Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: PHARMACOLOGICAL THERAPIES | 6- Management of Symptomatic hyperglycemia and/or metabolic decompensation • If presenting with evidence of metabolic decompensation (marked hyperglycemia, ketosis or unintended weight loss) and/or symptomatic hyperglycemia (polyuria, polydipsia, polyphagia): → Initiate insulin therapy regardless of presenting A1C and consider adding metformin. (Note that because A1C is a reflection of blood sugars over the past 3 months, the A1C can be near-normal, while the person could be experiencing an acute hyperglycemic crisis) o Rationale: To reduce glucose toxicity and achieve rapid-lowering of BG levels. Hyperglycemia is associated with accelerated rates of beta cell apoptosis; early aggressive treatment of hyperglycemia with intensive insulin therapy has been shown to preserve beta cell function. Early insulin treatment may lead to remission in people with newly diagnosed type 2 diabetes (see Chapter 3: Pathophysiology) (24). o Can taper or discontinue insulin therapy once glycemic levels have been stabilized and acute hyperglycemic crises / underlying cause has been resolved. People stabilized on doses of <25 to 35 units of insulin per day can likely achieve glucose targets with oral antihyperglycemic therapy (25). o Temporary use of insulin at diagnosis : During illness, pregnancy, stress, medical procedure or surgery or during an acute hyperglycemic crisis such as diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar non-ketotic syndrome (HHNS) 2. SUPPORT HEALTHY BEHAVIOUR INTERVENTIONS AND ASSESS GLYCEMIC CONTROL Once urgent medical care is ruled out, conversations to support the person with diabetes should seek to engage the individual in healthy behaviour interventions (lifestyle changes expected to reduce blood glucose levels, including healthy eating and physical activity, as well as smoking cessation, to reduce the risk of developing smoking-related diseases). SELECT INDIVIDUALIZED A1C TARGET Glycemic control is assessed and consideration is made to select the person’s individualized A1C target, see Diabetes Canada Quick Reference Guide “Targets for glycemic control” (image below). Of note, unlike the management of a person with type 1 diabetes, where the lowest individualized A1C target considered would likely be less than or equal to 7.0%, [DCCT (1)] in the management of an adult with type 2 diabetes at low risk of hypoglycemia, an A1C target of less than or equal to 6.5% should be considered to reduce the risk of CKD and retinopathy [ADVANCE(6)]. 3a. • Assess recent dietary patterns and weight change as unintentional weight loss should prompt consideration of other diagnoses, e.g. type 1 diabetes and pancreatic disease