 hours after at least one meal per day, and vary the tested meal from day to day. This information helps us evaluate whether the insulin dose is sufficient to "cover" the meal. Also consider the carbohydrate content of the meal. For example, if the patient is taking a fixed dose of insulin before meals but varying the amount of carbohydrate, the postmeal blood glucose will also vary. If the premeal blood glucose is high and the patient takes a fixed dose of insulin before the meal, the postmeal glucose will most likely be high because the insulin taken was only intended to cover the meal.

Variable mealtime doses based on the amount of carbohydrate and premeal blood glucose are more likely to result in a 2-hour postprandial glucose level of less than 140 mg/dL. A consultation with a certified diabetes educator or endocrinologist might be needed to institute such an intensive management plan.

Tips for Success

• When initiating or titrating insulin doses, more frequent blood testing will provide information necessary to make adjustments.

• Glargine should usually be taken once daily at about the same time each day.

• Glargine cannot be mixed in the same syringe with any other insulin.

• Combination insulins such as 70/30 and suspension insulins such as NPH should be mixed before administering each dose, to reconstitute the mixture.

• Insulin pens are generally easier to use and more discreet. Patients may find it easier to take all their doses when not at home. Pens are more expensive, so insurance coverage may be an issue.

• With the exception of glargine, insulin works fastest when injected in the abdomen, followed by the arms and thighs. The buttocks provide the slowest absorption. Unless the blood glucose level is low, premeal insulin should be given in the abdomen or arm to work faster.

• An opened insulin vial or pen should be kept at room temperature for patient comfort. All insulin vials can be used for about 30 days once opened. Recommendations vary for prefilled pens and cartridges, ranging from 10 to 30 days. Check the corresponding package insert for specific guidelines.

Hypoglycemia

The prevention of complications such as hypoglycemia is an ongoing issue. Low blood glucose is more often a risk in patients striving to keep their blood glucose close to normal range.¹⁹ Hypoglycemia is caused by an excess of glucose-lowering medication in relation to food intake and level of activity. People with type 2 diabetes who use insulin or insulin secretagogues are at particular risk for hypoglycemia. The elderly and patients with poor nutrition or hepatic or renal disease are at increased risk for hypoglycemia.

Patients (and many providers) often fear hypoglycemia, making it a barrier to optimal diabetes management. This fear often develops after previous episodes of low or relatively low blood glucose and associated unpleasant symptoms. Patients may feel embarrassed by these episodes, or be afraid of injury or accidents. This can lead to inappropriate self-management practices, such as intentionally keeping glucose levels above target or not taking the full dose of medications. The mood shifts and behavioral changes caused by hypoglycemia can be distressing to family members and coworkers. Educate patients thoroughly about the symptoms, appropriate treatment and prevention of hypoglycemia through self-management training.

Hypoglycemia may occur gradually with some warning symptoms, or have a rapid onset requiring immediate treatment to prevent dangerously low blood glucose levels. Plasma blood glucose levels lower than approximately 70 mg/dL can be defined as hypoglycemia. However, hypoglycemic episodes can vary greatly, even in the same person. Thus, severity should be defined by symptoms as well as the blood glucose reading. Additionally, if the patient is elderly or has hypoglycemic unawareness because of autonomic neuropathy, the threshold for hypoglycemia may be higher. Mild hypoglycemia may include symptoms such as sweating, tachycardia, tingling in the extremities, anxiety and concentration difficulty. Mood shifts and behavioral changes can include giddiness, euphoria, irritation, anxiety, anger, crying and inappropriate behavior. Severe hypoglycemia is the inability to self-treat because of lethargy, mental confusion or unconsciousness.⁷

Your patients at risk for low blood sugar — as well as their close family members, friends and coworkers — should know how to treat hypoglycemia. If the blood glucose is <70 or the patient has symptoms, the patient should ingest 15 grams of a rapid-acting carbohydrate (three or four glucose tablets, 4 ounces of regular soda or juice), which should rapidly raise blood glucose 30 mg/dL to 45 mg/dL. Lower glucose levels (<50 mg/dL) may require 20 grams to 30 grams of carbohydrate. The patient should wait 15 minutes and recheck the blood glucose. If the reading is still low or the patient still has symptoms, he or she should repeat with 15 grams of carbohydrate. This sequence should be repeated until the blood glucose has normalized. The patient should then have a snack or meal within the next hour.²⁶ Instruct patients not to overtreat hypoglycemia, since this often leads to significant rebound hyperglycemia.

Specific advice will help your patient prevent hypoglycemia:

• Avoid delaying or skipping meals when you take diabetes medicines.

• Test blood sugar before exercising. Snack if needed.

• Eat more or take less medicine if you are more physically active than usual.

• Test blood sugar before and every hour while driving.

• Inform friends and coworkers of symptoms of hypoglycemia and where you keep fast-acting carbohydrates.

• Always carry glucose tablets or other fast-acting carbohydrate to treat hypoglycemia.

• Wear MedicAlert identification. It is available at www.medicalert.org.

Sick Day Management

During illness, the body releases stress hormones that cause hyperglycemia and the build-up of ketones. If untreated, this can result in severe dehydration, ketosis or a hyperosmolar hyperglycemic state (HHS) requiring hospitalization.27 Educate patients about how diabetes is affected by illness and what they should do when they are too sick to properly care for their diabetes.

Patients should be aware of the symptoms of hyperglycemia, including polyuria, polydipsia, fatigue, blurred vision and weight loss. Sick day management guidelines should include information on blood glucose targets and when to use supplemental insulin if indicated; how to treat a fever; appropriate diet including fluid replacement; and when to call a provider (uncontrolled hyperglycemia, protracted vomiting and diarrhea, difficulty breathing, persistent fever).

Family members and caregivers should be included in this education, since adequate supervision could help prevent severe dehydration and resulting hospitalization, especially in the elderly, who may be unable to detect their condition worsening.

During illness, the risk of dehydration is high due to decreased fluid intake, vomiting, diarrhea and polyuria. When they are sick and their blood glucose is high, patients should drink at least 8 ounces of calorie-free fluids (caffeine-free diet soda, water) every hour when awake. A major cause of ketosis is inadequate sodium intake, so patients should drink 8 ounces of clear soups or bouillon that provide sodium and electrolytes every 3 hours.⁷

When patients experience nausea or anorexia, liquids or soft foods can provide carbohydrate. In general, 45 to 50 grams of carbohydrates every 3 to 4 hours (150 g/day to 200 g/day) should be adequate to prevent starvation ketosis. Foods containing 15 grams of carbohydrate include ½ cup of apple juice or regular soda, one slice of dry toast, one cup of Gatorade, ½ cup of sherbet or pudding, and ½ cup of regular Jello or ice cream.⁷

A common mistake made by patients when they are sick and not eating normally is stopping diabetes medications, including insulin. This often results in severe hyperglycemia. Instruct patients not to discontinue medications when they are sick, and advise them to check with you early in their illness. The full dose of daily insulin is usually required, and sometimes supplemental doses of a rapid-acting insulin are needed. As mentioned earlier, metformin should be stopped in the presence of nausea, vomiting and diarrhea.

Minimizing Cardiovascular Risk

Cardiovascular disease (CVD) is the major cause of mortality for people with type 2 diabetes. Up to 80% of patients with type 2 diabetes die of macrovascular complications. Type 2 diabetes is an independent risk factor for CVD. Hypertension and dyslipidemia, common conditions in type 2 diabetes, also increase CVD risk.^9,17 When treating patients with type 2 diabetes, interventions must be tailored to modify this increased risk.

Blood pressure measurement is an important part of every diabetes visit. Hypertension is a major risk factor for CVD and the microvascular complications of diabetes, including retinopathy and nephropathy.^19,28 Numerous clinical trials have documented the benefit of blood pressure control in patients with diabetes by reducing CVD events, stroke and nephropathy.^19,25 Aggressive blood pressure control is just as important as glycemic control in reducing morbidity and mortality in patients with type 2 diabetes.²⁹

The ADA and the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) recommend a blood pressure goal of <130/80 mm Hg for patients with diabetes.^9,28 Blood pressure elevations should be confirmed on a separate day. Strategies to achieve blood pressure goals include lifestyle modification and pharmacologic therapy. Recommended lifestyle changes include weight control, sodium restriction, regular physical activity, moderation of alcohol intake and smoking cessation. Often, lifestyle modifications alone are not adequate to achieve blood pressure goals, so medications are needed. All patients with diabetes and hypertension should be treated with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (if tolerated). Both agents delay the progression to macroalbuminuria and nephropathy and reduce CVD events.^30,31 If these agents are not tolerated or additional medication therapy is needed, beta blockers, diuretics and calcium channel blockers can also reduce cardiovascular events.³² Many patients require multidrug regimens to reach goal blood pressure. The choice of medications depends on patient preference, comorbid conditions, the ability to tolerate side effects and cost.

Patients with type 2 diabetes are predisposed to dyslipidemia, which contributes to a two- to fourfold increased risk of CVD.⁹ The most common lipid abnormalities are elevated triglycerides and low HDL. The LDL are smaller, denser and therefore more atherogenic. Management strategies to lower LDL and triglycerides and raise HDL can reduce macrovascular disease and mortality, especially in patients with a prior cardiovascular event.³³

The ADA recommends checking lipids at least annually in type 2 diabetes patients, and more often if needed to achieve goals. The ADA recommendation for lipid goals are total cholesterol of <200, triglycerides <150, LDL <100, and HDL >40 in men, >50 in women. Lifestyle modification (diet low in cholesterol and saturated fat, weight loss, regular physical activity and smoking cessation) can help improve lipids in patients with diabetes. Patients who cannot achieve lipid goals with lifestyle changes need medication therapy.

The revised National Cholesterol Education Program Adult Treatment Panel III cholesterol treatment guidelines also recommend LDL of <100 in high-risk patients, and an even lower goal (<70) for patients at extremely high risk (diabetes with a history of a cardiovascular event).³⁴ Statins are the drugs of choice.³⁴

The emphasis on statin therapy is evident in the results of the Heart Protection Study, which demonstrated that in diabetes patients older than 40 years with a total cholesterol of >135, lowering LDL with a statin reduced major cardiovascular events by approximately 25%, regardless of baseline LDL.³⁵ The American College of Physicians (ACP) recommends statins for all adult patients with type 2 diabetes and other cardiovascular risk factors for the primary prevention of macrovascular complications.³⁶ Combination therapy with statins and a fibrate or niacin may be used to improve parts of the lipid profile. One arm of the ongoing ACCORD trial compares whether treatment with a statin plus fibrates reduces the rate of CVD more than using statin therapy alone.³⁷ Combination therapy can be associated with an increased risk for transaminitis, myositis and rhabdomyolysis.⁹

Low-dose aspirin therapy is recommended as primary and secondary therapy to prevent cardiovascular events.³⁸ Ask all patients about smoking status and aggressively encourage smoking cessation.³⁹

Preserving Kidney Function

Diabetic nephropathy is the leading cause of end-stage renal disease (ESRD). Microalbuminuria (30 mcg/mg to 299 mcg/mg creatinine) is a marker for the development of nephropathy in type 2 diabetes, as well as a marker of increased cardiovascular risk.^9,40

All type 2 patients should be screened at diagnosis and annually for microalbuminuria. This is easily accomplished with a spot urine sample. Results are interpreted according to established parameters: normal is <30 mcg/mg, microalbuminuria is 30 mcg/mg to 299 mcg/mg, and macroalbuminuria is 300 mcg/mg and higher. To diagnose microalbuminuria, at least two of three tests measured within a 6-month period should show elevated levels. Many factors can affect urine albumin excretion, including fever, infections, marked hyperglycemia, hypertension, heart failure and recent exercise.⁴¹

To reduce the risk of nephropathy or slow its progression, the goals for your patients should be optimal blood glucose and blood pressure control.^19,29 Prescribe either ACE inhibitors or angiotensin receptor blockers (if tolerated and not contraindicated), since both can delay the progression to macroalbuminuria and nephropathy.⁴¹

Saving Vision

Diabetic retinopathy is the leading cause of blindness in adults between the ages of 20 and 74 years.⁴² Since many type 2 patients with potentially vision-threatening disease often have no symptoms, it is imperative that all patients have an initial and annual dilated comprehensive eye exam by an ophthalmologist or optometrist experienced in diagnosing and managing diabetic retinopathy.⁹ More frequent exams may be necessary if retinopathy is present or progressing, or other diabetes-related eye conditions, including cataracts and glaucoma, are present.

As with nephropathy, glucose and blood pressure control are key to preventing or delaying the onset and progression of diabetic retinopathy.^19,29

Foot Care

Foot ulceration and amputation are the most common consequences of diabetic neuropathy and are major causes of disability, morbidity and mortality. Amputation is one of the most feared consequences of uncontrolled diabetes.⁴³ Early recognition and management of risk factors, along with preventive foot care, can reduce the incidence of lower extremity complications.

The risk of foot ulcers and amputation is increased in men and patients whose diabetes is poorly controlled, whose disease was diagnosed more than 10 years prior, and who have cardiovascular, retinal or renal complications. Other conditions that increase amputation risk include peripheral neuropathy with loss of protective sensation, bony deformities, calluses or erythema indicating increased pressure, peripheral vascular disease, nail pathology, smoking and past history of ulcers or amputation.⁴⁴

Perform a comprehensive foot exam on all patients with diabetes to identify risk factors for ulcers and amputations. This includes assessment of foot structure, skin integrity, protective sensation (using a Semmes-Weinstein monofilament), and vascular status (pedal pulses). Note bony deformities (bunions, hammertoes) that can result in pressure and skin breakdown. Evaluate any problems with balance and gait. Check between the toes for tinea. Screen for peripheral vascular disease by asking about a history of claudication. An ankle-brachial index (ABI) may be appropriate, since many patients with arterial insufficiency have no symptoms.⁹ Refer for further vascular assessment if necessary. Urge cessation in any patient who smokes.

Perform a comprehensive annual foot exam on all patients with diabetes, and a visual inspection at each routine visit. Refer high-risk patients to a podiatrist or other foot care specialist for regular follow-up and preventive care, including therapeutic footwear if needed. Teach patients the basic principles of foot care as part of their self-management plan. Daily foot care is an important step in preventing lower extremity amputations. Patient education material is available free from BD at http://www.bddiabetes.com/us/understanding/footcomp.asp?printfriendly=true.

Dental Care

People with diabetes are at increased risk for periodontal disease, dental caries and other oral infections. That risk is significantly reduced with good oral hygiene, regular dental checkups and blood glucose control.⁴³ Encourage patients to have a cleaning and checkup at least every 6 months, and more often if periodontal disease exists.

Immunizations

Influenza and pneumonia are preventable infectious diseases associated with high morbidity and mortality in patients with diabetes. The Centers for Disease Control and Prevention recommend influenza and pneumococcal vaccines for all people with diabetes.^45,46 The ADA recommends an annual flu vaccine for diabetic patients 6 months and older and one lifetime pneumonia vaccine for all patients with diabetes. A one-time revaccination for pneumonia is recommended for patients older than 64 years if the previous vaccine was given when they were younger than 65 and if the vaccine was given more than 5 years previously.⁴⁷

Collaboration

Diabetes education and management is evidence based and goal directed. Goals should be individualized based on each patient's overall health status, motivation and support systems. For example, the goals we mentioned for A1C and blood glucose monitoring may need to be adjusted for elderly patients, or patients with frequent hypoglycemia or hypoglycemia unawareness. Also, a patient may be motivated to check blood glucose more often, but may lack a prescription plan that pays for the testing supplies, which can be prohibitively expensive if paying out of pocket.

Patient involvement in diabetes self-management is key to successful glucose control. All therapeutic choices should involve collaboration between you and your patient. Knowing what the most effective treatment options are is not always the same as knowing what's best for each patient. For instance, there is a tendency to label patients "noncompliant" if they do not follow a complex diabetes regimen. A patient may choose not to follow advice for many reasons: side effects or fear of them, inconvenience, time, cost and lack of self-efficacy. Identify these potential barriers to adherence (including knowledge deficits, lack of health insurance or depression) and provide the necessary education and support. When asked to adopt a new diabetes self-management behavior, patients often perform a cost-benefit analysis in their head. It is our job to help tip the scale by highlighting the benefits and reducing the barriers.

Patient education should build on existing knowledge and motivate the patient to perform self-management. Handing out educational material without review is not education. Handouts should reinforce and expand on what has just been taught. Instruction in survival skills such as blood glucose monitoring and insulin administration should include demonstration and return demonstration. Encourage family members to sit in on educational sessions, especially whoever shops for food and does the cooking.

The most important point when establishing self-management goals is that patients perceive the goals as both valuable and achievable. Telling your obese patient that he has to lose 50 or more pounds can cause him to be frustrated before even starting any weight loss program.

To assist your patients in setting self-management goals, ask what they would most like to work on, or what part of managing diabetes they find most difficult. By focusing on meaningful goals, patients will be more motivated to make appropriate behavioral and lifestyle changes.

To keep track of patient self-management, we find it helpful to use flow sheets in each chart. With electronic records, you can incorporate reminders to alert you to the tests needed. We provide patients with a "passport" to help them keep track of their goals, with information about how often tests and screening are needed. The passport can also include medications, appointments and provider information (Table 7).

The secret to optimally managing type 2 diabetes is to build a partnership with your patient and set mutually agreed upon goals. Start by setting one or two small, achievable goals so that the patient will be successful. Small successes over time will add up to big gains in reducing long-term complications and improving quality of life.

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Jane Jeffrie Seley is a gerontological nurse practitioner and certified diabetes educator who specializes in diabetes at New York Presbyterian/Weill Cornell Medical Center in New York City. She serves on the program publications editorial board of the American Diabetes Association, is a member of the New York City Leadership Council of the ADA, and chairs the annual NYC Diabetes Expo. She is also a contributing editor for the American Journal of Nursing, for which she coordinates a column called "Diabetes Under Control."

Esther Wei is an adult nurse practitioner who specializes in diabetes at Cornell Internal Medicine Associates at New York Presbyterian/Weill Cornell Medical Center in New York City. She is a certified diabetes educator and a clinical coordinator for the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.

The authors have completed a disclosure statement and report no real or perceived conflicts of interest related to this article.