Diabetes
A Complex Disease with Many Options for Management
June 16, 2010
Davida F. Kruger, MSN, APN-BC, BC-ADM
Diabetes is a complex disease that requires more than just managing blood glucose levels for a positive outcome. Standards of care include paying attention to blood pressure, lipids, and weight. Our understanding of diabetes continues to evolve as we learn better ways to care for people with the disease.
For many years we thought the only hormones involved in the management of diabetes were insulin and glucagon. Today we know better. We have an improved understanding of the incretin effect and also the hormone amylin’s role in diabetes. Through our knowledge of the incretin effect and the hormone amylin, new therapies have become available for diabetes management. Additionally, a variety of new technologies are available to better manage the disease as well.
When I became part of the diabetes world more than 20 years ago, we had limited choices in therapies and little technology to manage diabetes. With so many choices, how does one decide which to incorporate into the care of their patients? And how do patients decide which they want to use in their diabetes care? How does one decide if the new therapies and tools are better, provide an improved outcome, or just add complexity to the process?
For patients with type 2 diabetes, both DDP-4 inhibitors and GLP-1 agonists leverage the incretin physiology. DPP-4 inhibitors are oral medication, while GLP-1 agonists are injectables. In the past, the only injectable therapy for a type 2 diabetes was insulin, and was not used until later in the course of diabetes when, in addition to insulin resistance, the beta cell began showing signs of burnout. Despite being an injectable therapy, current GLP-1 therapies may offer patients with diabetes clinical benefits beyond glycemic control and could be used earlier.
Insulin therapy continues to evolve. Prandial insulin’s actions are now faster, thus making it a more versatile therapy. The new analogue insulins provide less hypoglycemia and less weight gain. New therapies that leverage the amylin physiology offer insulin-using patients better postprandial control, less glycemic fluctuation, and the potential for weight loss.
How about technology? A continuous glucose monitor (CGM) is the newest available technology to monitor blood glucose. The sensor worn on the body transmits over 200 blood glucose values daily to a receiver. Patients have an opportunity to look at the trends of their blood glucose as they are transmitted as well as download the data to share with their healthcare team to assist with interpretation. The data provided by the CGM has the ability to assist with better management of blood glucose excursions, and help the patient achieve treatment goals.
Insulin pump therapy continues to improve and remains a valuable tool for the patient. There is a learning curve associated with initiation of pump therapy requiring training on the mechanical components as well as how to dose insulin. However, for the patients that use this therapy it can help achieve better blood glucose control.
With our evolving understanding of the diabetes disease state, new therapies and technologies will continue to emerge. As new therapies become available it will be important for the healthcare provider to understand each of them so that they can be offered to the patient. Education and support for the patient is needed so that these new therapies can be incorporated into their lives and maximize the benefits they provide. It is easy to shy away from newer therapies that may be less complex, but ultimately the goal is to provide the best diabetes care and each patient deserves the opportunity to have the best possible outcome.
Davida Kruger is a certified nurse practitioner in diabetes at
Henry Ford Health System in Detroit, Michigan.
For more related articles, click Diabetes Perspectives.