Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: PHARMACOLOGICAL THERAPIES | 6-62 o A1C 0.44% (p<0.001, higher likelihood of achieving A1C <7.0% (1.92; p<0.0001). o Weight loss (-3.22kg; p<0.0001) with no increased risk of hypoglycemia. o When compared with basal-bolus therapy, the combination basal/GLP1-RA:  Lowered A1C by 0.1% (p=0.460) and the risk of hypoglycemia by 0.67 (p=0.526).  Associated with a mean weight loss of 5.66 kg (p<0.0001). • Consider uptitrate GLP-1 RA to maximally-tolerated dose before adding prandial insulin • Refer to the later section on fixed dose combination GLP1-RA and basal insulin for more information. 3. Add prandial insulin: Basal plus insulin therapy • Starting with one injection of prandial (bolus) insulin at the largest meal • Metformin, DPP-4 inhibitor, GLP1-RA or SGLT2 inhibitor should be continued to improve glycemic control, minimize the dose of bolus insulin required, and minimize risk of weight gain and hypoglycemia. • Additional mealtime bolus injections should be added using a stepwise approach (for example, at three-month intervals) as needed. o Studies have shown the stepwise progression to basal-bolus therapy was associated with similar glycemic control, less hypoglycemia and better individual satisfaction than immediately implementing a basal-bolus regimen (42). Education The principles of adult learning and techniques, such as motivational interviewing and empowerment theory must be applied to facilitate the education of the person with diabetes on insulin therapy. It is important to be sensitive to each individual’s feelings, concerns, and needs related to insulin self-administration. Other factors, such as cultural health beliefs, the social stigma of using needles/injecting, regimen complexity and cost can contribute to the individual’s reluctance to initiate insulin therapy (154,155). There is extensive research illustrating a reluctance to initiate insulin by both the individual with diabetes and the healthcare provider (154). These barriers can result in the delay in insulin initiation at a cost of poor glycemic control and the subsequent development of complications. A study by Polonsky showed that 28.2% of insulin-naïve people with diabetes indicated an unwillingness to take insulin, if ordered (156). The Diabetes Attitudes, Wishes and Needs study (DAWN) found 50 to 55% of general physicians delayed insulin treatment until it was deemed “absolutely necessary”; however, this was less of an issue with specialist care (157). Other health-care provider barriers include the following: insulin is associated with hypoglycemia, weight gain and subsequent increased insulin resistance; the person’s reluctance to start; and