H. Referral for diabetes management - Diabetes Care

H. Referral for diabetes management
For a variety of reasons, some people with diabetes and their health care providers do not achieve the desired goals of treatment (Table 6). Intensification of the treatment regimenis suggested and includes identification (or assessment) of barriers to adherence, culturally appropriate and enhanced DSME, comanagement with a diabetes team, change in pharmacological therapy, initiation of or increase in SMBG, more frequent contact with the patient, and referral to an endocrinologist.

I. Intercurrent illness

The stress of illness, trauma, and/or surgery frequently aggravates glycemic control and may precipitate diabetic ketoacidosis (DKA) or nonketotic hyperosmolar state. Any condition leading to deterioration in glycemic control necessitates more frequent monitoring of blood glucose and urine or blood ketones. A vomiting illness accompanied by ketosis may indicate DKA, a life-threatening condition that requires immediate medical care to prevent complications and death; the possibility of DKA should always be considered. Marked hyperglycemia requires temporary adjustment of the treatment program and, if accompanied by ketosis, frequent interaction with the diabetes care team. The patient treated with oral glucose-lowering agents or MNT alone may temporarily require insulin. Adequate fluid and caloric intake must be assured. Infection or dehydration is more likely to necessitate hospitalization of the person with diabetes than the person without diabetes. The hospitalized patient should be treated by a physician with expertise in the management of diabetes, and recent studies suggest that achieving very stringent glycemic control may reduce mortality in the immediate postmyocardial infarction period. Aggressive glycemic management with insulin may reduce morbidity in patients with severe acute illness.

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For further information on management of patients in the hospital with DKA or nonketotic hyperosmolar state, refer to the ADA position statement.

J. Hypoglycemia


* Glucose (15??20 g) is the preferred treatment for hypoglycemia, although any form of carbohydrate that contains glucose may be used, and treatment effects should be apparent in 15 min. (E)
* Treatment effects on hypoglycemia may only be temporarily corrected. Therefore, plasma glucose should be tested again in 15 min as additional treatment may be necessary. (B)
* Glucagon should be prescribed for all patients at significant risk of severe hypoglycemia and does not require a health care professional for its administration. (E)

Hypoglycemia, especially in insulin-treated patients, is the leading limiting factor in the glycemic management of type 1 and type 2 diabetes. Treatment of hypoglycemia (plasma glucose <70 mg/dl) requires ingestion of glucose- or carbohydrate-containing foods. The acute glycemic response correlates better with the glucose content than with the carbohydrate content of the food. Although pure glucose may be the preferred treatment, any form of carbohydrate that contains glucose will raise blood glucose. Adding protein to carbohydrate does not affect the glycemic response and does not prevent subsequent hypoglycemia. Adding fat, however, may retard and then prolong the acute glycemic response.

Rare situations of severe hypoglycemia (where the individual requires the assistance of another person and cannot be treated with oral carbohydrate) should be treated using emergency glucagon kits, which require a prescription. Those in close contact with, or having custodial care of, people with diabetes, such as family members, roommates, school personnel, child care providers, correctional institution staff, and coworkers, should be instructed in use of such kits. An individual does not need to be a health care professional to safely administer glucagon. Care should be taken to ensure that unexpired glucagon kits are available.

K. Immunization


* Annually provide an influenza vaccine to all diabetic patients 6 months of age. (C)
* Provide at least one lifetime pneumococcal vaccine for adults with diabetes. A one-time revaccination is recommended for individuals >64 years of age previously immunized when they were <65 years of age if the vaccine was administered >5 years ago. Other indications for repeat vaccination include nephrotic syndrome, chronic renal disease, and other immunocompromised states, such as after transplantation. (C)

Influenza and pneumonia are common, preventable infectious diseases associated with high mortality and morbidity in the elderly and in people with chronic diseases. There are limited studies reporting the morbidity and mortality of influenza and pneumococcal pneumonia specifically in people with diabetes. Observational studies of patients with a variety of chronic illnesses, including diabetes, show that these conditions are associated with an increase in hospitalizations for influenza and its complications. Based on a case-control series, influenza vaccine has been shown to reduce diabetes-related hospital admission by as much as 79% during flu epidemics. People with diabetes may be at increased risk of the bacteremic form of pneumococcal infection and have been reported to have a high risk of nosocomial bacteremia, which has a mortality rate as high as 50%.

Safe and effective vaccines are available that can greatly reduce the risk of serious complications from these diseases. There is sufficient evidence to support that people with diabetes have appropriate serologic and clinical responses to these vaccinations. The Centers for Disease Control??s Advisory Committee on Immunization Practices recommends influenza and pneumococcal vaccines for all individuals >65 years of age, as well as for all individuals of any age with diabetes.

For a complete discussion on the prevention of influenza and pneumococcal disease in people with diabetes, consult the technical review and position statement on this subject.


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May 27, 10 • Diabetes mellitus