Self-Care for Diabetes

Case 1: Herbal Supplements for Diabetes TreatmentQ: SI, a 65-year old woman is seeking advice about supplementing her medication regimen with herbals that she has heard can help lower her glycated hemoglobin (A1C) values and better control her blood sugar. She reports having type 2 diabetes for the past 10 years and that her medications includes metformin 1000 mg twice daily and a basal insulin, along with premeal boluses. Despite reporting that her lifestyle includes exercise as often as she can and attempting to eat a healthier diet, SI says that her A1C values have recently began to climb and were between 8% and 9% at her last 2 follow-up appointments. What recommendation on the use of dietary supplements as adjuncts for managing diabetes do you have for SI?

A: There are a variety of natural products and dietary supplements said to improve glycemic control, including banaba, bitter melon, and fenugreek, which may have hypoglycemic effects by stimulating pancreatic insulin products or direct insulin-like actions.¹ Other supplements, such as cinnamon and chromium, have garnered much interest due to their purported insulin-sensitizing effects and use for overcoming insulin resistance.¹ Importantly, especially because SI is on a regimen that includes insulin, there are concerns that supplementation with these agents may precipitate or increase her risk of experiencing hypoglycemia due to the likely physiologic effects attributed to these supplements. Further, there are not enough data to recommend routine use of any of these supplements to help her improve her glucose control.¹ A thorough review of SI’s diet and lifestyle behaviors, including participation in daily exercise; dietary habits, including an assessment of her fat, protein, carbohydrate, and fiber intake; limiting her alcohol intake; and reassessing her medication compliance are reasonable interventions in helping her to achieve her A1C goals.

Case 2: Managing Diabetic Neuropathy with Self-CareQ: FS, a 58-year-old man, inquires about an OTC treatment for pain in his feet. He reports a 15-year history of type 2 diabetes (T2D), which has been poorly controlled over the past few years due to medication and healthy lifestyle noncompliance and infrequent medical follow-ups. FS is looking for a treatment at the pharmacy to relieve painful tingling in his feet, which has been ongoing for several months. The pain has become particularly bothersome at night and is contributing to poor sleep quality. FS has tried a number of different OTC pain relievers and an OTC sleep aid, which have not provided him adequate symptom relief. What recommendations do you have for FS?

A: A particularly disabling and difficult-to-treat manifestation of diabetes, neuropathic pain can influence the quality of life for individuals with diabetes. Patients may not make the connection that new-onset pain or tingling in their extremities may be a result of inadequate or suboptimal blood glucose control. However, as an initial educational intervention, it would be reasonable to suggest this now.^2,3 This symptom should be evaluated by FS’s primary care provider, in addition to assessing his glucose control and presence of other complications, including retinopathy and nephropathy, that can accompany uncontrolled hyperglycemia and diabetes. Although there are no specific treatments to reverse the effects of nerve damage, prescription-only medications, including pregabalin, duloxetine, and tapentadol, are approved to alleviate pain associated with diabetic neuropathy.^2,3 Other treatments, including tricyclic antidepressants and topical capsaicin, have been used by patients to alleviate pain symptoms. If FS elects to try and use OTC capsaicin, counsel him on washing his hands carefully and on key aspects of diabetic foot care, including self-examinations, wearing shoes and never going barefoot, proper nail and foot hygiene, and techniques for washing and moisturizing to reduce the risk of further complications.^2,3

Case 3: Preventing Diabetic RetinopathyQ: TN, a 63-year old woman, is seeking information on preventing diabetic eye disease. Her past medical history includes hypertension, hyperlipidemia, and T2D for the past several years. TN takes a number of medications, including hydrochlorothiazide and lisinopril, atorvastatin, metformin, and glipizide each day. She was encouraged to undergo a comprehensive eye examination at her last doctor’s visit but wasn’t sure about how imperative or urgent it was to follow up with this. TN is looking for information and a recommendation from the pharmacist about how to protect her eyes and guidance about what to do about her eye appointment visit. What recommendations do you have for TN?

A: A microvascular complication of diabetes, diabetic retinopathy is associated with several different factors, including an individual’s history of diabetes, how well blood sugars are controlled, and whether the patient suffer from other microvascular complications, including nephropathy. Dyslipidemia and hypertension may also increase TN’s risk of developing eye complications related to her diabetes.⁴ With regard to recommendations for preventing or delaying the onset of retinopathy symptoms, remind her that the best things she can do to reduce her risk of eye disease include controlling her blood glucose by adhering to a therapeutic lifestyle, including dietary, weight loss, or exercise recommendations; being compliant with her prescription medications, and controlling her elevated blood pressure and lipid levels.⁴ Encourage TN to follow her physician’s recommendation and get a comprehensive eye examination. For individuals diagnosed with T2D, an initial dilated and comprehensive examination by an eye care professional, at the time of diagnosis, followed by a dilated retinal examination by an ophthalmologist or optometrist at least once per year if diabetic retinopathy is identified, is recommended.^4,5 Any changes in TN’s vision, including floaters, blurry or double-vision, and eye pain, should be evaluated by an ophthalmologist immediately.^4,5

Case 4: Managing HypoglycemiaQ: WE, a 79-year old man, is asking about adjusting his medication regimen. Over the past week, after suffering from an upper respiratory illness, he describes feeling “shakier” than usual and describes palpitations that he has not experienced before. WE reports checking his blood glucose values more frequently at home and says that his finger stick values have been between 70 and 80 mg/dL, rather than the usual 120 to 140 mg/dL. On a few occasions, he has experienced values in the high 50s, especially in the morning, which has prompted him to drink some juice or milk. WE says that he follows a complex medication regimen, including a recent antibiotic course for managing his respiratory condition, and metformin and repaglinide for his diabetes, which he has been taking for several years. He takes several other medications for congestive heart failure and hypertension, dyslipidemia, gout, and chronic arthritis pain. WE has no known allergies. What recommendations do you have for WE?

A: WE is likely suffering from hypoglycemia, which can be attributed to acute illness and his antidiabetic medication. Remind him of the symptoms of hypoglycemia (eg, diaphoresis, tremulousness, palpitations, and dizziness) and to keep a source of glucose handy in case he experiences these symptoms again.⁶ Remind WE that although his prescribed metformin can be taken with food to offset nausea and gastrointestinal intolerance, the repaglinide should be taken 30 minutes before a meal but may need to be skipped or held accordingly if missing a meal. Without knowing more about this patient’s renal function, blood glucose control, or A1C, it is difficult to gauge what alternative class of agents might be best suitable for him. Encourage WE to follow up with his primary care provider to help avoid this potential complication and to determine if a dosage adjustment to his regimen, or adjustment of his glycemic goals, might be necessary.^5,6

Dr. Bridgeman is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.Dr. Mansukhani is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and a transitions-of-care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey.

References

• Natural Medicines Comprehensive Database. Natural medicines in the clinical management of diabetes. Therapeutic Research Center website. therapeuticresearch.net. Accessed September 25, 2017.
• Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM; American Diabetes Association. Preventive foot care in diabetes. Diabetes Care. 2004;27(suppl 1):S63-S64.
• American College of Foot and Ankle Surgeons. Diabetes foot care guidelines. ACFAS website. acfas.org/footankleinfo/diabetic-guidelines.htm. Accessed August 20, 2017.
• American Diabetes Association. Eye care. ADA website. diabetes.org/living-with-diabetes/complications/eye-complications/eye-care.html. Updated April 7, 2015. Accessed September 25, 2017.
• American Diabetes Association. Microvascular complications and foot care. Diabetes Care. 2017;40(suppl 1):S88-S98.
• American Diabetes Association. Erratum. Standards of medical care in diabetes — 2017. Diabetes Care. 2017 2017;40(7):986. doi: 10.2337/dc17-er07c. American Diabetes Association. Standards of medical care in diabetes — 2017.11. Older Adults. Diabetes Care. 2017;40(Suppl 1):S99-S104.