This is why Dr. Miller urges rheumatologists to get in touch with the patient’s endocrinologist or primary care physician (PCP) before starting glucocorticoids—and to let the patient know the importance of this communication and collaboration. “I’ll tell patients to give me a call, and we can devise changes to their diabetes regimen that prevent their blood sugar from going up too much,” Dr. Miller says. Some patients and doctors are good about making that call; others are not.
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Explore This IssueMay 2018
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The use of glucocorticoids can increase the need for daily insulin by 20–50%, Dr. Miller says. He will increase a patient’s insulin use accordingly when the patient is using glucocorticoids.
The kind of insulin used may change during treatment with glucocorticoids, says endocrinologist Elizabeth S. Halprin, MD, clinical director, Adult Diabetes, Joslin Diabetes Center, Boston. She sometimes prescribes an older insulin, called NPH, when patients use prednisone every morning.
Even with these measures, it can be hard to maintain blood sugar control, and Dr. Miller cautions patients to expect reasonable, but not perfect, blood sugar numbers when they are using steroids.
As an extra safety measure, do your best to communicate any major medication change with a patient’s diabetes care provider, Dr. Vasquez advises. “It is essential for an endocrinologist to know the specific therapy, drug type and dose that a patient with a rheumatological disease is using to tailor their diabetic treatment appropriately,” she says.
2. Push physical activity.
“Lifestyle modifications, including weight loss and exercise, are important for both diabetes and arthritis,” says rheumatologist Petros Efthimiou, MD, FACR, clinical professor of medicine, NYU Langone Health, New York. “Many times, the rheumatologist will manage the concomitant arthritis so the patient can exercise more, lose weight, and decrease cardiovascular risk factors.”
When Dr. Askanase treats a patient with both diabetes and a rheumatological disease, she emphasizes weight loss, exercise and tight diabetes control.
Of course, some patients may have limitations on how, or how often, they can move. Dr. Halprin works closely with exercise physiologists to tailor physical activity for each patient based on the individual’s joint issues. Still, everyone can benefit from some sort of movement.
“A very small increase will help, such as chair exercises, bands or a 10-minute walk a day,” Dr. Halprin says. “There’s always some movement that can be done.”
Water exercises, low-impact cardio and physical therapy also may be recommended for patients with diabetes and functional limitations from joint pain, Dr. Vasquez says.
3. Encourage education.
Physical therapist and diabetes educator Karen Kemmis, PT, DPT, CDE, FAADE, SUNY Upstate Medical University, Syracuse, New York, encourages those with a rheumatological disease and diabetes to see a diabetes educator for better education and support. A rheumatologist can suggest such a visit to patients, even if they need to follow up with their PCP or endocrinologist for more information or a referral. When a patient sees a diabetes educator, self-care behaviors, such as healthy eating, being active, taking medication and healthy coping are covered, Dr. Kemmis says. “A complete evaluation would be performed, followed by an individualized plan that would take the rheumatological disease, treatments, and effects of treatments into account,” she says.
4. Closely monitor the patient’s falls and fracture risk.
This is likely something you are already doing if a patient has RA, osteoporosis or other rheumatologic illness. However, there’s another reason why you should assess and monitor falls and fracture risk.