Pitfalls in Outpatient Diabetes Management

Abstract

T he challenges of treating patients with diabetes are many. Patients usually require oral medications and/or insulin to control glucose levels. Such medications require careful titration as well as monitoring for side effects or adverse reactions. Additionally, patients must be educated and motivated by their caregivers to monitor glucose levels, control carbohydrate consumption, and aggressively participate in self-care to control their disease. Such treatment allows patients to minimize the likelihood that they will develop chronic complications of diabetes such as microvascular or macrovascular disease. In addition to the usual challenges regarding diabetes control, diabetes can also be exacerbated by factors such as medication changes, surgery, and illnesses. Such conditions can lead to acute decompensation of glucose control even in the setting of previously well-controlled disease. Acute complications of diabetes such as diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) may develop, which can be life-threatening and must be treated aggressively.1 Although it is important for physicians to understand the treatment of acute complications of diabetes, it is perhaps even more important to be versed in techniques of averting acute hyperglycemia. Three common causes of diabetes exacerbation include intercurrent illness, surgery or trauma, and use of corticosteroids. Intercurrent illnesses can be challenging to any patient with a chronic disease, but they are especially problematic in patients with diabetes. Such conditions exacerbate hyperglycemia, and even patients with well-controlled diabetes may develop considerable hyperglycemia. Infections have long been recognized as a major cause of acute hyperglycemia, DKA, and HHS.1,2 Hyperglycemia in response to infection likely takes place as a result of several pathogenic mechanisms. Gram-negative lipopolysaccharide has been shown to increase insulin resistance significantly, possibly mediated through increase in stress hormones such as cortisol and growth hormone.3 Because patients with diabetes are unable to increase insulin production and …