COMMENTARY

Put the Focus on Dinner for Blood Sugar Control

Cyrus V. Desouza, MBBS

Disclosures

November 07, 2018

How often have you advised your patients to have a good breakfast, lunch, and supper, to have spaced-out meals, and reminded them of all the fundamentals of diabetes management so that their blood sugars can be easily controlled? And how often have you realized that they never do that?

If you give your patients complex regimens that have to be taken in the morning and evening, they tend to forget doses.

Most people will consume their largest meal in the evening when they get home from work. You may have many patients who are beginning to fail multiple combinations of oral anti-hyperglycemics. How do you tackle this problem?

If you give your patients complex regimens that have to be taken in the morning and then again in the evening, patients tend to forget doses. Therefore, adherence may be compromised, leading to diminished diabetes control.

Here are a couple of ideas that you could implement.

Focus on the Largest Meal of the Day

On a background of metformin, if the patient has failed other combinations, such as with a sulfonylurea or a DPP-4 inhibitor, people have added basal insulin. If your patient is failing with basal insulin and you need to take another step, remember that the largest meal is often in the evening.

You could combine the basal insulin with a GLP-1 agonist, such as a combination of insulin degludec plus liraglutide. Patients could take that just once with their largest meal, which would be in the evening, and it would be very effective in controlling their blood sugars.

Studies have shown that when you compare this combination with [a basal insulin], the A1c-lowering effect is similar.[1,2,3] The amount of hypoglycemia and weight gain is also decreased. This combination is probably going to be more easily followed by a patient because of these factors. It will also increase patient quality of life.

If that does not control your patient's blood sugar levels, you can give a combination of a basal insulin plus a fast-acting insulin—such as degludec plus aspart—once with their largest meal, which is usually in the evening when they are relaxed and able to remember. This combination will also control their A1c and postprandial highs much better than a multiple daily injection dose because of issues with adherence.

I hope that these solutions will help you manage your patients with diabetes who are losing control of their blood sugars with oral anti-hyperglycemics. Thank you.

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