Counseling Patients With Type 1 Diabetes

Diabetes is a chronic condition characterized by hyperglycemia, because of reduced insulin secretion from the pancreas and/or insulin resistance. Type 1 (T1D) and type 2 (T2D) are 2 main types of diabetes with different presentations and management modalities for improving glycemic outcomes and preventing complications.

T1D is an autoimmune condition where the body destroys beta cells in the pancreas necessary for insulin production. It accounts for 5% to 10% of diabetes cases, and insulin therapy is required. Many patients are diagnosed as children but not all. Most patients have T2D, and though it is usually seen in adults, diagnosis is occurring at younger ages, because of the rise of obesity, a lack of exercise, and poor diets. T2D is associated with insulin resistance and a progressive decrease in insulin production. Metformin is initially the drug of choice for T2D, with other classes being added to reach glycemic goals.^1,2

Managing diabetes requires effective patient communication and education for successful treatment plans. Among health care providers, pharmacists are recognized by the American Diabetes Association as an important part of the care management team.¹Here is a review on T1D counseling and information essential for pharmacists to know.

Treatment

Patients with T1D require basal (background) and prandial (bolus) insulin, or basal-bolus therapy. Instead of multiple daily injections, basal-bolus therapy can also be achieved using continuous subcutaneous insulin infusion. Both methods can improve glycemic outcomes in children and adults.

Typically, rapid-acting analogs and basal insulins are preferred over regular human insulin and NPH, because of hypoglycemia, but it is more expensive. Inhaled insulin for prandial coverage is another option, along with biosimilar insulin for basal and prandial insulin, which may offer cost savings for patients.¹

Counseling

Insulin is important in T1D. However, if it is used improperly, efficacy and safety can be issues. Key counseling points for patients injecting insulin are proper administration and hypoglycemia treatment. Additionally, pharmacists should be aware of adjunctive therapy for T1D either on or off FDA label.

Administration

Proper injection technique is important to improve glycemic control, decrease the risk of hypoglycemia, and reduce lipohypertrophy.

Pen needles lengths are available in 4, 5, 6, 8, and 12.7 mm. Adult skin thickness ranges from 1.25 to 3.25 mm, regardless of age, race, or weight. For most people, longer needles are not needed, and a 4 mm needle would be sufficient to deliver insulin to the right place. Most children have a thinner fat layer than adults, making it important to use the shortest needles. Studies show that 4 mm needles provide equivalent blood glucose control, compared with longer needles, even in obese patients. Patients using shorter needles also reported less pain.

Injection site selection, rotation, and not reusing needles decreases the risk of developing lipohypertrophy (lipo). Lipo occurs when a site is not rotated and may reduce insulin absorption, leading to unpredictable glucose levels. Needles are no longer sterile, become dull, and damaged after 1 use, and this is associated with injection pain or bleeding.

Rotating sites and using new needles every time helps prevent lipo.³

Hypoglycemia

Patients injecting insulin are at a higher risk for hypoglycemia, with some common signs including confusion, diaphoresis, dizziness, and shakiness. It is important to recognize these symptoms so that patients can provide proper management.

Patients should be instructed to consume 15 to 20 grams of carbohydrates and check their blood glucose after 15 minutes. If they are still hypoglycemic, repeat the first step. Once the blood glucose is normalized, the patient should eat a small meal or snack. All patients with T1D should be prescribed a glucagon injection, and their families or friends should be educated about how and when to use it.^1,2

Drugs Used in Addition to Insulin

Pramlintide is FDA approved to add to basal-bolus therapy and is associated with weight loss and lowered insulin doses. It is injected with meals and helps to slow gastric emptying, blunts post-meal glucagon secretion, and increases satiety. Adding metformin could reduce insulin requirements and improve metabolic control. GLP-1 receptor agonists and DPP-4 inhibitors are being evaluated for their potential β-cell mass protection and glucagon release suppression. SGLT-2 inhibitors are used off-label to improve glycemic control and can help with weight loss. Pharmacists should note that the FDA issued a warning of euglycemic ketoacidosis in this drug class, which should be discussed with patients using SGLT-2 inhibitors.¹ The same counseling on these medications for T2D should be provided in patients with T1D to ensure proper use, improved efficacy, and minimal toxicity.

Continuous Glucose Monitoring (CGM)

Diabetes can be managed with the right partnership between the patient and health care team, but sometimes, patients still have difficulty reaching their goals. CGM is a way to capture data on multiple blood glucose levels throughout the day, and it offers a solution by showing glucose fluctuations. Pharmacists can help identify issues or adjust insulin doses based on these trends.¹

Conclusion

Advancements are continuing to be made for T1D treatments. Pharmacists must stay current with these treatments, as they interact frequently with patients. Education on injection techniques, hypoglycemia, and new options can improve patients’ lives and position pharmacists as an integral part of the care team.

Betty Lu, PharmD is a graduate of Temple University School of Pharmacy and a fellow of global medical affairs for MCPHS University/BD. Jennifer D. Goldman, RPh, PharmD, CDE, BC-ADM, FCCP, is a professor of pharmacy practice at MCPHS University in Boston, Massachusetts, a faculty preceptor of the MCPHS University/BD fellowship in medical affairs, and a clinical pharmacist at Well Life in Peabody, Massachusetts.

References

• American Diabetes Association. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes-2018 [published erratum appears in Diabetes Care. 2017; 40(suppl 1): S64-S74]. Diabetes Care. 2018;41(suppl 1):S73-S85. doi: 10.2337/dc17-S011.
• Chiang JL, Kirkman MS, Laffel LMB, Peters AL, Type 1 Diabetes Sourcebook Authors. Type 1 diabetes through the life span: a position statement of the American Diabetes Association. Diabetes Care. 2014;37(7):2034—2054. doi: 10.2337/dc14-1140.
• Frid AH, Kreugel G, Grassi G, et al. New insulin delivery recommendations. Mayo Clin Proc. 2016;91(9):1231-1255. doi: 10.1016/j.mayocp.2016.06.010.