Patient discussions

  • Patients should be advised that frequent medication adjustments represent good care, and are not a sign of failure or a reason for self-blame or guilt.

  • The use of blood glucose monitoring (previously known as self-monitoring of blood glucose) to promptly identify loss of glucose control and proactively adjust therapy is an essential self-management skill when using multidose insulin regimens, and requires patient education and easy access to health team members between scheduled office visits.[2]

  • Those on multidose insulin regimens are often advised to use continuous glucose monitoring equipment, or to monitor blood glucose before meals and at bedtime.[2]

  • In other patients with diabetes, blood glucose monitoring may be useful to assess the impact of changes in diet, medication regimen, and exercise, as well as to guide dietary and fluid intake and medication management during episodes of illness.[431][445]

  • Digital coaching and digital self-management interventions can be effective methods to deliver diabetes self-management education and support.[2]

  • All women of childbearing age with diabetes should be counseled about the importance of strict glycemic control prior to conception, and offered advice on nutrition as well as general diabetes education.[2][315]​ They should also be advised of the risks that uncontrolled diabetes can pose to themselves and the pregnancy.[315] Inform patients that during pregnancy: glycemic targets are generally lower; regimens need to be regularly adjusted; and insulin is the chosen antihyperglycemic agent when nutrition therapy is not enough to achieve glycemic goals.[315] Contraception options should be explored for those not planning a pregnancy.[315] Prenatal counseling should include information about the increased risk of development and/or progression of diabetic retinopathy during pregnancy.[2] Due to the higher risk of fetal neural tube defects in patients with diabetes, women should be strongly advised to start taking folic acid once they are planning a pregnancy.[315]

  • Patients should receive counseling on how to prevent and promptly identify eye, foot, kidney, and cardiovascular (CV) complications. Communication of CV risk to patients has been shown to lead to small but significant reductions in the CV risk score at 6- to 12-month follow-up, as well as reductions in mean blood pressure and cholesterol, and should be considered in routine consultations.[446]

  • Patients should be taught how to identify and manage hypoglycemia, and the importance of preventing it.[103] A standardized education format is recommended, with evidence demonstrating a reduction in severe hypoglycemia with this approach.[103] Advice should be individualized, accessible in a variety of forms and evolve according to the needs of the patient.[103] They should be advised that low blood glucose (<70 mg/dL [<3.9 mmol/L]) is often accompanied by symptoms such as tachycardia, sweating, shakiness, intense hunger, or confusion, and must be dealt with promptly by ingesting 15-20 g of carbohydrate (equivalent to 3-4 glucose tablets of 5 g per tablet).[2] After self-treatment, blood glucose should be checked if possible and the treatment repeated if required. Once the blood glucose trend is increasing, the person should consume a meal or snack to prevent the recurrence of hypoglycemia.[2] Instruct patients to promptly report nocturnal hypoglycemia or recurrent episodes of hypoglycemia so that therapy may be adjusted.[2] Patients should have a carbohydrate snack prior to exercise if blood glucose is <90 mg/dL (<5.0 mmol/L) and the patient is taking insulin or an insulin secretagogue (e.g., a sulfonylurea or meglitinide).[2] Glucagon is indicated for hypoglycemia in patients unable or unwilling to consume carbohydrates by mouth, and those at increased risk of level 2 or 3 hypoglycemia.[2] Different formulations of glucagon are available, with the Endocrine Society recommending ready-to-use preparations.[103] A close companion should be instructed on how to administer glucagon.[2] For further information, see Diabetic hypoglycemia.

  • Well-fitting footwear is recommended for people with neuropathy or increased plantar pressure.[2] The use of specialized therapeutic footwear is recommended for people with diabetes at high risk for ulceration, including those with loss of protective sensation, foot deformities, ulcers, callous formation, poor peripheral circulation, or history of amputation.[2]

  • Patients should be encouraged to discuss any mental health concerns or feelings of depression with their physicians so that appropriate treatment can be offered.[2] Physicians can help prompt these conversations with informal verbal inquiries: for example, by asking whether the patient has experienced any persistent changes in mood, or if there are any new or different barriers to their diabetes treatment.[2] Ideally, qualified mental health professionals with specialized training and experience in diabetes should be integrated with or provide collaborative care as part of diabetes care teams.[2]

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