TABLE 1

Moving From Therapeutic Inertia to Therapeutic Action: Challenges, Strategies, and Opportunities

Common ChallengeStrategiesOpportunities
Inadequate glucose dataCollect collateral data (e.g., from caregiver verbal reports and school nurse).Discuss existing challenges to monitoring (e.g., lack of supplies, discomfort, forgetting, or not wanting to stop activities) and engage in shared decision-making about monitoring options such as CGM if the patient is not already using it.
Use available data (i.e., growth pattern, A1C level, and prescribed insulin units/kg) to ascertain if current insulin doses are appropriate. If evidence suggests that patient is receiving inadequate insulin, judicious dose adjustments can be made with plan for close follow-up.
Overwhelming and perplexing glucose dataFollow a standard method of reviewing glucose and insulin delivery data (similar to learning how to read an electrocardiogram).Seek opportunities to limit variability to gain new insights into treatment (e.g., basal rate testing on weekends).
For insulin pump users, consider limiting the number of different settings used until a more consistent pattern emerges.Adopt advanced technology solutions for data interpretation (e.g., DreaMed Advisor Pro).
Persistent elevated A1C; “not doing anything”Ask about how often long-acting (basal) insulin is given and what circumstances help the patient to remember these doses.Review treatment options for insulin delivery (injections, pump therapy, or untethered pump therapy with long-acting/basal insulin in background to account for prolonged periods when the pump is disconnected).
Ask about the patient's activities and goals outside of diabetes management.Consider alternative basal insulin with more forgiving pharmacokinetic profile (e.g., degludec) if doses are given at different times of day.
Use a supportive tone while acknowledging that diabetes management is difficult.
Static diabetes managementTeach families a dynamic approach to diabetes management (e.g., how to incorporate CGM trend arrows into real-time management decisions).Provide patient-centered education modules (e.g., 30–60–90 Rule) to encourage dynamic diabetes management.
Fear of hypoglycemiaAcknowledge the concerns of patients and parents/caregivers.Educate patient's family on the signs, symptoms, and treatment of mild, moderate, and severe hypoglycemia.
Determine whether the patient retains hypoglycemia awareness symptoms.Offer technology options (e.g., CGM, integrated insulin pumps with low glucose suspend features, and automated insulin delivery systems).
Address dose adjustment needs with a priority to reduce patterns of recurrent hypoglycemia.
Diabetes burnoutScreen adolescents with type 1 diabetes routinely for diabetes distress and depression symptoms.Discuss roles with patients and parents/caregivers. Negotiate some responsibilities parents/caregivers can take on for a few weeks to alleviate patients' burden (e.g., ordering supplies, giving injections, overseeing pattern management, or packing lunches that include carbohydrate counts).
Acknowledge the challenges of diabetes management, and ask about the patient's activities and goals outside of diabetes management.Encourage engagement with peer support groups in the diabetes community.
Refer patients and families to mental health services if needed.
Satisfaction with A1C “close enough” to targetAcknowledge successful efforts and accomplishments to date, but resist complacency.Shift the treatment paradigm to focus on time in range rather than A1C or mean blood glucose level.
Review patients' ambulatory glucose profile with actionable, individualized goal-setting to increase time spent in the target glycemic range (i.e., 70–180 mg/dL) and reduce time spent in hyperglycemia (i.e., >180 or >250 mg/dL).
Limited time in clinicSchedule more frequent clinic visits for higher-risk patients.Explore telehealth opportunities, patient portal communication, community outreach, and other mechanisms to promote touch points between clinic visits.