Self-Management Education Key in Managing Hyperglycemia in Diabetes

Diabetes self-management education and support (DSMES) is a key intervention in managing hyperglycemia in type 2 diabetes (T2D), according to a new consensus update.

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) co-published the consensus update on management of hyperglycemia in T2D in the ADA journal Diabetes Care¹ and EASD’s journal Diabetologia.

DSMES is as important to the treatment plan as the selection of pharmacotherapy, the consensus update noted. “High-quality evidence has consistently shown that DSMES significantly improves knowledge, glycemic levels, and clinical and psychological outcomes, reduces hospital admissions and all-cause mortality, and is cost-effective,” the authors wrote.

DSMES is delivered through structured educational programs provided by trained diabetes care and education specialists who focus on lifestyle behaviors (healthy eating, physical activity, and weight management), medication-taking behavior, self-monitoring when needed, self-efficacy, coping, and problem solving.

The consensus update also recommends an individualized, personalized approach in treating hyperglycemia. “Providing person-centered care that addresses multimorbidity and is respectful of and responsive to individual preferences and barriers, including the differential costs of therapies, is essential for effective diabetes management,” the authors wrote.

They also noted that, with “compelling” indications for therapies such as sodium/glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) for high-risk individuals with cardiovascular disease, heart failure, or chronic kidney, “shared decision-making is essential to contextualize the evidence on benefits, safety, and risks.”

“Providers should evaluate the impact of any suggested intervention in the context of cognitive impairment, limited literacy, distinct cultural beliefs, and individual fears or health concerns,” the authors added.

The consent also includes updates the science on glucose-lowering therapies, such as SGLT2i oral medications.

The use of SGLT2i medications have significantly expanded, based on cardiovascular and renal outcome studies. Cardiorenal outcome trials have demonstrated their efficacy in reducing the risk of composite major adverse cardiovascular events, cardiovascular death, myocardial infarction, hospitalization for heart failure, and all-cause mortality and improving renal outcomes in individuals with T2D with an established/high risk of cardiovascular disease.

Although early studies brought attention to several safety areas of interest (acute kidney injury, dehydration, orthostatic hypotension, amputation, and fractures) with SGLT2i drugs, longer-term studies that have prospectively assessed and monitored these events “have not seen a significant imbalance in risks,” the authors noted.

Suboptimal medication-taking behavior and low rates of continued medication use affects almost half of people with T2D, leading to suboptimal glycemic and cardiovascular disease risk factor control as well as increased risks of diabetes complications, mortality, and hospital admissions and increased health care costs, the authors noted.

“Focusing on facilitators of adherence, such as social/family/provider support, motivation, education, and access to medications/foods, can provide benefits,” the authors wrote.

In addition, medication adherence rates and persistence vary across medication classes and between agents, so “careful consideration of these differences may help improve outcomes,” the authors wrote. "Ultimately, individual preferences are major factors driving the choice of medications. Even when clinical characteristics suggest the use of a particular medication based on the available evidence from clinical trials, preferences regarding route of administration, injection devices, side effects, or cost may prevent use by some individuals,” they wrote.

The update also provides guidance on improving equity of care and reviews how social determinants of health affect the management of hyperglycemia. It also focuses on the importance of weight loss and the use of evidence from randomized controlled trials on glucose-lowering medications to support evidence on weight loss/weight gain.

Reference

1. Davies M, Aroda VR, Collins BR, et al. Management of hyperglycemia in Type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2022 Sep 23;dci220034. doi: 10.2337/dci22-0034.