Diabetes Treatment Options: One Size Does NOT Fit All

I wake up every day wondering about the challenges the day will hold. I say this in the most positive and excited manner. In 2012, there are numerous treatments for diabetes care. As a health care provider, I am challenged to stay current in my knowledge and to understand how best to incorporate the various therapies into the plan of care for each of my patients. How do I cope?

As a nurse practitioner in the diabetes world, I see my role as providing support to my patients to help them achieve the best possible treatment outcomes and reduce their risk of diabetes-related complications. When recommending treatment options, I strive to keep in mind the importance of the therapy, the unique characteristics of the patient, and the impact the therapy may have on the patient's quality of life.

My practice model relies on the development of an open and honest relationship with my patients that includes the expectation of frequently verbalized reality checks. I strive to provide honest answers about diabetes care, available treatments, accurate interpretation and application of research findings, and long-term views of diabetes outcomes to help the person in front of me understand the options. In addition, I rely on honesty from my patients regarding what they are willing and able to do for their diabetes care and how they will proceed upon leaving my office to go where their real life exists.

Patients are ultimately in control of their own diabetes care, and I am a support system to assist and guide them toward their goals. They are in charge, and luckily for both of us, I do not go home with them!

All patients' needs are not the same, and my patients trust me to be “in the know.” It is my job to be knowledgeable about and understand the value of all available medical treatments and devices. I must keep an open mind about the value each treatment can provide and not allow any potential personal bias to influence decisions. Additionally, I must avoid falling into a “program rut” in which I defer to a one-size-fits-all approach to treating my patients with diabetes.

I must also recognize and seek out the other health care team members needed to help with the care of my patients.

As health care providers, we often overestimate patients' concerns about daily treatment requirements and underestimate their concerns regarding their long-term outcomes. Although diabetes and its available therapies are often a burden, patients are less worried about the number of injections they must take and more concerned about whether they will escape kidney failure. If they have an understanding of the therapy and its potential benefit to them, they are more likely to be willing to try that therapy.

When presenting a therapy to my patients, I am obligated to have a clear understanding of how it works, convey a realistic view of its potential benefits, provide a detailed explanation about how to use the therapy, and verify that the patient has sufficient information to be successful. I rely on my patients to work with me to incorporate the therapy into their lives. Along the way, further discussion is often needed to ensure that patients have the information they need to achieve their desired goals. If the therapy is not optimal, we must continue to try other options until we determine the best therapy for that patient at that point in time.

The big question is, how do we, as health care providers, stay up to date on all available therapies? It is not an easy task for any profession, but it is immensely challenging for primary care providers who are expected to have an understanding of many diseases and conditions beyond diabetes.

The answer: we read, attend meetings, participate in grand rounds, and communicate with each other. We share patients and use all professional resources available. In our center, that includes reaching out to dietitians, educators, psychologists, and many others. As a team, we challenge each other to learn and grow. We discuss the needs of our patients and ask what else can be done to provide a better life with diabetes for our patients. How do we provide care that will result in a better outcome? If I want to continue to practice in the world of diabetes, it is my job, as well as the job of my colleagues on the multidisciplinary diabetes care team, to always be on the cutting edge.

In this issue of Clinical Diabetes, we offer two feature articles that may bolster readers' understanding of the best uses of and costs associated with the available diabetes therapies. The first, by Lisa S. Rotenstein, BA, et al. (p. 44) describes the characteristics of an “ideal” diabetes therapy from the perspectives of patients, providers, payors, and financial analysts. The authors take a careful look at how well existing and emerging therapies meet the criteria for “ideal” by these various stakeholders. The second, by Pendar Farahani, MD, MSc (p. 54), highlights the methodological considerations that should be addressed in designing and interpreting comparative cost-effectiveness drug studies to support clinical decision-making.

Also in this issue, Nathaniel G. Clark, MD, MS, RD, reviews a recent research study of postprandial glucose (PPG), cardiovascular events, and all-cause mortality (p. 67). This article provides information about the influence of PPG on the measure of A1C and about the impact of PPG on cardiovascular risk, and it offers guidance on when PPG should be monitored in clinical practice.

Case studies showcasing real-life experiences using U-500 concentrated insulin (p. 70) and advancing therapy for type 2 diabetes after metformin (p. 72) are also included. These case studies provide guidance through example about how to handle such common situations in routine clinical practice.

I realize that the information offered in the pages of this journal is just the tip of the iceberg of what we need to know to manage diabetes care. As editor of Clinical Diabetes, it is my goal to add to our readers' knowledge and to support their efforts to deliver up-to-date, individualized, and quality care.

In 2012, we have so much to offer our patients. Please don't say, “I just don't have the time to use that new therapy.” Find the time or get assistance from other health care team members or make referrals.

Our patients deserve the best care possible. We have many choices and tools to manage diabetes. If you are not using these newer therapies, I encourage you to ask yourself why. Are you stuck in a “program rut”? Challenge the boundaries of your treatment comfort zone to explore and embrace the numerous options available so that you can provide exceptional and individualized care to your patients with diabetes.

As always, I encourage each of you to share your thoughts, ideas, and case studies for possible publication in the journal. I can be reached via e-mail at dkruger1{at}hfhs.org.

• American Diabetes Association(R) Inc., 2012