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Cheung JTK, Yang A, Wu H, Lau ESH, Lui J, Kong APS, Ma RCW, Luk AOY, Chow E, Chan JCN. Association of dipeptidyl peptidase-4 inhibitor initiation at glycated haemoglobin <7.5% with reduced major clinical events mediated by low glycated haemoglobin variability. Diabetes Obes Metab 2024; 26:3339-3351. [PMID: 38802991 DOI: 10.1111/dom.15662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/29/2024]
Abstract
AIM Therapeutic inertia, hypoglycaemia and poor treatment persistence can lead to glycaemic fluctuation and poor outcomes in type 2 diabetes (T2D). We compared glycated haemoglobin (HbA1c) variability, insulin initiation, severe hypoglycaemia and clinical events in patients with T2D initiated dipeptidyl peptidase-4 inhibitors (DPP4is) at low versus high HbA1c thresholds. METHODS Using territory-wide electronic medical records in Hong Kong, we curated a propensity score-matched cohort of patients initiated DPP4i at HbA1c <7.5% versus ≥7.5% in 2007-2019. We expressed the HbA1c variability score (HVS) as a proportion of HbA1c varied by ≥0.5% compared with preceding values. We used the Cox model to compare the risks of insulin initiation and clinical outcomes, adjusted for time-varying variables between the two groups. Mediation analysis estimated the effects of HbA1c variability on outcomes. RESULTS Among 6874 insulin-naïve patients who initiated DPP4i, 88.7% were treated with metformin and 79.6% with sulphonylureas at baseline (54.9% men; mean age 65.2 ± 11.4 years). After a median follow-up of 4.6 years, compared with the high-threshold plus high-HVS group (≥50%), the low-threshold plus low-HVS (<50%) group had reduced hazard ratios (95% confidence interval) of insulin initiation (0.35, 0.31-0.40), severe hypoglycaemia (0.38, 0.34-0.44), major adverse cardiovascular endpoints (0.76, 0.66-0.88), heart failure (0.42, 0.36-0.49), end-stage kidney disease (0.65, 0.36-0.49) and mortality (0.45, 0.35-0.57). Reduced HbA1c variability explained 31.1%-81.2% of the effect size of DPP4i initiation at HbA1c <7.5% versus ≥7.5% on outcomes. CONCLUSIONS In Chinese patients with T2D, avoiding therapeutic inertia with intensified glycaemic control at HbA1c <7.5% using drugs with low risk of hypoglycaemia and good tolerability, such as DPP4i, delayed insulin treatment, reduced HbA1c variability and improved clinical events.
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Affiliation(s)
- Johnny T K Cheung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Aimin Yang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Hongjiang Wu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Eric S H Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Juliana Lui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Alice P S Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Ronald C W Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Andrea O Y Luk
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Phase 1 Clinical Trial Centre, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Elaine Chow
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Phase 1 Clinical Trial Centre, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Juliana C N Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
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Haluzik M, Taybani Z, Araszkiewicz A, Cerghizan A, Mankovsky B, Zuhdi A, Malecki M. Expert Opinion on Optimising Type 2 Diabetes Treatment Using Fixed-Ratio Combination of Basal Insulin and GLP-1 RA for Treatment Intensification and Simplification. Diabetes Ther 2024; 15:1673-1685. [PMID: 38935189 PMCID: PMC11263442 DOI: 10.1007/s13300-024-01610-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
The management of type 2 diabetes (T2D) often necessitates treatment intensification, and sometimes simplification to achieve glycaemic targets and mitigate complications. This expert opinion paper evaluates the use and positioning of the fixed-ratio combinations (FRCs) of basal insulin (BI) and glucagon-like peptide 1 receptor agonists (GLP-1 RAs) in optimising T2D management. On the basis of the evidence presented and discussions, these FRCs offer a promising approach for both treatment intensification and simplification in people with suboptimal glucose control despite receiving various therapies. In treatment intensification, FRCs provide a synergistic effect by addressing multiple pathophysiological defects contributing to hyperglycaemia. These FRCs effectively control both fasting and postprandial glucose (PPG) excursions, offering significantly improved glycaemic control with a lower hypoglycaemia risk and weight neutrality compared to traditional or complex insulin regimens. Moreover, the reduced injection frequency (once daily) and flexibility in the dosing schedule (with any major meal of the day) help mitigate patient resistance to insulin initiation or titration. This further reduces treatment burden, facilitating treatment adherence and enhancing patient convenience. These key benefits of FRCs over complex insulin regimens play a crucial role in long-term glycaemic management and overall treatment outcomes. Hence, the timely use of FRCs in the treatment algorithm for people with T2D represents a valuable strategy for optimising glycaemic control, addressing treatment barriers and enhancing patient-reported outcomes.
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Affiliation(s)
- Martin Haluzik
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Vídeňská 1958/9, 140 21, Prague 4, Czech Republic.
| | - Zoltan Taybani
- 1st Department of Endocrinology, Békés County Central Hospital, Dr Réthy Pál Member Hospital, Békécsaba, Hungary
| | - Aleksandra Araszkiewicz
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznań, Poland
| | - Anca Cerghizan
- Diabetes Center, Emergency Country Hospital, Cluj-Napoca-Napoca, Romania
| | - Boris Mankovsky
- Department of Diabetology, National Healthcare University of Ukraine, Kiev, Ukraine
| | - Agbaria Zuhdi
- Clalit Health Services, Degani, Hadera, Israel
- Taybeh Specialist Doctor's Clinic, Taybeh, Israel
| | - Maciej Malecki
- Department of Metabolic Diseases, Jagiellonian University Medical College, Kraków, Poland
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McDaniel CC, Lo-Ciganic WH, Huang J, Chou C. A machine learning model to predict therapeutic inertia in type 2 diabetes using electronic health record data. J Endocrinol Invest 2024; 47:1419-1433. [PMID: 38160431 DOI: 10.1007/s40618-023-02259-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/24/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To estimate the therapeutic inertia prevalence for patients with type 2 diabetes, develop and validate a machine learning model predicting therapeutic inertia, and determine the added predictive value of area-level social determinants of health (SDOH). METHODS This prognostic study with a retrospective cohort design used OneFlorida data (linked electronic health records (EHRs) from 1240 practices/clinics in Florida). The study cohort included adults (aged ≥ 18) with type 2 diabetes, HbA1C ≥ 7% (53 mmol/mol), ≥one ambulatory visit, and ≥one antihyperglycemic medication prescribed (excluded patients prescribed insulin before HbA1C). The outcome was therapeutic inertia, defined as absence of treatment intensification within six months after HbA1C ≥ 7% (53 mmol/mol). The predictors were patient, provider, and healthcare system factors. Machine learning methods included gradient boosting machines (GBM), random forests (RF), elastic net (EN), and least absolute shrinkage and selection operator (LASSO). The DeLong test compared the discriminative ability (represented by C-statistics) between models. RESULTS The cohort included 31,087 patients with type 2 diabetes (mean age = 58.89 (SD = 13.27) years, 50.50% male, 58.89% White). The therapeutic inertia prevalence was 39.80% among the 68,445 records. GBM outperformed (C-statistic from testing sample = 0.84, 95% CI = 0.83-0.84) RF (C-statistic = 0.80, 95% CI = 0.79-0.80), EN (C-statistic = 0.80, 95% CI = 0.80-0.81), and LASSO (C-statistic = 0.80, 95% CI = 0.80-0.81), p < 0.05. Area-level SDOH significantly increased the discriminative ability versus models without SDOH (C-statistic for GBM = 0.84, 95% CI = 0.84-0.85 vs. 0.84, 95% CI = 0.83-0.84), p < 0.05. CONCLUSIONS Using EHRs of patients with type 2 diabetes from a large state, machine learning predicted therapeutic inertia (prevalence = 40%). The model's ability to predict patients at high risk of therapeutic inertia is clinically applicable to diabetes care.
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Affiliation(s)
- C C McDaniel
- Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, 4306 Walker Building, Auburn, AL, 36849, USA.
| | - W-H Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, PA, USA
- North Florida/South Georgia Veterans Health System, Geriatric Research Education and Clinical Center, Gainesville, FL, USA
| | - J Huang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - C Chou
- Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, 4306 Walker Building, Auburn, AL, 36849, USA
- Department of Medical Research, China Medical University Hospital, Taichung City, Taiwan
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Rodriguez P, San Martin VT, Pantalone KM. Therapeutic Inertia in the Management of Type 2 Diabetes: A Narrative Review. Diabetes Ther 2024; 15:567-583. [PMID: 38272993 PMCID: PMC10942954 DOI: 10.1007/s13300-024-01530-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/05/2024] [Indexed: 01/27/2024] Open
Abstract
Adequate glycemic control is key to prevent morbi-mortality from type 2 diabetes (T2D). Despite the increasing availability of novel, effective, and safe medications for the treatment of T2D, and periodically updated guidelines on its management, the overall rate of glycemic goal attainment remains low (around 50%) and has not improved in the past decade. Therapeutic inertia (TI), defined as the failure to advance or de-intensify medical therapy when appropriate to do so, has been identified as a central contributor to the lack of progress in the rates of HbA1c goal attainment. The time to treatment intensification in patients not meeting glycemic goals has been estimated to be between 1 and 7 years from the time HbA1c exceeded 7%, and often, even when an intervention is carried out, it proves insufficient to achieve glycemic goals, which led to the concept of intensification inertia. Therefore, finding strategies to overcome all forms of TI in the management of T2D is a fundamental initiative, likely to have an enormous impact in health outcomes for people with T2D. There are several factors that have been described in the literature leading to TI, including clinician-related, patient-related, and healthcare system-related factors, which are discussed in this review. Likewise, several interventions addressing TI had been tested, most of them proving limited efficacy. Within the most effective interventions, there appear to be two common factors. First, they involve a team-based effort, including nurses, pharmacists, and diabetes educators. Second, they were built upon a framework based on results of qualitative studies conducted in the same context where they were later implemented, as will be discussed in this article. Given the complex nature of TI, it is crucial to use a research method that allows for an in-depth understanding of the phenomenon. Most of the literature on TI is focused on quantitatively describing its consequences; unfortunately, however, not many study groups have undertaken qualitative studies to deeply investigate the drivers of TI in their diverse contexts. This is particularly true in the United States, where there is an abundance of publications exploring the effects of different strategies to overcome TI in type 2 diabetes, but a severe shortage of qualitative studies aiming to truly understand the phenomenon.
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Affiliation(s)
- Paloma Rodriguez
- Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk F-20, Cleveland, Ohio, 44195, USA
| | - Vicente T San Martin
- Department of Endocrinology and Diabetes, Macromedica Dominicana, Santo Domingo, Dominican Republic
| | - Kevin M Pantalone
- Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk F-20, Cleveland, Ohio, 44195, USA.
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Alvis-Guzman N, Romero M, Salcedo-Mejia F, Carrasquilla-Sotomayor M, Gómez L, Rojas MM, Urrego JC, Beltrán CC, Ruíz JE, Velásquez A, Orengo JC, Pinzón A. Clinical inertia in newly diagnosed type 2 diabetes mellitus among patients attending selected healthcare institutions in Colombia. Diabetol Metab Syndr 2024; 16:42. [PMID: 38360703 PMCID: PMC10868072 DOI: 10.1186/s13098-023-01245-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 12/18/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND The burden of disease of diabetes in Colombia have increased in the last decades. Secondary prevention is crucial for diabetes control. Many patients already treated remain with poor glycemic control and without timely and appropriate treatment intensification. This has been called in the literature as Clinical Inertia. Updated information regarding clinical inertia based on the Colombian diabetes treatment guidelines is needed. OBJECTIVE To measure the prevalence of clinical inertia in newly diagnosed Type 2 Diabetes Mellitus (T2DM) patients in healthcare institutions in Colombia, based on the recommendations of the current official guidelines. METHODS An observational and retrospective cohort study based on databases of two Health Medical Organizations (HMOs) in Colombia (one from subsidized regimen and one from contributory regimen) was conducted. Descriptive analysis was performed to summarize demographic and clinical information. Chi-square tests were used to assess associations between variables of interest. RESULTS A total of 616 patients with T2DM (308 for each regimen) were included. Median age was 61 years. Overall clinical inertia was 93.5% (87.0% in contributory regimen and 100% in subsidized regimen). Patients with Hb1Ac ≥ 8% in the subsidized regimen were more likely to receive monotherapy than patients in the contributory regimen (OR 2.33; 95% CI 1.41-3.86). CONCLUSIONS In this study, the prevalence of overall clinical inertia was higher in the subsidized regime than in the contributory regime (100% vs 87%). Great efforts have been made to equalize the coverage between the two systems, but this finding is worrisome with respect to the difference in quality of the health care provided to these two populations. This information may help payers and clinicians to streamline strategies for reducing clinical inertia and improve patient outcomes.
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Affiliation(s)
- Nelson Alvis-Guzman
- Universidad de la Costa, Cl. 58 #55 - 66, Barranquilla, Atlántico, Colombia.
- Grupo de Investigación en Economía de la Salud, Universidad de Cartagena, Cartagena, Colombia.
| | | | | | - Maria Carrasquilla-Sotomayor
- Universidad de la Costa, Cl. 58 #55 - 66, Barranquilla, Atlántico, Colombia
- School of Public Health, Postgraduate Program in Epidemiology, Laboratory of Causal Inference in Epidemiology (LINCE-USP), University of São Paulo, São Paulo-SP, Brazil
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Tsai Y, Kuo T, Lin M, Shen F, Lin Y. Mandatory monthly outpatient visits could improve therapeutic inertia in patients with poorly controlled type 2 diabetes. J Diabetes Investig 2024; 15:227-236. [PMID: 37882416 PMCID: PMC10804897 DOI: 10.1111/jdi.14102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/30/2023] [Accepted: 10/10/2023] [Indexed: 10/27/2023] Open
Abstract
AIMS/INTRODUCTION Delayed intensification of treatment, or therapeutic inertia, increases the risk of diabetic complications and death. The aim of this study was to determine the effect of mandatory monthly outpatient visits on therapeutic inertia in patients with suboptimal control of type 2 diabetes. MATERIALS AND METHODS This retrospective cohort study used data from the Chang Gung Research Database and defined two study periods: the baseline period and the intervention period. The intervention period began when the Kaohsiung branch initiated a mandatory monthly outpatient visits program. Type 2 diabetes patients with baseline glycated hemoglobin (HbA1c) >7% and a follow-up HbA1c measurement were enrolled in each period, and divided into a Kaohsiung branch (intervention) group and the other branches (control) group. Therapy intensification was evaluated by comparing prescriptions after the follow-up HbA1c measurement with the prescriptions after the baseline HbA1c measurement. RESULTS A total of 5,045 patients at the Kaohsiung branch and 13,400 participants at other branches were enrolled in the baseline period; and 5,573 and 15,603 patients, respectively, were enrolled in the intervention period. The adjusted odds ratio (AOR) for therapy intensification in patients with baseline HbA1c ≥9% was not significantly higher at 1.21 (95% CI, 1.00-1.47) in the intervention period at the Kaohsiung branch, but was significantly higher (AOR, 1.53; 95% CI, 1.02-2.30) in the subgroup with worsened HbA1c. CONCLUSIONS Mandatory monthly outpatient visits could improve therapeutic inertia in patients with poorly controlled type 2 diabetes, especially in those with worsened control. The trajectory of HbA1c could significantly influence the assessment of the prevalence of therapeutic inertia.
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Affiliation(s)
- Ying‐Ying Tsai
- Division of Traditional Chinese MedicineChang Gung Memorial Hospital Chiayi BranchChiayiTaiwan
| | - Ting‐Yu Kuo
- Health Information and Epidemiology LaboratoryChang Gung Memorial Hospital Chiayi BranchChiayiTaiwan
| | - Meng‐Hung Lin
- Health Information and Epidemiology LaboratoryChang Gung Memorial Hospital Chiayi BranchChiayiTaiwan
| | - Feng‐Chih Shen
- Division of Endocrinology and Metabolism, Department of Internal MedicineKaohsiung Chang Gung Memorial HospitalKaohsiungTaiwan
| | - Yung‐Hsiang Lin
- Division of Endocrinology and MetabolismChang Gung Memorial Hospital Chiayi BranchChiayiTaiwan
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Medina Néri AK, Silva RP, Meneses GC, Costa Martins AM, Portela Lima AO, Callou Filho CR, Cavalcante Vidal FD, de Oliveira Lima JM, Rocha EA, da Silva Júnior GB. Association between endothelial biomarkers and lipid and glycemic levels: a cross-sectional study with diabetic patients. Biomark Med 2023; 17:935-946. [PMID: 38230971 DOI: 10.2217/bmm-2023-0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
Abstract
Background: Biomarkers can help understand the impact of achieving therapeutic goals in developing vascular diseases in diabetics. Aim: To assess the association between lipid and glycemic profiles and endothelial biomarkers in diabetics. Methods: Cross-sectional study that evaluated lipid and glycemic levels and biomarkers (VCAM-1, Sdc-1, FGF-23 and KIM-1 in diabetics. Results: Higher VCAM-1 levels were associated with higher low-density lipoprotein cholesterol and non-high-density lipoprotein (HDL) cholesterol levels (in the group with inadequate glycohemoglobin A1c [HbA1c] levels), with higher glycemic levels (in the group with inadequate HDL cholesterol levels) and with lower HDL cholesterol levels (both groups). VCAM-1 was independently associated with not achieving adequate HbA1c levels. Conclusion: In uncontrolled diabetics, VCAM-1 was independently associated with having inadequate HbA1c levels, suggesting they may already have endothelial damage.
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Affiliation(s)
- Ane Karoline Medina Néri
- University of Fortaleza, Health Sciences Center, Postgraduate Program in Collective Health, Fortaleza, 60811-905, Brazil
| | - Ricardo Pereira Silva
- Federal University of Ceará, Walter Cantídio Teaching Hospital, Cardiology Service, Fortaleza, 60430-372, Brazil
| | - Gdayllon Cavalcante Meneses
- Federal University of Ceará, Federal University of Ceará, Medical Sciences Post-Graduate Program, Fortaleza, 60430-140, Brazil
| | - Alice Maria Costa Martins
- Federal University of Ceará, Clinical and Toxicological Analysis Department, School of Pharmacy, Fortaleza, 60430-160, Brazil
| | - Ana Ofélia Portela Lima
- University of Fortaleza, Health Sciences Center, Postgraduate Program in Collective Health, Fortaleza, 60811-905, Brazil
| | - Cesário Rui Callou Filho
- University of Fortaleza, Health Sciences Center, Postgraduate Program in Collective Health, Fortaleza, 60811-905, Brazil
| | | | - Jeruza Mara de Oliveira Lima
- Federal University of Ceará, Walter Cantídio Teaching Hospital, Cardiology Service, Fortaleza, 60430-372, Brazil
| | - Eduardo Arrais Rocha
- Federal University of Ceará, Walter Cantídio Teaching Hospital, Cardiology Service, Fortaleza, 60430-372, Brazil
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Clinical Inertia in the Management of Type 2 Diabetes Mellitus: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010182. [PMID: 36676805 PMCID: PMC9866102 DOI: 10.3390/medicina59010182] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023]
Abstract
This review seeks to establish, through the recent available literature, the prevalence of therapeutic intensification delay and its sequences in poorly controlled Type 2 Diabetes Mellitus (T2DM) patients. The strategy identified studies exploring the clinical inertia and its associated factors in the treatment of patients with T2DM. A total of 25 studies meeting the pre-established quality criteria were included in this review. These studies were conducted between 2004 and 2021 and represented 575,067 patients diagnosed with T2DM. Trusted electronic bibliographic databases, including Medline, Embase, and the Cochrane Central Register of Controlled Trials, were used to collect studies by utilizing a comprehensive set of search terms to identify Medical Subject Headings (MeSH) terms. Most o the studies included in this review showed clinical inertia rates over 50% of T2DM patients. In the USA, clinical inertia ranged from 35.4% to 85.8%. In the UK, clinical inertia ranged from 22.1% to 69.1%. In Spain, clinical inertia ranged from 18.1% to 60%. In Canada, Brazil, and Thailand, clinical inertia was reported as 65.8%, 68%, and 68.4%, respectively. The highest clinical inertia was reported in the USA (85.8%). A significant number of patients with T2DM suffered from poor glycemic control for quite a long time before treatment intensification with oral antidiabetic drugs (OADs) or insulin. Barriers to treatment intensification exist at the provider, patient, and system levels. There are deficiencies pointed out by this review at specialized centers in terms of clinical inertia in the management of T2DM including in developed countries. This review shows that the earlier intensification in the T2DM treatment is appropriate to address issues around therapeutic inertia.
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Benson G, Hayes J, Bunkers-Lawson T, Sidebottom A, Boucher J. Leveraging Registered Dietitian Nutritionists and Registered Nurses in Medication Management to Reduce Therapeutic Inertia. Diabetes Spectr 2022; 35:491-503. [PMID: 36561653 PMCID: PMC9668720 DOI: 10.2337/ds21-0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective To conduct a systematic review of studies that used registered dietitian nutritionists (RDNs) or registered nurses (RNs) to deliver pharmacological therapy using protocols for diabetes, dyslipidemia, or hypertension. Research Design and Methods A database search of PubMed, the Cochrane Central Register of Controlled Trials, Ovid, and the Cumulative Index to Nursing and Allied Health Literature was conducted of literature published from 1 January 2000 to 31 December 2019. Results Twenty studies met the inclusion criteria, representing randomized controlled trials (12), retrospective (1) and prospective cohort design studies (6), and time series (1). In all, the studies include 7,280 participants with a median study duration of 12 months (range 6-25 months). Fifteen studies were led by RNs alone, two by RDNs, and three by a combination of RDNs and RNs. All demonstrated improvements in A1C, blood pressure, or lipids. Thirteen studies provided a lifestyle behavior change component in addition to medication protocols. Conclusion This systematic review provides evidence that RDN- and RN-led medication management using physician-approved protocols or treatment algorithms can lead to clinically significant improvements in diabetes, dyslipidemia, and hypertension management and is as good or better than usual care.
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Affiliation(s)
| | - Joy Hayes
- Minneapolis Heart Institute Foundation, Minneapolis, MN
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10
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Liu J, Bloomgarden Z. The Chinese Metabolic Management Centers. J Diabetes 2022; 14:362-364. [PMID: 35712984 PMCID: PMC9366566 DOI: 10.1111/1753-0407.13290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jianmin Liu
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic DiseasesRuijin Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical GenomicsRuijin Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
| | - Zachary Bloomgarden
- Department of Medicine, Division of Endocrinology, Diabetes, and Bone DiseaseIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Abstract
PURPOSE OF REVIEW In this review, we examine the expanding role of continuous glucose monitoring in glycaemic management in primary care. RECENT FINDINGS Improving technology and decreasing cost have increased the uptake of use of continuous glucose monitoring (CGM) for glycaemic management in primary care, wherein most diabetes is managed. Optimized use of this technology, however, will require a convergence of several factors. Availability of devices for people with diabetes, availability of data at the time of clinical interactions, and expertise in interpretation of CGM and ambulatory glucose profile (AGP) data, as well as optimization of therapies, will be required. Significant progress has been made in all three areas in recent years, yet creating systems of support for widespread use of CGM in primary care remains an area of active investigation. SUMMARY There has been significant uptake in the use of CGM in the management of diabetes in primary care. Optimized use, however, requires both access to CGM data and the expertise to use the data. Although promising strategies have emerged, the task of generalizing these strategies to the broad population of primary care in America is ongoing. CGM technology holds significant potential for improving glycaemic management in primary care, yet important work remains to leverage the full potential of this promising technology.
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Affiliation(s)
- Thomas W Martens
- International Diabetes Center, HealthPartners Institute and Park Nicollet Department of Internal Medicine, Minneapolis, Minnesota, USA
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Dzięgielewska-Gęsiak S, Fatyga E, Piłot M, Wierzgoń A, Muc-Wierzgoń M. Are There Differences in Gut Microbiome in Patients with Type 2 Diabetes Treated by Metformin or Metformin and Insulin? Diabetes Metab Syndr Obes 2022; 15:3589-3599. [PMID: 36426212 PMCID: PMC9680967 DOI: 10.2147/dmso.s377856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/28/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Recently, gut microbiota has been described as being involved in the health and diseases of the host, and together with diet and drugs may influence metabolic health. Yet, there is still no answer which type of treatment plays the most important role in the interplay of gut microbiota and type of treatment for type 2 diabetes (T2DM). An attempt was made to answer the question of which factors have the most significant impact on the intestinal microbiome in the context of metformin or metformin+insulin use in treatment of the patients with T2DM. Thus the aim of the study was to compare the gut microbiome profiles of patients with T2DM and two of the most traditional treatment methods. METHODS T2DM patients treated by metformin (Met) and metformin+insulin (Met+Ins), with the treatment duration of 5-10 years were enrolled. Biochemically blood glucose and glycated hemoglobin (HbA1c), lipids and kidney function were investigated and the quantitative and qualitative examination of the fecal intestinal flora were performed through the next-generation sequencing. RESULTS There were no significant differences in the study of the gut microbiome: the dominant bacterial phyla were Firmicutes and Verrucomicrobia, while Bacteroidetes and Proteobacteria shared smaller proportions in both groups. However, the group Met+Ins had worse metabolic control in terms of blood glucose and HbA1c in comparison with the Met group. CONCLUSION As there are no differences in gut microbiome in T2DM patients treated with metformin only or metformin plus insulin, adding insulin in the treatment of T2DM may delay late diabetic complications development.
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Affiliation(s)
- Sylwia Dzięgielewska-Gęsiak
- Department of Internal Medicine Prevention, Medical University of Silesia in Katowice, Katowice, Poland
- Correspondence: Sylwia Dzięgielewska-Gęsiak, Department of Internal Preventive Medicine, Medical University of Silesia in Katowice, 41-902 Bytom, Piekarska 18 st, Katowice, Poland, Tel/Fax +48/32/39-76-527, Email
| | - Edyta Fatyga
- Department of Internal Medicine Prevention, Medical University of Silesia in Katowice, Katowice, Poland
| | - Magdalena Piłot
- Department of Internal Medicine Prevention, Medical University of Silesia in Katowice, Katowice, Poland
| | - Aleksander Wierzgoń
- Department of Environmental Biotechnology, Faculty of Energy and Environmental Engineering, Silesian University of Technology, Gliwice, Poland
| | - Małgorzata Muc-Wierzgoń
- Department of Internal Medicine Prevention, Medical University of Silesia in Katowice, Katowice, Poland
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Williams NA, Brunton SA, Scott GA. CRS Diabetes: An Effective Model for Improving Family Medicine Resident Knowledge, Competence, and Performance in Diabetes Care. Clin Diabetes 2022; 40:62-69. [PMID: 35221473 PMCID: PMC8865790 DOI: 10.2337/cd21-0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The Chief Residents Summit on Intensifying Diabetes Management, now in its 15th year, has resulted in real-world improvements in patient outcomes and has shown itself to be an effective model for teaching diabetes to family medicine residents. This article describes the program and the evidence supporting its effectiveness.
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McCoy RG, O'Connor PJ. Overcoming Therapeutic Inertia in Type 2 Diabetes Care-Timing, Context, and Appropriateness of Treatment Intensification. JAMA Netw Open 2021; 4:e2130926. [PMID: 34673968 PMCID: PMC8764972 DOI: 10.1001/jamanetworkopen.2021.30926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Rozalina G McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
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Abdul-Ghani M, DeFronzo RA. Personalized approach for type 2 diabetes pharmacotherapy: where are we and where do we need to be? Expert Opin Pharmacother 2021; 22:2113-2125. [PMID: 34435523 DOI: 10.1080/14656566.2021.1967319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Cluster analysis has identified distinct groups of type 2 diabetes (T2D) subjects with distinct metabolic characteristics. Thus, personalizing pharmacologic therapy to individual phenotypic and pathophysiologic characteristics has potential to improve metabolic control and reduce risk of microvascular and macrovascular complications. AREAS COVERED The authors review the classification of T2D, genetic markers, pathophysiology and natural history of T2D, the ABCDE approach to therapy, the ADA/EASD stepwise approach to therapy, available antidiabetic agents, and provide a more rational therapeutic approach based upon pathophysiology and cardiovascular and renal outcome trials. EXPERT OPINION Although insulin resistance is the earliest detectable abnormality, overt T2D does not occur in the absence of progressive beta cell failure. Because of the complex etiology of T2D (Ominous Octet), initiation of therapy with combined agents that (i) target both insulin resistance and beta cell dysfunction and (ii) prevent macrovascular, as well as microvascular, complications will be required. The ratio of C-peptide at 120 minutes (OGTT) to baseline C-peptide predicts with high sensitivity who will respond to metformin, the response to glucose-lowering agents and provides a useful tool to guide optimal glucose lowering therapy.
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