DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

Version 4.0
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
K. Determine If There Are Side Effects or Contraindications to Current Treatment
OBJECTIVE
Modify therapy due to the side effects of drug therapy.
RECOMMENDATIONS
1. The patient with recurrent or severe hypoglycemia should be evaluated for precipitating factors that may be
easily correctable (e.g., missed meals, exercise, incorrect administration of insulin—dosage or timing).
DISCUSSION
Side effects of pharmacotherapy can include drug-drug, hypoglycemia, and specific adverse drug effects. Patients
may experience side effects from medications if adjustments are not made when patients undergo medical or
surgical procedures, have a change in their condition, or develop an intercurrent illness.
Patients with recurrent or severe hypoglycemia should be evaluated for precipitating factors that may be easily
correctable (e.g., missed meals, exercise, incorrect administration of insulin—dosage or timing). In many cases, a
simple adjustment can be made in nutrition, exercise, medication and/or patient self-monitoring. In patients with
near-normal glycemic control (notably patients with type 1 DM on intensive insulin treatment or patients with
autonomic neuropathy), it may be necessary to relax the degree of glycemic control, at least temporarily. Complex
adjustments may best be accomplished through co-management with a diabetes team.
Certain drug effects (e.g., gastrointestinal symptoms) may improve over time or with modification of the dosage
regimen and thus may not necessitate discontinuance of medication. On the other hand, some drugs may have
adverse effects that require vigilant monitoring, such as frequent measurement of serum liver function tests in
patients treated with thiazolidinediones. Finally, patients may develop contraindications to continued use of a
previously successful maintenance medication. Examples include newly recognized renal insufficiency or severe
congestive heart failure in a patient treated with metformin (see detailed pharmacologic tables in Appendix G-3).
L. Are There Problems With Patient Adherence?
OBJECTIVE
Identify barriers to full adherence to the prescribed treatment regimen.
RECOMMENDATIONS
1. If the patient does not achieve his/her target range, the provider should identify barriers to patient
adherence to the treatment regimen (e.g., miscommunication, lack of education or understanding,
financial/social/psychological barriers, and cultural beliefs).
2. If barriers are identified, referral to a case manager or behavioral/financial counselor may be considered as
appropriate.
DISCUSSION
It is appropriate to briefly review adherence to the prescribed nutritional and exercise regimens, as well as to review
the dosages and timing of administration of medication. If the patient does not achieve his or her target range, the
practitioner should look for barriers to patient adherence to regimen. Barriers may include miscommunication, lack
of education or understanding, financial, social, psychological, and cultural beliefs (e.g., learned helplessness). In
addition, the patient may have treatment preferences that are not being addressed.
The patient may be considered for case management or referral to a behavioral or a financial counselor, as
appropriate.
M. Should Glycemic Control Target Be Adjusted?
OBJECTIVE
Determine whether the recommended glycemic control goal remains appropriate for the patient.
Module G: Glycemic Control Page 76