Skill Checkup: A 55-Year-Old Man With Type 2 Diabetes and High A1C Level Despite Previous Treatments

DSME is one of the pillars of good diabetes care because patients themselves must be committed to and involved in managing their day-to-day care. The ADA recommends evaluating the need for DSME and support at diagnosis, and then annually or more often if targets are not being met. Additional evaluation is necessary if the patient's overall health status changes. DSME can be delivered individually or in group settings and may be in person or via telemedicine portals. The ADA states that the overall goals of DSME are to support patients in making informed decisions and self-care behaviors, as well as problem-solving and active collaboration with their healthcare team. Studies have demonstrated the benefits of DSME in improved clinical outcomes, self-care, weight reduction, glycemic control, and coping behavior.

All patients being managed for T2D should be educated about and supported to achieve nonpharmacologic interventions. Interventions recommended by the ADA include self-care, maintaining physical activity and healthy weight, and sodium restriction within a nutritious diet.

A good example of a reduced sodium, healthy diet is the Dietary Approaches to Stop Hypertension diet, which has been shown to reduce cardiovascular injury markers, including NT-proBNP that is associated with heart failure (HF). This type of diet is also recommended by the ADA for the management of hypertension and weight gain.

Additional interventions of value are assessments for depression or anxiety, staying current with vaccinations against respiratory and other diseases, and developing resources that support adherence with treatment. Patients with HF also should be educated to recognize signs or symptoms of worsening HF and to report these promptly to their healthcare team.

Management of all cardiovascular risk factors is crucial to improving outcomes for patients with T2D and minimizing risk for long-term diabetes complications; however, this patient currently has blood pressure and lipid measurements within acceptable limits. He should be followed closely to monitor risk factors; current targets for patients with T2D are blood pressure < 130/<80 mm Hg and low-density lipoprotein-cholesterol < 100 mg/dL.

The patient discontinued the DPP-4 inhibitor and added once-weekly semaglutide to ongoing treatment with metformin and empagliflozin 10 mg. To streamline his daily regimen, he was switched to a fixed-dose combination of empagliflozin 10 mg plus extended-release metformin 1000 mg, and now takes only 1 pill a day. He attended weekly sessions for DSME support for 4 weeks. At 3-month follow-up, his HbA1C is 6.6%, and he reports feeling energized and happy about getting his weight and T2D under control.

Editor's Note: Skill Checkups are wholly fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

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Cite this: Romesh Khardori. Skill Checkup: A 55-Year-Old Man With Type 2 Diabetes and High A1C Level Despite Previous Treatments - Medscape - Apr 27, 2023.