Optimal glycemic control will help reduce the risks of diabetes-related complications. Diabetes education focused on risk reduction involves the patient clearly understanding how to prevent and identify acute complications. Chronic complications of diabetes include microvascular and macrovascular complications, retinopathy, nephropathy, and neuropathy. Inform patients on the frequency of screening.
- Eye exam: Annual comprehensive dilated eye exam starting at diagnosis for T2DM and five years after diagnosis for T1DM.
- Neuropathy: Annually complete a comprehensive foot exam assessing for deformity, neurological assessment including vibratory and monofilament sensation, and vascular assessment. Patient education includes the daily visual inspection of the feet, as foot ulcers are common in those with neuropathy.
- Nephropathy: Annual measurements of glomerular filtration rate (GFR) and urinary albumin-to-creatinine ratio starting at diagnosis for T2DM and five years after diagnosis for T1DM (ADA, 2024d).
How to instruct patients on daily foot checks:
- Check the feet every day, and do not forget to examine the bottom of the feet. Look for blisters, calluses, cuts, red spots, swelling, or any other abnormalities, and call your physician or healthcare provider if there is a problem.
- Wash the feet every day. Dry them gently, and then apply a moisturizing lotion or cream.
- Always wear comfortable shoes – they should not be tight – and wear clean, dry socks.
- Trim the toenails straight across. Do not cut them too short, and do not cut them down the sides.
- Diabetes often causes peripheral nerve damage, so cold and heat sensations can be blunted. Do not expose the feet to very cold or hot conditions. Do not go barefoot.
Acute complications of diabetes include DKA, HHS, and hypoglycemia. DKA is an acute condition related to hyperglycemia in which the body has insufficient endogenous or exogenous insulin to maintain adequate glycemic control. This insulin deficiency causes the body to break down fat and muscle for fuel, resulting in ketosis. If not identified and corrected, DKA can be life-threatening. DKA typically occurs in those with T1DM but has been seen in other ketosis-prone individuals and those taking sodium-glucose cotransporter 2 (SGLT2) inhibitors. DKA presents with blood glucose levels over 250 mg/dL, though those taking SGLT2 inhibitors can have euglycemic DKA with mildly elevated or normal glucose levels. Symptoms of DKA include fatigue, polydipsia, abdominal pain, nausea or vomiting, acetone breath, hypotension, tachycardia, confusion, and, ultimately, coma (Hassan et al., 2022).
HHS is a non-ketotic state of severe hyperglycemia that occurs typically in those with T2DM and can also be life-threatening. HHS typically presents with glucose levels over 600 mg/dL. Since there is endogenous insulin production in HHS, hyperglycemia is multifactorial and includes decreased insulin action, increased counterregulatory hormones, and profound dehydration. Both DKA and HHS require intensive glycose-lowering treatment with insulin and rehydration, requiring hospitalization. Symptoms of HHS include ongoing polyuria, dehydration, tachycardia, stupor, unconsciousness, and ultimately coma (Hassan et al., 2022).
Hypoglycemia is more common than DKA or HHS, though it can also be life-threatening. The occurrence of hypoglycemia increases with the duration of diabetes, in those with T1DM, and in those with recurrent hypoglycemic events (Lin et al., 2020). Symptoms of hypoglycemia include diaphoresis, hunger, shakiness, irritability, and confusion. Hypoglycemia unawareness is when patients with hypoglycemia have no symptoms during a hypoglycemic event; this can be particularly dangerous. Hypoglycemia increases the risk of not only death but also is associated with higher rates of dementia, microvascular and macrovascular complications, falls, and fractures, particularly in older adults (Mattishent & Loke, 2021).
Treatment plans need to be altered to avoid hypoglycemia in these patients. The use of CGM technology can be beneficial for those who have hypoglycemia unawareness or recurrent hypoglycemia to improve recognition and treatment (Macon et al., 2023). Hypoglycemia, in those with diabetes, is a blood glucose reading below 70 mg/dL. The levels of hypoglycemia are (ADA, 2024c):
- Level 1: Glucose < 70 mg/dL but ≥ 54 mg/dL
- Level 2: Glucose < 54 mg/dL
- Level 3: A severe event that requires assistance for treatment due to altered mental status, irrespective of glucose level
Hypoglycemia should be discussed at each visit to monitor the frequency of hypoglycemic events and ensure a plan for identifying and treating hypoglycemia is in place.
Some common risk factors for hypoglycemia include (ADA, 2024c):
- Recurrent hypoglycemia
- Recent hypoglycemic event (within the past 3-6 months)
- Chronic kidney disease
- Fasting – often done for lab work, medical procedures, for health or religious reasons
- Use of insulin or other high-risk hypoglycemia medications
- Cardiovascular disease
- Female sex
- Polypharmacy
- Alcohol use
- SDOH – food insecurity, homelessness, low literacy, low-income status
Treatment of hypoglycemia for patients who are awake and alert:
Ingest 15 grams of carbohydrates and check the blood sugar in 15 minutes. Repeat if needed. Avoid carbohydrate sources that include fat and protein, as this will slow the absorption of the carbohydrate.
For those unable or unwilling to ingest carbohydrates by mouth, glucagon can treat hypoglycemia. Glucagon, previously only available in a formulation that required reconstitution, now comes in various forms, including a nasal powder spray and prefilled injectable pens or syringes. The Endocrine Society recommends using the newer forms of glucagon for ease of administration and efficacy (McCall et al., 2023).
