Table 1

Topics for discussion with patients (or as part of structured education programs) regarding potential adverse reactions to glucose-lowering pharmacotherapy

Problems to addressTopics for patient education
InsulinLate initiation of insulin treatmentOvercoming resistance to insulin therapy
Careful balance of risks and benefits
Necessity for glucose monitoringIndividualized self-monitoring plan (how frequently, what times of day)
Dependence on integrity of insulin preparation and ascertainment of proper timing of administration into subcutaneous tissueProper insulin storage
Proper injection technique
HypoglycemiaPrevention of conditions potentially leading to hypoglycemia
Early recognition of hypoglycemia
Self-treatment of hypoglycemia
Treatment of hypoglycemia through proxies
Weight gainNutritional strategies to prevent weight gain or reduce body weight
Alternatives to progression to multiple injections after failing “bedtime” insulin treatmentInstead of meal-time insulin:
 Add a GLP-1 receptor agonist
 Add a TZD
 Add an SGLT-2 inhibitor
SUsHypoglycemiaSee hypoglycemia recommendations for insulin
Risk for hypoglycemia recurrence after initially successful treatment; necessity for continued surveillance
Weight gainSee weight gain recommendations for insulin
Concerns regarding cardiovascular risksBalanced discussion of current evidence (pro: observational studies; con: UKPDS, ADVANCE)
TZDsAdvantage of best record for durabilityDiscussion of the concept of durability and its importance for the individual patient
Advantage of potential cardiovascular benefitDiscussion of cardiovascular outcomes with pioglitazone
Weight gainSee weight gain recommendations for insulin
Risk for fluid retention and related adverse effects (edema, congestive heart failure, anemia)Warning signs
Screening measures
Appropriate dosing
Increased risk for fracturesDiscussion of individual susceptibility for fractures
Preventive measures
Appropriate dosing
Increased risk for bladder cancerDiscussion of this as an unresolved issue
Information about the potential quantitative impact
Screening and surveillance measures
Incretin-based therapiesNausea, vomiting, diarrhea (GLP-1 receptor agonists only)Rare and transient nature
Possibility that drug needs to be withdrawn in a minority of patients
Potential pharmacotherapy for side effects
Injection site reactions and nodules (GLP-1 receptor agonists only)Information about nature of this side effect (immunological responses potentially related to antibody formation)
Possibility that repeated episodes may suggest the need to discontinue this treatment
Increased risk for hospitalization for heart failure (?)Information on recognition of symptoms
Clinical significance of study findings are undetermined
Caution for those at high risk
Increased risk for acute pancreatitis (?)Discussion of this as an unresolved issue
Early signs and symptoms of pancreatitis, behavioral advice in such a case (seek medical advice, discontinue treatment)
Advice for alternative treatment in the case of past episodes of pancreatitis
Increased risk for medullary thyroid carcinoma (?)Information about the low likelihood in the face of the rarity of this disease
Advice for alternative treatment in the case of a personal or family history or with a given genetic background (multiple endocrine neoplasia syndrome type 2)
SGLT-2 inhibitorsGenital infections (Candida and other fungi)Signs and symptoms
Preventive measures (hygiene)
Consider other treatments after repeated occurrence
Urinary tract infections (bacterial)Signs and symptoms (including those of more severe, ascending infections [urosepsis])
Preventive measures (hygiene)
Consider other treatments after repeated occurrence
Negative fluid balanceInformation about potential consequences (too great a drop in blood pressure, impairment of kidney function)
Elevated LDL cholesterolImpact on overall cardiovascular risk
Treatment options (statins, target values, careful dose-finding)
Risk for bladder cancerDiscussion of this as an unresolved issue
Information about the potential quantitative impact
Screening and surveillance measures