Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: PHARMACOLOGICAL THERAPIES | 6-6

THE IMPORTANCE OF PHARMACOLOGICAL MANAGEMENT

A comprehensive approach to the management of both type 1 and type 2 diabetes involves a shared approach to individualized SMART goal and target setting, healthy behaviour intervention support, individualized pharmacologic glycemic management and medications for cardiovascular and renal protection in certain identified populations. This chapter will address the pharmacologic glycemic management considerations for people living with either type 1 or type 2 diabetes. For more information on indicated medications for cardiovascular and renal protection in high-risk populations, readers are referred to The Essentials, chapter 9. The Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada (2018 Guidelines) and its updates advocate for the holistic management of all people with diabetes to minimize risk and improve health outcomes (13), yet studies still reveal 40-60% of people with diabetes have suboptimal glycemic control (14). This disparity between guideline recommendations and clinical practice is known as clinical inert ia “the failure of health-care providers to initiate or intensify therapy in a timely manner according to evidence-based clinical guidelines” (15). • A systematic review on the management of hyperglycemia in people with type 2 diabetes demonstrated the median time to treatment intensification was greater than one to three years (0.3 to >7.2 years) after an elevated A1C measurement (15). • A UK cohort study of >80,000 people with type 2 diabetes showed it took 1.6 to three years before another oral antihyperglycemic agent was added with A1C >7.0% to >8.0%. The median time for intensification with a third oral antihyperglycemic agent or insulin therapy was six to seven years in people with a mean A1C of 8.7%-9.7% (14). Clinical inertia, also known as therapeutic inertia, can be attributed to both health-care provider and person-centred factors. It is important providers not only be cognizant of their own views on intensifying diabetes management, but routinely address concerns of individuals with diabetes. The diabetes educator can play an instrumental role in helping reduce therapeutic inertia by supporting the person with diabetes through goal-setting, blood glucose monitoring (awareness and education), healthy behaviour support and/or advocating for the initiation and intensification of therapy.