tric emptying. Nausea, the most common AE, limits its use.
Insulin pumps, which deliver a basal short-acting
insulin continuously in the subcutaneous tissue at a
modifiable rate with bolus insulin as needed for food,
can be very effective tools in managing T1DM. Patients with T1DM who want to have more control over
their insulin delivery benefit from a pump. Classically,
the patient with T1DM with frequent hypoglycemia
may benefit from a pump, because it provides the patient the opportunity to fine-tune insulin delivery by
the hour and in smaller doses. One absolute requirement of any patient with a pump is the ability to problem solve and troubleshoot. If the pump malfunctions,
unprepared patients with T1DM can go into diabetic
There have been significant technologic advancements in insulin pumps since the first portable pumps
were available commercially in the 1980s. With the introduction of continuous glucose sensors and insulin
pumps that not only warn the patient about the low
or high blood glucose, but also have the ability to automatically shut off for a couple of hours if hypoglycemia is detected, an artificial pancreas is not far off.
Care of any patient with diabetes requires a multidisciplinary team. However, this need is heightened when
managing diabetes in the VHA. The VHA-specific issues
include the significantly intractable issues associated
with PTSD, the issues of homelessness and drug abuse
(not covered in this article), an increasingly elderly
population that is at increased risk of hypoglycemia
from use of high-risk medications (primarily insulins),
and the increased number of comorbidities seen in this
population. Although modern medicine has given us
many options, diabetes management requires a tailored
approach, sometimes requiring abandoning tight control for goals that improve QOL and balancing prevention of complications against potential harms.
Finally, despite national VA guidelines and although
many of the options highlighted here are available, not
all therapies are available to practitioners. It is not uncommon to have clinicians decry that what may be
easily available for use at one VISN (eg, the gliptins
or GLP-1 agonists) are nearly impossible to obtain at
other VISNs. The basis for such disparate availability
is beyond the scope of this topic but is an important
factor when providing individualized care.
The authors report no actual or potential conflicts of interest
with regard to this article.
The opinions expressed herein are those of the authors and
do not necessarily reflect those of Federal Practitioner,
Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review
complete prescribing information for specific drugs or drug
combinations—including indications, contraindications,
warnings, and adverse effects—before administering pharmacologic therapy to patients.
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