Evaluation of Out-of-Pocket Costs and Treatment Intensification With an SGLT2 Inhibitor or GLP-1 RA in Patients With Type 2 Diabetes and Cardiovascular Disease

Importance

The latest guidelines continue to recommend sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for patients with type 2 diabetes (T2D) and established cardiovascular disease (CVD). Despite this, overall use of these 2 drug classes has been suboptimal.

Objective

To assess the association of high out-of-pocket (OOP) costs and the initiation of an SGLT2 inhibitor or GLP-1 RA among adults with T2D and established CVD who are treated with metformin-treated.

Design, Setting, and Participants

This retrospective cohort study used 2017 to 2021 data from the Optum deidentified Clinformatics Data Mart Database. Each individual in the cohort was categorized into quartiles of OOP costs for a 1-month supply of SGLT2 inhibitor and GLP-1 RA based on their health plan assignment. Data were analyzed from April 2021 to October 2022.

Exposures

OOP cost for SGLT2 inhibitors and GLP-1 RA.

Main Outcomes and Measures

The primary outcome was treatment intensification, defined as a new dispensing (ie, initiation) of either an SGLT2 inhibitor or GLP-1 RA, among patients with T2D previously treated with metformin monotherapy. For each drug class separately, Cox proportional hazards models were used to adjust for demographic, clinical, plan, clinician, and laboratory characteristics to estimate the hazard ratios of treatment intensification comparing the highest vs the lowest quartile of OOP costs.

Results

Our cohort included 80 807 adult patients (mean [SD] age, 72 [9.5] years, 45 129 [55.8%] male; 71 128 [88%] were insured with Medicare Advantage) with T2D and established CVD on metformin monotherapy. Patients were followed for a median (IQR) of 1080 days (528 to 1337). The mean (SD) of OOP costs in the highest vs lowest quartile was $118 [32] vs $25 [12] for GLP-1 RA, and $91 [25] vs $23 [9] for SGLT2 inhibitors. Compared with patients in plans with the lowest quartile (Q1) of OOP costs, patients in plans with the highest quartile (Q4) of costs were less likely to initiate a GLP-1 RA (adjusted HR, 0.87 [95% CI, 0.78 to 0.97]) or an SGLT2 inhibitor (adjusted HR, 0.80 [95% CI, 0.73 to 0.88]). The median (IQR) number of days to initiating a GLP-1 RA was 481 (207-820) days in Q1 and 556 (237-917) days in Q4 of OOP costs and 520 (193-876) days in Q1 vs 685 (309-1017) days in Q4 for SGLT2 inhibitors.

Conclusions and Relevance

In this cohort study of more than 80 000 older adults with T2D and established CVD covered by Medicare Advantage and commercial plans, those in the highest quartile of OOP cost were 13% and 20% less likely to initiate a GLP-1 RA or SGLT2 inhibitor, respectively, when compared with those in the lowest quartile of OOP costs.

Real-world weight-loss effectiveness of glucagon-like peptide-1 agonists among patients with type 2 diabetes: A retrospective cohort study

OBJECTIVE

Weight loss achieved with standard doses of glucagon-like peptide-1 (GLP-1) agonists among real-world patients with type 2 diabetes has not been determined. This study sought to describe the percent change in body weight 72 weeks after starting a GLP-1 agonist.

METHODS

A retrospective cohort study of nonpregnant adults who were first dispensed a GLP-1 agonist between 2011 and 2018 was conducted using electronic health record data from patients receiving care at a large health system. Linear mixed models were used, with a person-level random intercept controlling for baseline variables associated with missing weight data to estimate percent body weight change during follow-up.

RESULTS

The cohort included 2405 patients (mean [SD] age 48 [10] years, 53% female), with a mean BMI of 37 (8) kg/m2 and a mean baseline weight of 238 (54) lb. Mean percent weight loss significantly increased from 1.1% (95% CI: 0.6%-1.6%) 8 weeks after GLP-1-agonist dispensing to 2.2% (95% CI: 1.7%-2.6%) 72 weeks after GLP-1-agonist dispensing (p value for quadratic trend < 0.001). One-third of patients lost ≥5% body weight at 72 weeks.

CONCLUSIONS

In this real-world study of more than 2400 patients with overweight or obesity and type 2 diabetes, starting a GLP-1 agonist at standard glycemic control doses was associated with modest weight loss through 72 weeks.

Incidence and Predictors of Primary Nonadherence to Sodium Glucose Co-transporter 2 Inhibitors and Glucagon-Like Peptide 1 Agonists in a Large Integrated Healthcare System

BACKGROUND

Newer glucose-lowering drugs, including sodium glucose co-transporter 2 inhibitors (SGLT2i) and GLP-1 agonists, have a key role in the pharmacologic management of type 2 diabetes. No studies have measured primary nonadherence for these two drug classes, defined as when a medication is prescribed for a patient but ultimately not dispensed to them.

OBJECTIVE

To describe the incidence and predictors of primary nonadherence to SGLT2i (canagliflozin, empagliflozin) or GLP-1 agonists (dulaglutide, liraglutide, semaglutide) using a dataset that links electronic prescribing with health insurance claims.

DESIGN AND PARTICIPANTS

A retrospective cohort design using data of adult patients from a large health system who had at least one prescription order for a SGLT2i or GLP-1 agonist between 2012 and 2019. We used mixed-effects multivariable logistic regression to determine associations between sociodemographic, clinical, and provider variables and primary nonadherence.

MAIN MEASURES

Primary medication nonadherence, defined as no dispensed claim within 30 days of an electronic prescription order for any drug within each medication class.

KEY RESULTS

The cohort included 5146 patients newly prescribed a SGLT2i or GLP-1 agonist. The overall incidence of 30-day primary medication nonadherence was 31.8% (1637/5146). This incidence rate was 29.8% (n = 726) and 33.6% (n = 911) among those initiating a GLP-1 agonist and SGLT2i, respectively. Age ≥ 65 (aOR 1.37 (95% CI 1.09 to 1.72)), Black race vs White (aOR 1.29 (95% CI 1.02 to 1.62)), diabetic nephropathy (aOR 1.31 (95% CI 1.02 to 1.68)), and hyperlipidemia (aOR 1.18 (95% CI 1.01 to 1.39)) were associated with a higher odds of primary nonadherence. Female sex (aOR 0.86 (95% CI 0.75 to 0.99)), peripheral artery disease (aOR 0.73 (95% CI 0.56 to 0.94)), and having the index prescription ordered by an endocrinologist vs a primary care provider (aOR 0.76 (95% CI 0.61 to 0.95)) were associated with lower odds of primary nonadherence.

CONCLUSIONS

One third of patients prescribed SGLT2i or GLP-1 agonists in this sample did not fill their prescription within 30 days. Black race, male sex, older age, having greater baseline comorbidities, and having a primary care provider vs endocrinologist prescribe the index drug were associated with higher odds of primary nonadherence. Interventions targeting medication adherence for these newer drugs must consider primary nonadherence as a barrier to optimal clinical care.

Association of formulary restrictions and initiation of an SGLT2i or GLP1-RA among Medicare beneficiaries with type 2 diabetes

BACKGROUND

Use of SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP1-RA) among older adults with type 2 diabetes (T2D) has been limited.

OBJECTIVE

To examine factors associated with initiation of an SGLT2i or GLP-1RA among Medicare beneficiaries with T2D in the early years after their market approval, with a particular focus on formulary restrictions (e.g. prior authorization, step therapy requirements, higher co-pays).

METHODS

A retrospective cohort study using data from a 5% random sample of Medicare beneficiaries with T2D followed from 1/1/2015-12/31/16. Formulary restrictiveness was defined as: (1) the number of target drugs (i.e. SGLT2is or GLP1-RAs) included in tiers 1-3 of a beneficiary's formulary (greater number of drugs in tiers 1-3 being less restrictive) and (2) the number of drugs without prior authorization or step therapy (requirement to try less expensive drugs prior to "stepping up" to more expensive therapies). We used multivariable logistic regression models to estimate the association between measures of formulary restrictiveness and initiation of a target drug, controlling for patient demographics, diabetes duration, clinical comorbidities, and provider specialty.

RESULTS

Among 112,985 beneficiaries with T2D, 5,619 (5%) initiated an SGLT2i or GLP1-RA. After adjusting for baseline characteristics, patients enrolled in formularies with ≥ 2 target drugs available in tiers 1-3 had 17% higher odds of initiating an SGLT2i or GLP1-RA (aOR 1.17, 95% CI 1.05-1.31) compared to patients enrolled in formularies with 0 drugs available in tiers 1-3. There was no significant association between the number of drugs without prior authorization or step therapy requirements and initiation of a target drug (aOR 0.96, 95% CI, 0.85-1.09). Age 75 years or older (vs < 65, aOR 0.23, 95% CI 0.21-0.26) and black race (vs white, aOR 0.65, 95% CI 0.59-0.71) were associated with lower odds of initiating a target drug.

CONCLUSIONS

Having a greater number of target drugs available on less expensive formulary tiers is associated with increased odds of initiating an SGLT2i or GLP-1RA among Medicare beneficiaries with T2D.

Observed couple interactions among White and Black persons with type 2 diabetes

The majority of observed couple communication research has focused on physically healthy couples and those who are White, educated, and affluent. In the present study, we observed persons with Type 2 diabetes and their romantic partners discuss how to improve diabetes management; afterward, we measured positive affect, negative affect, and discussion evaluations. We also measured mood and self-care behavior over the next 2 weeks. Couples (n = 207) were recruited from the community and varied in education, income, and race. Half of patients were White (53%), and half were Black (47%). Results showed that observed patient warmth was related to a more positive evaluation of the discussion, more postdiscussion positive affect, less postdiscussion negative affect, and better 2-week daily happy mood; observed patient negativity was related to less postdiscussion progress, a more negative evaluation of the discussion, less postdiscussion positive affect, and poorer 2-week dietary adherence; and observed patient distress was related to a more negative discussion evaluation, more postdiscussion negative affect, and worse mood over the next 2 weeks. Two of the findings were moderated by race, in the direction of links being stronger for Black than White patients. Partner warmth was rarely related to outcomes, but partner negativity was related to patients' poorer discussion evaluation, patient's lower happy mood and higher angry mood over the next 2 weeks, and patient's poorer 2-week dietary adherence. Future research on couple interactions should attend to important contextual variables such as race, ethnicity, income, and social status. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Changes in mood and health-related quality of life in Look AHEAD 6 years after termination of the lifestyle intervention

OBJECTIVE

The Action for Health in Diabetes (Look AHEAD) study previously reported that intensive lifestyle intervention (ILI) reduced incident depressive symptoms and improved health-related quality of life (HRQOL) over nearly 10 years of intervention compared with a control group (the diabetes support and education group [DSE]) in participants with type 2 diabetes and overweight or obesity. The present study compared incident depressive symptoms and changes in HRQOL in these groups for an additional 6 years following termination of the ILI in September 2012.

METHODS

A total of 1,945 ILI participants and 1,900 DSE participants completed at least one of four planned postintervention assessments at which weight, mood (via the Patient Health Questionnaire-9), antidepressant medication use, and HRQOL (via the Medical Outcomes Scale, Short Form-36) were measured.

RESULTS

ILI participants and DSE participants lost 3.1 (0.3) and 3.8 (0.3) kg [represented as mean (SE); p = 0.10], respectively, during the 6-year postintervention follow-up. No significant differences were observed between groups during this time in incident mild or greater symptoms of depression, antidepressant medication use, or in changes on the physical component summary or mental component summary scores of the Short Form-36. In both groups, mental component summary scores were higher than physical component summary scores.

CONCLUSIONS

Prior participation in the ILI, compared with the DSE group, did not appear to improve subsequent mood or HRQOL during 6 years of postintervention follow-up.

Links of communal coping to relationship and psychological health in type 2 diabetes: actor-partner interdependence models involving role, sex, and race

BACKGROUND

Communal coping is one person's appraisal of a stressor as shared and collaboration with a partner to manage the problem. There is a burgeoning literature demonstrating the link of communal coping to good relationships and health among persons with chronic disease.

PURPOSE

We examined links of communal coping to relationship and psychological functioning among couples in which one person was recently diagnosed with type 2 diabetes. We distinguished effects of own communal coping from partner communal coping on both patient and spouse relationship and psychological functioning, as well as whether communal coping effects were moderated by role (patient, spouse), sex (male, female), and race (White, Black).

METHODS

Participants were 200 couples in which one person had been diagnosed with type 2 diabetes (46% Black, 45% female) within the last 5 years. Couples completed an in-person interview, participated in a discussion to address diabetes-related problems, and completed a postdiscussion questionnaire.

RESULTS

Own communal coping and partner communal coping were related to good relationship and psychological functioning. Interactions with role, sex, and race suggested: (i) partner communal coping is more beneficial for patients than spouses; (ii) own communal coping is more beneficial for men, whereas partner communal coping is more beneficial for women; and (iii) White patients and Black spouses benefit more from own communal coping than Black patients and White spouses.

CONCLUSION

These findings demonstrate the benefits of communal coping across an array of self-report and observed indices, but suggest there are differential benefits across role, sex, and race.

Within-Trial Cost-Effectiveness of a Structured Lifestyle Intervention in Adults With Overweight/Obesity and Type 2 Diabetes: Results From the Action for Health in Diabetes (Look AHEAD) Study

OBJECTIVE

To assess the cost-effectiveness (CE) of an intensive lifestyle intervention (ILI) compared with standard diabetes support and education (DSE) in adults with overweight/obesity and type 2 diabetes, as implemented in the Action for Health in Diabetes study.

RESEARCH DESIGN AND METHODS

Data were from 4,827 participants during their first 9 years of study participation from 2001 to 2012. Information on Health Utilities Index Mark 2 (HUI-2) and HUI-3, Short-Form 6D (SF-6D), and Feeling Thermometer (FT), cost of delivering the interventions, and health expenditures was collected during the study. CE was measured by incremental CE ratios (ICERs) in costs per quality-adjusted life year (QALY). Future costs and QALYs were discounted at 3% annually. Costs were in 2012 U.S. dollars.

RESULTS

Over the 9 years studied, the mean cumulative intervention costs and mean cumulative health care expenditures were $11,275 and $64,453 per person for ILI and $887 and $68,174 for DSE. Thus, ILI cost $6,666 more per person than DSE. Additional QALYs gained by ILI were not statistically significant measured by the HUIs and were 0.07 and 0.15, respectively, measured by SF-6D and FT. The ICERs ranged from no health benefit with a higher cost based on HUIs to $96,458/QALY and $43,169/QALY, respectively, based on SF-6D and FT.

CONCLUSIONS

Whether ILI was cost-effective over the 9-year period is unclear because different health utility measures led to different conclusions.

Perspectives of Parents With Type 1 Diabetes: Role of Children in Self-Management and Support

PURPOSE

The purpose of this study was to examine parents' perceptions of the role children play in their type 1 diabetes (T1DM) care. Family members are a resource to support T1DM self-management, but how children are involved in their parents' diabetes has not been well explored.

METHODS

Parents with T1DM (n = 85) and a subset of their romantic partners (n = 55) participated in interviews during which they described their children's knowledge of and involvement in diabetes care. Interviews were transcribed, responses coded/tallied, and themes identified.

RESULTS

All parents reported that children knew of their diabetes, which they learned about progressively from a young age. Most parents reported children to be accepting and understanding of the ways that diabetes affected their family experiences (eg, pause to treat low blood glucose). When asked about specific support, parents rated "making parent feel better about diabetes" as the most frequently occurring behavior. Some parents felt that children, particularly younger ones, occasionally detracted from T1DM management, but this was usually expected and considered transient. Regardless of child age, many parents did not want diabetes to burden children and limited their involvement. Both parents with T1DM and partners requested resources to enhance child awareness and preparedness to support diabetes. Respondents, particularly partners, were also interested in learning how to communicate better as a family and share perspectives on how diabetes affects individual family members.

CONCLUSIONS

Diabetes care and education specialists should consider developmentally and relationally appropriate ways to engage children of parents with T1DM in education and self-management.

Intensive Weight Loss Intervention and Cancer Risk in Adults with Type 2 Diabetes: Analysis of the Look AHEAD Randomized Clinical Trial

OBJECTIVE

This study was designed to determine whether intensive lifestyle intervention (ILI) aimed at weight loss lowers cancer incidence and mortality.

METHODS

Data from the Look AHEAD trial were examined to investigate whether participants randomized to ILI designed for weight loss would have reduced overall cancer incidence, obesity-related cancer incidence, and cancer mortality, as compared with the diabetes support and education (DSE) comparison group. This analysis included 4,859 participants without a cancer diagnosis at baseline except for nonmelanoma skin cancer.

RESULTS

After a median follow-up of 11 years, 684 participants (332 in ILI and 352 in DSE) were diagnosed with cancer. The incidence rates of obesity-related cancers were 6.1 and 7.3 per 1,000 person-years in ILI and DSE, respectively, with a hazard ratio (HR) of 0.84 (95% CI: 0.68-1.04). There was no significant difference between the two groups in total cancer incidence (HR, 0.93; 95% CI: 0.80-1.08), incidence of nonobesity-related cancers (HR, 1.02; 95% CI: 0.83-1.27), or total cancer mortality (HR, 0.92; 95% CI: 0.68-1.25).

CONCLUSIONS

An ILI aimed at weight loss lowered incidence of obesity-related cancers by 16% in adults with overweight or obesity and type 2 diabetes. The study sample size likely lacked power to determine effect sizes of this magnitude and smaller.

A Pragmatic Approach to Inpatient Diabetes Management during the COVID-19 Pandemic

The pandemic of COVID-19 has presented new challenges to hospital personnel providing care for infected patients with diabetes who represent more than 20% of critically ill patients in intensive care units. Appropriate glycemic management contributes to a reduction in adverse clinical outcomes in acute illness but also requires intensive patient interactions for bedside glucose monitoring, intravenous and subcutaneous insulin administration, as well as rapid intervention for hypoglycemia events. These tasks are required at a time when minimizing patient interactions is recommended as a way of avoiding prolonged exposure to COVID-19 by health care personnel who often practice in settings with limited supplies of personal protective equipment. The purpose of this manuscript is to provide guidance for clinicians for reconciling recommended standards of care for infected hospitalized patients with diabetes while also addressing the daily realities of an overwhelmed health care system in many areas of the country. The use of modified protocols for insulin administration, bedside glucose monitoring, and medications such as glucocorticoids and hydroxychloroquine that may affect glycemic control are discussed. Continuous glucose monitoring systems have been proposed as an option for reducing time spent with patients, but there are important issues that need to be addressed if these are used in hospitalized patients. On-site and remote glucose management teams have potential to provide guidance in areas where there are shortages of personnel who have expertise in inpatient glycemic management.

Association Between Preoperative Metformin Exposure and Postoperative Outcomes in Adults With Type 2 Diabetes

Importance

Adults with comorbidity have less physiological reserve and an increased rate of postoperative mortality and readmission after the stress of a major surgical intervention.

Objective

To assess postoperative mortality and readmission among individuals with diabetes with or without preoperative prescriptions for metformin.

Design, Setting, and Participants

This cohort study obtained data from the electronic health record of a multicenter, single health care system in Pennsylvania. Included were adults with diabetes who underwent a major operation with hospital admission from January 1, 2010, to January 1, 2016, at 15 community and academic hospitals within the system. Individuals without a clinical indication for metformin therapy were excluded. Follow-up continued until December 18, 2018.

Exposures

Preoperative metformin exposure was defined as 1 or more prescriptions for metformin in the 180 days before the surgical procedure.

Main Outcomes and Measures

All-cause postoperative mortality, hospital readmission within 90 days of discharge, and preoperative inflammation measured by the neutrophil to leukocyte ratio were compared between those with and without preoperative prescriptions for metformin. The corresponding absolute risk reduction (ARR) and adjusted hazard ratio (HR) with 95% CI were calculated in a propensity score-matched cohort.

Results

Among the 10 088 individuals with diabetes who underwent a major surgical intervention, 5962 (59%) had preoperative metformin prescriptions. A total of 5460 patients were propensity score-matched, among whom the mean (SD) age was 67.7 (12.2) years, and 2866 (53%) were women. In the propensity score-matched cohort, preoperative metformin prescriptions were associated with a reduced hazard for 90-day mortality (adjusted HR, 0.72 [95% CI, 0.55-0.95]; ARR, 1.28% [95% CI, 0.26-2.31]) and hazard of readmission, with mortality as a competing risk at both 30 days (ARR, 2.09% [95% CI, 0.35-3.82]; sub-HR, 0.84 [95% CI, 0.72-0.98]) and 90 days (ARR, 2.78% [95% CI, 0.62-4.95]; sub-HR, 0.86 [95% CI, 0.77-0.97]). Preoperative inflammation was reduced in those with metformin prescriptions compared with those without (mean neutrophil to leukocyte ratio, 4.5 [95% CI, 4.3-4.6] vs 5.0 [95% CI, 4.8-5.3]; P < .001). E-value analysis suggested robustness to unmeasured confounding.

Conclusions and Relevance

This study found an association between metformin prescriptions provided to individuals with type 2 diabetes before a major surgical procedure and reduced risk-adjusted mortality and readmission after the operation. This association warrants further investigation.

Current Smoking: An Independent Predictor of Elevated A1C in Persons With Type 2 Diabetes

Purpose

The purpose of this study is to examine the association of current smoking as one of several potential predictors of elevated A1C in adults with type 2 diabetes (T2D).

Methods

Using a cross-sectional design, baseline data (N = 282) were analyzed from a randomized clinical trial examining treatment of obstructive sleep apnea in persons with T2D. Sociodemographic, clinical, and behavioral data were collected using questionnaires and physical examinations. Physical activity (mean daily steps walked) was measured with the BodyMedia Armband. Participants were asked if they never smoked, had previously smoked, or currently smoke. The sample distributions of demographic and clinical characteristics were examined using descriptive statistics. Continuous variables were described using means and standard deviations; categorical variables were described as numbers and percentages. Multiple linear regression analysis with backward selection was conducted to develop a parsimonious predictive model for the dependent variable A1C.

Results

Participants were generally middle-aged and, on average, obese with suboptimal blood glucose control; almost 1 of every 5 participants currently smoked. After controlling for age, race, education, financial difficulty, diabetes education, physical activity, and diabetes knowledge, 4 variables were found in the final model to be independently associated with higher A1C: (1) current smoking status, (2) younger age, (3) longer diabetes duration, and (4) higher diabetes-related distress.

Conclusions

The study found that not only is smoking prevalent among persons with T2D with self-reported sleep problems but smoking is also an independent predictor of elevated A1C. The results highlight the vital role diabetes educators have in promoting risk reduction through education and support for smoking cessation.

Diabetes sleep treatment trial: Premise, design, and methodology

The Diabetes Sleep Treatment Trial (DSTT) is a multi-site, double-blinded, randomized, sham-controlled trial. The study objective is to test whether treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) treatment results in improved glycemic control and diabetes self-management behavior compared to participants on a sham-CPAP (sub-therapeutic) device in participants with type 2 diabetes mellitus (T2DM) and co-morbid OSA. The purpose of this paper is to describe the premise for the DSTT, the study design, and the methodology used in this on-going trial. The target enrollment is 210 randomly assigned participants recruited from two sites. The primary outcome for glucose control is HbA1C; additional outcomes for diabetes self-management include objectively measured steps walked and subjectively measured diabetes-related distress, diabetes empowerment, and diabetes knowledge. All participants receive individual diabetes education and counseling for 6 weeks over two individual sessions and three telephone calls. Participants are randomized to receive either sham or active CPAP for 12 weeks, after which, they "guess" their group assignment; this will assist in determining the success of blinding participants to treatment group assignment. Participants revealed to be on active CPAP will be encouraged to continue CPAP for an additional 12 weeks; participants who had been on sham devices will be encouraged to have a repeat CPAP titration study and to crossover to active CPAP treatment for 24 weeks. An intention-to-treat approach will be used for efficacy analyses. The trial is registered with Clinicaltrials.gov (NCT01901055).

An Overview of Safety Issues on Use of Insulin Pumps and Continuous Glucose Monitoring Systems in the Hospital

PURPOSE OF REVIEW

Summarize safety issues related to patients using insulin pump therapy and continuous glucose monitoring systems (CGMS) in the outpatient setting when they are hospitalized and to review steps that can be taken to mitigate risk associated with use or discontinuation of these devices.

RECENT FINDINGS

Two recent consensus conferences were held on the topics of inpatient use of insulin pumps and CGMS devices. In addition to commonly known safety issues (e.g., device malfunction, infection), cybersecurity and the vulnerability of contemporary technology to hacking have emerged. CGMS capabilities offer the promise of advancing the goal for development of glucometry (centralized monitoring of real-time glucose data). Strategies to assuring safe use of insulin pumps and CGMS in the hospital include collaboration between the patient and staff, proper patient selection, and clear policies and procedures outlining safe use. Available data indicates few adverse events associated with these devices in the hospital. Current data suggests, with proper patient selection and a clear process in place for glycemic management, that adverse events are rare, and consensus favors allowing use of the technology in the hospital. The topic of insulin pump and CGMS in the hospital would greatly benefit from more institutions reporting on their experiences and prospective clinical trials.

Consensus Statement on Use of Continuous Subcutaneous Insulin Infusion Therapy in the Hospital

In May 2017, the Diabetes Technology Society convened a panel of US experts on inpatient diabetes management to discuss the current and potential role of continuous subcutaneous insulin infusion (CSII) therapy in the hospital. The panel (1) discussed evidence for current use of CSII in the hospital, (2) recommended contraindications for use in the hospital, and (3) recommended guidelines to maximize chances for safe use of CSII in the hospital. Panel members agreed that larger, prospective, randomized studies are needed to evaluate safety and efficacy of CSII use in the hospital. As CSII technology becomes more complex and its use increases, it is imperative that institutional protocols be in place to ensure safe use of this technology and safe transitions across care areas. Providers need to be cognizant that not all patients currently using CSII as an outpatient are appropriate candidates for continued use in the hospital. This consensus statement provides guidelines for practitioners who may encounter patients using this technology in the inpatient setting.

Clinical Diabetes Centers of Excellence: A Model for Future Adult Diabetes Care

Although diabetes research centers are well defined by National Institutes of Health, there is no clear definition for clinical Diabetes Centers of Excellence (DCOEs). There are multiple clinical diabetes centers across the United States, some established with philanthropic funding; however, it is not clear what defines a DCOE from a clinical perspective and what the future will be for these centers. In this Perspective we propose a framework to guide advancement for DCOEs. With the shift toward value-based purchasing and reimbursement and away from fee for service, defining the procedures for broader implementation of DCOEs as a way to improve population health and patient care experience (including quality and satisfaction) and reduce health care costs becomes critically important. It is prudent to implement new financial systems for compensating diabetes care that may not be provided by fiscally constrained private and academic medical centers. We envision that future clinical DCOEs would be composed of a well-defined infrastructure and six domains or pillars serving as the general guiding principles for developing expertise in diabetes care that can be readily demonstrated to stakeholders, including health care providers, patients, payers, and government agencies.

Implicit and Explicit Communal Coping in Couples with Recently Diagnosed Type 2 Diabetes

When an individual in a close relationship is diagnosed with a chronic illness, coping can be the responsibility of the patient, or couple-members can cope communally. Communal coping reflects a shared appraisal of a stressor (our problem instead of my problem) and collaborative efforts to address the stressor. The current study examined whether patients' and partners' communal coping levels were associated with relational and health functioning among 70 couples in which one member was recently diagnosed with type 2 diabetes. We assessed explicit communal coping with self-reported "inclusion of the other in the self" in regard to diabetes management and implicit communal coping with first person plural pronoun usage during a diabetes discussion. We also assessed patient reports of support received from partners, patient and partner psychological distress, and patient self-care behavior. Results showed that patient explicit communal coping was related to better patient relationship quality and greater support receipt from partners. Patient and partner explicit communal coping also were related to reduced partner distress but not patient distress. Instead, partner implicit communal coping was related to reduced patient distress. Most noteworthy, partner implicit communal coping was related to better patient self-care behavior. These results suggest that communal coping may be beneficial for both relationships and health, but that the effects of explicit measures differ from those of implicit measures. Patients might benefit especially from partner communal coping efforts that are less obvious.

Implications of supportive and unsupportive behavior for couples with newly diagnosed diabetes

OBJECTIVE

To examine the relation between daily diary reports of diabetes-specific social interactions to patient and partner mood and patient self-care behaviors, and whether relations are moderated by unmitigated communion.

METHOD

Participants were 70 couples in which 1 person had been diagnosed with Type 2 diabetes in the past 3 years. They were interviewed in-person at baseline and completed daily diary reports on an iPad. Daily diary questionnaires measured support, mood, and self-care behavior (patients only). Unmitigated communion, a personality trait characterized by an overinvolvement in others to the exclusion of the self, was measured at baseline.

RESULTS

Multilevel statistical modeling revealed that daily fluctuations in partner emotional support were related to daily fluctuations in happy mood, more exercise, and dietary compliance. Partner controlling behavior was related to poor mood but was unrelated to self-care. Relations of support and controlling behavior to mood were strongest for individuals high (vs. low) in unmitigated communion.

CONCLUSION

Patients newly diagnosed with Type 2 diabetes who felt understood and cared for by partners reported a better mood and were more likely to take care of themselves on a daily basis, whereas patients whose partners were controlling on a daily basis reported poorer mood. Patients characterized by unmitigated communion were most affected by partner supportive and unsupportive behavior. (PsycINFO Database Record

Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia

Diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS) and hypoglycaemia are serious complications of diabetes mellitus that require prompt recognition, diagnosis and treatment. DKA and HHS are characterized by insulinopaenia and severe hyperglycaemia; clinically, these two conditions differ only by the degree of dehydration and the severity of metabolic acidosis. The overall mortality recorded among children and adults with DKA is <1%. Mortality among patients with HHS is ~10-fold higher than that associated with DKA. The prognosis and outcome of patients with DKA or HHS are determined by the severity of dehydration, the presence of comorbidities and age >60 years. The estimated annual cost of hospital treatment for patients experiencing hyperglycaemic crises in the USA exceeds US$2 billion. Hypoglycaemia is a frequent and serious adverse effect of antidiabetic therapy that is associated with both immediate and delayed adverse clinical outcomes, as well as increased economic costs. Inpatients who develop hypoglycaemia are likely to experience a long duration of hospital stay and increased mortality. This Review describes the clinical presentation, precipitating causes, diagnosis and acute management of these diabetic emergencies, including a discussion of practical strategies for their prevention.

Perioperative Glycemic Management of Patients Undergoing Bariatric Surgery

Bariatric surgery in patients with type 2 diabetes has been shown to improve glycemic control and reduce need for glucose-lowering medications. Some of these improvements occur in the early postoperative period prior to any weight loss. These early reductions in circulating glucose can be attributed to primarily perioperative caloric restriction and prolonged fasting. Inpatient glycemic targets for patients undergoing bariatric surgery are similar to those recommended for other surgical procedures as a way of minimizing risk for complications. There is evidence that achieving perioperative and postoperative glycemic targets can improve the ability to achieve remission of type 2 diabetes following gastric bypass surgery. This review provides recommendations regarding glycemic goals, strategies for achieving these goals with minimal risk for hypoglycemia, and an examination of the data suggesting an association between perioperative glycemic management and diabetes remission following bariatric surgery.

Post-Gastric Bypass Hypoglycemia

Obesity is a major public health problem worldwide. Obesity-related illnesses, such as coronary heart disease, type 2 diabetes, hypertension, dyslipidemia, stroke, sleep apnea, and several forms of cancer (endometrial, breast, and colon), contribute to a significant number of deaths in the USA. Bariatric surgery, including the Roux-en-Y gastric bypass (RYGB) procedure, has demonstrated significant improvements in obesity and obesity-related co-morbidities and is becoming more popular as the number of obese individuals rises. Despite the reported benefits of bariatric surgery, there are potential complications that physicians need to be aware of as the number of patients undergoing these procedures continues to increase. One challenging and potentially life-threatening complication that to date is not well understood is post-RYGB surgery hypoglycemia (PGBH). In this review, we will present the definition, historical perspective, diagnostic approach, currently available treatment options, and anecdotal assessment and treatment algorithm for this disorder.

Gender Differences in the Response to Impaired Sleep in Adults with Diabetes

This study analyzed cross-sectional data to examine gender differences in the association of sleep quality and daytime sleepiness with mood and functional outcomes in adults with type 2 diabetes (T2DM). Measures included demographic and clinical data as well as scales that measured subjective daytime sleepiness, sleep quality, mood disturbances, and functional outcomes. The majority of the sample (N = 116) had poor sleep quality and was subjectively sleepy. We observed in males and females significantly different associative patterns between the predictor variables of daytime sleepiness and sleep quality and the outcome variables of mood and functional outcome. There was no significant difference in daytime sleepiness or impaired sleep quality between men and women with T2DM; however, there was a difference in the expression of impaired sleep on mood and functional outcomes between genders.

Ankle-brachial index and inter-artery blood pressure differences as predictors of cognitive function in overweight and obese older adults with diabetes: results from the Action for Health in Diabetes movement and memory study

OBJECTIVE

Ankle-brachial index (ABI) and interartery systolic blood pressure differences, as markers of vascular disease, are plausible risk factors for deficits in cognitive function among overweight and obese adults with type 2 diabetes.

METHODS

The ABI and maximum interartery differences (MIAD) in systolic blood pressures were assessed annually for five years among 479 participants assigned to the control condition in a randomized clinical trial of a behavioral weight loss intervention. A battery of standardized cognitive function tests was administered 4 to 5 years later. Analyses of covariance were used to assess relationships that ABI, MIAD, and progression of ABI and MIAD had with cognitive function.

RESULTS

There was a curvilinear relationship between ABI and a composite index of cognitive function (p = 0.03), with lower ABI being associated with poorer function. In graded fashions, both greater MIAD and increases in MIAD over time also had modest relationships with poorer verbal memory (both p ≤ 0.05), processing speed (both p ≤ 0.05), and composite cognitive function (both p < 0.04). These relationships were independent of each other and remained evident after extensive covariate adjustment.

CONCLUSIONS

In overweight and obese adults with type 2 diabetes, lower ABI and larger interartery systolic blood pressure differences have modest, independent, graded relationships with poorer cognitive function 4-5 years later.

SAFETY AND EFFICACY OF A PERI-OPERATIVE PROTOCOL FOR PATIENTS WITH DIABETES TREATED WITH CONTINUOUS SUBCUTANEOUS INSULIN INFUSION WHO ARE ADMITTED FOR SAME-DAY SURGERY

OBJECTIVE

The number of people with diabetes using continuous subcutaneous insulin infusions (CSII) with an insulin pump has risen dramatically, creating new challenges when these patients are admitted to the hospital for surgical or other procedures. There is limited literature guiding CSII use during surgical procedures.

METHODS

The study was carried out in a large, urban, tertiary care hospital. We enrolled 49 patients using insulin pump therapy presenting for 57 elective surgeries. We developed a CSII peri-operative glycemic management protocol (PGMP) to standardize insulin pump management in patients admitted to a same-day surgery unit (SDSU). The purpose was evaluate the safety (% capillary blood glucose (CBG) <70 mg/dL and/or pump incidents) and efficacy (first postoperative CBG ≤200 mg/dL) of the CSII PGMP. We determine the contribution of admission CBG, type of anesthesia, surgery length, and peri-operative steroid use on postoperative glycemic control.

RESULTS

Overall, 63% of patients treated according to the CSII PGMP had a first postoperative CBG ≤200 mg/dL. There were no episodes of intra- or postoperative hypoglycemia. For patients treated with the CSII PGMP, the mean postoperative CBG was lower in patients with anticipated or actual surgical length ≤120 minutes (158.1 ± 53.9 vs. 216 ± 77.7 mg/dL, P<.01). No differences were observed with admission CBG, type of anesthesia, or steroid use.

CONCLUSIONS

This study demonstrates that a CSII PGMP is both safe and effective for patients admitted for elective surgical procedures and provides an example of a standardized protocol for use in clinical practice.

Shorter sleep duration is associated with decreased insulin sensitivity in healthy white men

STUDY OBJECTIVES

Short sleep has been linked to increased risk for type 2 diabetes and incident cardiovascular disease and acute sleep restriction impairs insulin-mediated glucose disposal. Here, we examined whether indices of glucose metabolism vary with naturally occurring differences in sleep duration.

DESIGN AND MEASURES

Subjects were midlife, nondiabetic community volunteers (N = 224; mean age 44.5 ± 6.6 y [range: 30-54]; 52% female; 89% white). Laboratory measures of insulin sensitivity (Si) and acute secretion (AIRg), glucose effectiveness (Sg), and disposition index (Di) were obtained from a 180-min, intravenous glucose tolerance test.

RESULTS

Shorter self-reported sleep duration (in hours) was associated with lower Si (P = 0.043), although an interaction of sleep duration with participant race (β = -0.81, P = 0.002) showed this association significant only in whites. Moreover, sex-stratified analyses revealed that shorter sleep duration predicted lower Si in white men (β = 0.29, P = 0.003) but not in white women (P = 0.22). Findings were similar for AIRg. The relationship between sleep duration and AIRg was moderated by race as well as sex, such that shorter sleep duration associated with greater insulin release only in white men (β = -0.28, P = 0.004). Sleep duration was unrelated to Sg and Di (P's > 0.05).

CONCLUSIONS

Our findings suggest that shorter sleep duration may impair insulin sensitivity and beta-cell function in nondiabetic white men, possibly contributing to later type 2 diabetes and cardiovascular disease.

Sleep, health-related quality of life, and functional outcomes in adults with diabetes

PURPOSE

This study explored the association of sleep quality with physical and mental health-related quality of life (HRQoL) and functional outcomes in 116 participants with type 2 diabetes.

METHODS

The study is a secondary analysis of baseline data from a clinical trial that examined treatment of obstructive sleep apnea on physical activity and glucose control. Instruments included the Pittsburgh Sleep Quality Index, Medical Outcomes Short-Form Physical Component and Mental Component Scores, and Functional Outcomes of Sleep Questionnaire.

RESULTS

Higher physical HRQoL was significantly associated with better sleep quality and improved functional outcomes of increased activity and productivity. Higher mental HRQoL was associated with improved sleep quality and improved functional outcomes of increased activity, social interactions, vigilance, and productivity. Poor sleep quality was a predictor of decreased functional outcomes while controlling for age, race, education, BMI, marital status and physical and mental HRQoL.

CONCLUSION

Poor sleep quality is associated with negative physical, mental, and functional outcomes in adults with type 2 diabetes.

Improving activity in adults with diabetes and coexisting obstructive sleep apnea

This study in participants with type 2 diabetes and obstructive sleep apnea evaluated changes in activity, sleep quality, and daytime sleepiness after 4 weeks of continuous positive airway pressure (CPAP). This pilot study was a double-blind, randomized, placebo-controlled trial. Sleep apnea was quantified with an overnight sleep study. Sleep quality was measured by the Pittsburgh Sleep Quality Index, daytime sleepiness by the Epworth Sleepiness Scale, vigor and fatigue with the Profiles of Mood States, subjective activity with the Functional Outcomes of Sleep Questionnaire, and objective activity with the Bodymedia SenseWear Armband. Subjects were randomized to either CPAP (n = 12) or sham-devices (n = 11). The intervention group had reduced apneas and hypopneas, daytime sleepiness, and fatigue; they also had improved sleep quality and increased objective activity and vigor. The study suggested that treatment of obstructive sleep apnea results in a modest improvement of activity in persons with type 2 diabetes.

Is incretin-based therapy ready for the care of hospitalized patients with type 2 diabetes?: Insulin therapy has proven itself and is considered the mainstay of treatment

Significant data suggest that overt hyperglycemia, either observed with or without a prior diagnosis of diabetes, contributes to an increase in mortality and morbidity in hospitalized patients. In this regard, goal-directed insulin therapy has remained as the standard of care for achieving and maintaining glycemic control in hospitalized patients with critical and noncritical illness. As such, protocols to assist in management of hyperglycemia in the inpatient setting have become commonplace in hospital settings. Clearly, insulin is a known entity, has been in clinical use for almost a century, and is effective. However, there are limitations to its use. Based on the observed mechanisms of action and efficacy, there has been a great interest in using incretin-based therapy with glucagon-like peptide-1 (GLP-1) receptor agonists instead of, or complementary to, an insulin-based approach to improve glycemic control in hospitalized, severely ill diabetic patients. To provide an understanding of both sides of the argument, we provide a discussion of this topic as part of this two-part point-counterpoint narrative. In the point narrative preceding the counterpoint narrative below, Drs. Schwartz and DeFronzo provide an opinion that now is the time to consider GLP-1 receptor agonists as a logical consideration for inpatient glycemic control. In the counterpoint narrative provided below, Drs. Umpierrez and Korytkowski provide a defense of insulin in the inpatient setting as the unquestioned gold standard for glycemic management in hospitalized settings.

Sex differences in presentation and outcome among patients with type 2 diabetes and coronary artery disease treated with contemporary medical therapy with or without prompt revascularization: a report from the BARI 2D Trial (Bypass Angioplasty Revascularization Investigation 2 Diabetes)

OBJECTIVES

This study evaluated differences in outcome among women and men enrolled in the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial.

BACKGROUND

Women and men with coronary artery disease have different clinical presentations and outcomes that might be due to differences in management.

METHODS

We compared baseline variables, study interventions, and outcomes between women and men enrolled in the BARI 2D trial and randomized to aggressive medical therapy alone or aggressive medical therapy with prompt revascularization.

RESULTS

At enrollment, women were more likely than men to have angina (67% vs. 58%, p < 0.01) despite less disease on angiography (Myocardial Jeopardy Index 41 ± 24 vs. 46 ± 24, p < 0.01; number of significant lesions 2.3 ± 1.7 vs. 2.8 ± 1.8, p < 0.01). Over 5 years, no sex differences were observed in BARI 2D study outcomes after adjustment for difference in baseline variables (death/myocardial infarction/cerebrovascular accident: hazard ratio: 1.11, 99% confidence interval [CI]: 0.85 to 1.44). However, women reported more angina than men (adjusted odds ratio: 1.51, 99% CI: 1.21 to 1.89, p < 0.0001) and had lower scores for the Duke Activity Status Index (adjusted beta coefficient: -1.58, 99% CI: -2.84 to -0.32, p < 0.01).

CONCLUSIONS

There were no sex differences in death, myocardial infarction, or cerebrovascular accident among patients enrolled in the BARI 2D trial. However, compared with men, women had more symptoms and less anatomic disease at baseline, with persistence of higher angina rates and lower DASI scores after 5 years of medical therapy with or without prompt revascularization. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes [BARI 2D]; NCT00006305).

Effect of poor sleep quality and excessive daytime sleepiness on factors associated with diabetes self-management

PURPOSE

The purpose of this study is to investigate the association of impaired sleep quality and daytime sleepiness on self-reported diabetes control and psychological and social factors that affect diabetes self-management.

METHODS

Participants were 107 adults with type 2 diabetes (T2DM) with self-reported daytime sleepiness. Subjective sleepiness was assessed using the Epworth Sleepiness Scale (ESS); sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI) Global score and its 3 factors of Perceived Sleep Quality, Sleep Efficiency, and Daily Disturbances. The Diabetes Care Profile (DCP) scales (Control Problems, Social and Personal Factors, Positive Attitude, Negative Attitude, Self-Care Adherence, and Diet Adherence) were used to measure difficulty in maintaining glycemic control and factors important for diabetes control.

RESULTS

Poor sleep quality was associated with significantly worse scores on the DCP scales, with lower diabetes control, negative attitude, decreased positive attitude, lower self-care adherence, and decreased adherence to dietary adherence. Hierarchal linear regression modeling revealed no significant associations between diabetes control problems and age, education, gender, and daytime sleepiness. Being married or partnered significantly decreased glycemic control problems, whereas poor sleep quality increased diabetes control problems. Further examination of PSQI factors (perceived sleep quality, sleep efficiency, and daily disturbances) found that being married or partnered significantly decreased diabetes control problems, whereas of the 3 factors of the PSQI, only the Daily Disturbances factor was significantly associated with increased diabetes control problems.

CONCLUSIONS

Impaired sleep quality and daytime sleepiness are associated with decreased diabetes self-management in adults with T2DM.

Biophysiologic outcomes of the Enhancing Adherence in Type 2 Diabetes (ENHANCE) trial

BACKGROUND

Behavioral research to improve lifestyle in broadly defined populations of patients with type 2 diabetes is limited.

OBJECTIVE

We evaluated a behavioral intervention featuring technology-based self-monitoring on biophysiologic outcomes of glycemic control and markers of cardiovascular risk.

DESIGN

In this single-site, randomized clinical trial, participants were stratified by good and poor glycemic control (glycated hemoglobin <8% or ≥8%) and absence or presence of kidney disease, (estimated glomerular filtration rate ≥60 or <60 mL/min) and randomized within strata. Measurements were obtained at 0, 3, and 6 months.

PARTICIPANTS/SETTING

Self-referred, community-dwelling adults with type 2 diabetes mellitus.

INTERVENTION

The intervention group received Social Cognitive Theory-based counseling paired with technology-based self-monitoring, and results were compared with an attention control group.

MAIN OUTCOME MEASURES

Glycated hemoglobin, fasting serum glucose, lipid levels, blood pressure, weight, body mass index, and waist circumference were evaluated.

STATISTICAL ANALYSES PERFORMED

Mean differences within and between randomization groups were compared over time. Intervention effects over time were estimated using random intercept models.

RESULTS

Two hundred ninety-six subjects were randomized, 256 (86.5%) completed 3-month and 246 (83.1%) completed 6-month assessments. Glycated hemoglobin was reduced in the intervention group by 0.5% at 3 months and 0.6% at 6 months (P<0.001 for each), and the control group by 0.3% (P<0.001) at 3 months and 0.2% (P<0.05) at 6 months; but between-group differences were not significant. In those with baseline glycated hemoglobin ≥8% and estimated glomerular filtration rate ≥60 mL/min, glycated hemoglobin was reduced in the intervention group by 1.5% at 3 months and 1.8% at 6 months (P<0.001 for each), and the control group by 0.9% (P<0.001) at 3 months and 0.8% (P<0.05) at 6 months; but between-group differences were not significant. In random intercept models, the estimated reduction in glycated hemoglobin of 0.29% was not significant.

CONCLUSIONS

Two behavioral approaches to improving general lifestyle management in individuals with type 2 diabetes mellitus were effective in improving glycemic control, but no significant between-group differences were observed.

Factors associated with probability of personal digital assistant-based dietary self-monitoring in those with type 2 diabetes

Knowledge of factors associated with the use of technology could inform the design of technology-based behavioral interventions. This study examined modifiable and nonmodifiable factors associated with technology-based self-monitoring. 123 participants with type 2 diabetes self-monitored diet using a personal digital assistant in a 6-month behavioral intervention. Multinomial logistic regression was used to examine probability of nonadherent and suboptimally adherent behavior relative to adherent behavior. Sociodemographic characteristics were not associated with probability of self-monitoring. Probability of adherence generally was greater in the weeks preceding no group session, and lower in the weeks following no group session or following skipped sessions. Non-modifiable factors suggested by the literature to be associated with poorer access to technology (lower income, older age, minority race, and lower education) were not associated with probability of self-monitoring in this population.

Relation of severe coronary artery narrowing to insulin or thiazolidinedione use in patients with type 2 diabetes mellitus (from the Bypass Angioplasty Revascularization Investigation 2 Diabetes Study)

Patients with diabetes continue to die of coronary artery disease (CAD) at rates 2 to 4 times higher than patients without diabetes, despite advances in treatment of cardiovascular disease. The role of glycemic control therapies, independent of their glucose-lowering effects, on cardiovascular disease is a recurring question. We examined the association of glycemic control therapies with extent of CAD as measured by coronary angiogram obtained at baseline in 1,803 subjects in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial who had type 2 diabetes mellitus, documented moderate to severe CAD, and no previous cardiac revascularization procedures. The association between glycemic control therapy use recorded at baseline and percent coronary artery stenosis and myocardial jeopardy index was analyzed by multiple regression models. Insulin use at study entry was associated with 23% fewer highly stenotic lesions (> or =70%) (p <0.001) and a significantly lower myocardial jeopardy index compared with subjects not on insulin, despite a worse cardiac risk factor profile, more unstable angina, and increased inflammatory markers in insulin users. Subjects taking thiazolidinediones (TZDs) for > or =6 months had 17% fewer highly stenotic lesions (p = 0.02) and significantly lower C-reactive protein, fibrinogen, and plasminogen activator inhibitor-1 levels compared with those not taking TZDs. In conclusion, this cross-sectional study of patients with type 2 diabetes mellitus and CAD showed that treatment with insulin or TZDs was associated with fewer highly stenotic lesions, independent of disease duration, glycemic control, and other risk factors.

Design, feasibility, and acceptability of an intervention using personal digital assistant-based self-monitoring in managing type 2 diabetes

BACKGROUND

The information processing demands associated with behavioral self-management of diabetes are extensive. Pairing personal digital assistant (PDA)-based self-monitoring with a behavioral self-management intervention may improve adherence and patient outcomes.

METHODS

ENHANCE is a randomized controlled trial to test an intervention designed to improve regimen adherence in adults with type 2 diabetes. The intervention, based on Social Cognitive Theory (SCT), is paired with PDA-based self-monitoring. In this paper we describe the: (a) manner in which PDA-based self-monitoring is integrated within the SCT-based intervention, (b) feasibility and acceptability of PDA-based dietary self-monitoring, and (c) issues encountered in teaching participants to self-monitor using a PDA.

RESULTS

During the first 30 months of this 5-year study, 232 participants were screened and 151 were randomized. To date, 6 cohorts have completed the study. The retention rate is 85% (n=129). Of those randomized to the intervention (n=74) and completing the study (n=61), 88% reported understanding the usefulness of PDA-monitoring, 85% reported ease in entering foods into the device, 70% reported ease in interpreting feedback graphs, and 82% indicated that they would continue to use the PDA for self-monitoring after the study concluded. Assuming 3 meals per day, participants entered an average of 58% of their meals in their PDA, and 43% were entered assuming 4 meals per day. If we eliminate from the analysis those individuals who entered less than 10% of their expected meals (n=12), the average rate of self-monitoring was 69% assuming 3 meals per day, and 52% assuming 4 meals per day.

CONCLUSIONS

PDA-based dietary monitoring is perceived by participants to be useful and acceptable. The approach used to instruct participants in use of the PDA and lessons learned are discussed. PDA technology shows promise as a tool for assisting those with type 2 diabetes in their efforts to manage their disease.

Evolution of a diabetes inpatient safety committee

OBJECTIVE

To develop a multidisciplinary team, the Diabetes Inpatient Safety Committee (DPSC), to effectively address the many barriers to achieving glycemic control in the inpatient setting.

METHODS

The development, implementation, and successes of the DPSC are described.

RESULTS

By focusing on prevention of severe hypoglycemia, the DPSC identified and addressed areas related to inpatient management that contributed to uncontrolled glucose levels. The introduction of a hypoglycemia treatment protocol was followed by the development of a standardized order set for use of sliding scale insulin, with the eventual introduction of an Insulin Order Set guiding the use of scheduled and correctional insulin. Protocols and guidelines addressing more specific areas of inpatient glycemic management (insulin pump therapy, perioperative management, diabetic ketoacidosis, intravenous insulin) also have been developed.

CONCLUSION

The successes of the DPSC to date have been directly related to strong institutional support, the dedication of a multidisciplinary team to address specific areas of glycemic management, the programmed introduction of order sets in conjunction with structured educational programs that accompany each protocol, and the use of quality improvement measures to evaluate the safety and efficacy of these protocols. Effective committees such as this will be instrumental in preventing errors and maximizing euglycemia.

The medical emergency team and rapid response system: finding, treating, and preventing hypoglycemia

Administrative and quality improvement processes that occurred in response to one patient's series of critical hypoglycemic events ultimately contributed to systematic improvements in patient safety.

Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention

OBJECTIVE

To determine whether using the chronic care model (CCM) in an underserved community leads to improved clinical and behavioral outcomes for people with diabetes.

RESEARCH DESIGN AND METHODS

This multilevel, cluster-design, randomized controlled trial examined the effectiveness of a CCM-based intervention in an underserved urban community. Eleven primary care practices, along with their patients, were randomized to three groups: CCM intervention (n = 30 patients), provider education only (PROV group) (n = 38), and usual care (UC group) (n = 51).

RESULTS

A marked decline in HbA(1c) was observed in the CCM group (-0.6%, P = 0.008) but not in the other groups. The magnitude of the association remained strong after adjustment for clustering (P = 0.01). The same pattern was observed for a decline in non-HDL cholesterol and for the proportion of participants who self-monitor blood glucose in the CCM group (non-HDL cholesterol: -10.4 mg/dl, P = 0.24; self-monitor blood glucose: +22.2%, P < 0.0001), with statistically significant between-group differences in improvement (non-HDL cholesterol: P = 0.05; self-monitor blood glucose: P = 0.03) after adjustment. The CCM group also showed improvement in HDL cholesterol (+5.5 mg/dl, P = 0.0004), diabetes knowledge test scores (+6.7%, P = 0.07), and empowerment scores (+2, P = 0.02).

CONCLUSIONS

These results suggest that implementing the CCM in the community is effective in improving clinical and behavioral outcomes in patients with diabetes.

FlexPen®: Addressing issues of confidence andconvenience in insulin delivery

BACKGROUND

In people with type 1 or type 2 diabetes, poor adherence to insulin therapy can compromise disease management. There are several reasons for poor adherence, including social embarrassment, inconvenience, needle anxiety, fear of injection pain, and complicated regimens. Attempts to facilitate implementation of insulin therapy and to improve treatment adherence have focused on expanding the choices and features of insulin delivery devices.

OBJECTIVE

This review addresses the features, advantages, and disadvantages of insulin pen devices, with particular reference to FlexPen (Novo Nordisk, Bagsvaerd, Denmark), a prefilled/disposable pen device.

METHODS

Data from clinical studies published through June 2005 that evaluated the safety or efficacy of FlexPen in patients with type 1 or type 2 diabetes were reviewed. Key studies were selected following assessment of the sponsor's reference collection and as a result of MEDLINE searches (key words: FlexPen and pen devices). Particular attention was paid to studies comparing the FlexPen device with other pen devices. Peer-reviewed journal articles and published conference papers were included in the evaluation, as were reviews addressing the general use of these devices in the treatment of diabetes and associated issues.

RESULTS

Up to 65% of patients with type 1 or type 2 diabetes are not confident in their ability to effectively self-manage their disease. Only 23% of people with type 2 diabetes believe that insulin therapy would help them to better manage their disease. As many as 25% of people with diabetes who require insulin describe some anxiety regarding self-injection. Other barriers to effective insulin therapy include fear of injection pain, weight gain, and hypoglycemia; feelings of failure and guilt; and lack of motivation.

CONCLUSIONS

Insulin pen devices are discreet and offer patients convenience and flexibility. These features may give patients the confidence to overcome issues of needle anxiety and the social embarrassment associated with self-injection and, therefore, may lead to improved adherence to recommended insulin dosing schedules and compliance with multiple-injection regimens.

A multicenter, randomized, open-label, comparative, two-period crossover trial of preference, efficacy, and safety profiles of a prefilled, disposable pen and conventional vial/syringe for insulin injection in patients with type 1 or 2 diabetes mellitus

BACKGROUND

The accuracy and convenience of pen devices for insulin injection have improved quality of life for patients with insulin-treated diabetes mellitus (DM). Prefilled, disposable pens have the advantage of simplicity, with minimal training and attention required and no installation of new cartridges necessary.

OBJECTIVE

The aim of this study was to assess patient preference, efficacy, and safety profiles of a prefilled, disposable pen (FlexPen) and conventional vial/syringe injection method for insulin injection therapy among patients with DM.

METHODS

In a multicenter, randomized, open-label, crossover study, patients with type 1 or 2 DM were transferred from previous QD or BID conventional insulin therapy to a mixture of 70% insulin aspart protamine suspension and 30% insulin aspart injection (NovoLog Mix 7030) for 4 weeks of dose optimization using their usual type of syringe. Patients were then randomly assigned to use either vial/syringe or a prefilled, disposable pen to inject the biphasic insulin aspart 7030 mixture for the next 4 weeks, followed by 4 weeks of use of the other injection device. Efficacy, safety profiles, and patient preference for the delivery systems were compared.

RESULTS

A total of 121 patients (mean [SD] age, 57.0 [12.4] years; age range, 28-81 years; mean [SD] body mass index, 31 [5.5] kg/m(2)) were enrolled. One hundred three patients completed the study. Seventy-four percent of patients (78105) indicated a preference for the pen over the vial/syringe method (95% CI, 71%-87%), compared with 20% (21105) who preferred the vial/syringe. Eighty-five percent (88104) considered the pen more discreet for use in public (compared with 9% [9104] for the vial/syringe), 74% (77104) considered it easier to use overall (compared with 21% [22104] for the vial/syringe), and 85% (89105) found the insulin dose scale on the pen easier to read (compared with 10% [10105] for the vial/syringe). Patients had statistically significant improvement in glycosylated hemoglobin values during the study (P < 0.05). No statistically significant differences in fasting plasma glucose, mean 4-point blood glucose profiles, or serum fructosamine values were found between groups. Overall, the safety profiles during treatment periods with the pen were comparable to those with the vial/syringe.

CONCLUSIONS

In this trial, differences in efficacy and safety profiles between the vial/syringe and prefilled, disposable pen appeared negligible. However, more patients expressed a preference to continue use of the pen.

When oral agents fail: practical barriers to starting insulin

Insulin therapy has proven benefits in Type 2 diabetes patients when combination therapy has failed. However, there is some reluctance by both patients and healthcare professionals to initiate insulin therapy. This reluctance has been termed 'psychological insulin resistance'. Barriers to the initiation of insulin therapy include patients' fear of disease progression and needle anxiety; mutual concerns about hypoglycaemia and weight gain; and health professionals' use of insulin as a threat to encourage compliance with earlier therapies. It is essential that these obstacles are identified and investigated as a means of overcoming these impediments to recommended levels of glycaemic control, an initiative being pursued by the DAWN study. Where concerns are tangible, such as fear of hypoglycaemia, therapeutic solutions can be pursued. Overcoming psychological barriers relies more on innovative management techniques. Improving insulin delivery to meet these needs, coupled with enhanced healthcare services, can address psychological insulin resistance and contribute to the maintenance of good metabolic control.

Glimepiride improves both first and second phases of insulin secretion in type 2 diabetes

OBJECTIVE

The purpose of this study was to assess the effect of glimepiride on insulin sensitivity and secretion in subjects with type 2 diabetes.

RESEARCH DESIGN AND METHODS

After a 2-week washout from prior sulfonylurea therapy, 11 obese subjects with type 2 diabetes underwent euglycemic and hyperglycemic clamp studies before and during glimepiride therapy.

RESULTS

Glimepiride resulted in a 2.4-mmol/l decrease in fasting plasma glucose (P = 0.04) that was correlated with reductions in postabsorptive endogenous glucose production (EGP) (16.4 +/- 0.6 vs. 13.5 +/- 0.5 micro mol. kg(-1). min(-1), P = 0.01) (r = 0.21, P = 0.01). Postabsorptive EGP on glimepiride was similar to that of control subjects (12.8 +/- 0.9 micro mol. kg(-1). min(-1), NS). Fasting plasma insulin (66 +/- 18 vs. 84 +/- 48 pmol/l, P = 0.05), and first-phase (19 +/- 8 vs. 32 +/- 11 pmol/l, P = 0.04) and second-phase incremental insulin responses to glucose (48 +/- 23 vs. 72 +/- 32 pmol/l, P = 0.02) improved with glimepiride therapy. Insulin sensitivity did not change with treatment (4.6 +/- 0.7 vs. 4.3 +/- 0.7 micro mol. kg(-1). min(-1). pmol(-1)) and remained below that of control subjects (8.1 +/- 1.8 micro mol. kg(-1). min(-1). pmol(-1), P = 0.04).

CONCLUSIONS

The current study demonstrates that glimepiride improves both first and second phases of insulin secretion, but not insulin sensitivity, in individuals with type 2 diabetes.

Disturbances in beta-cell function in impaired fasting glycemia

In a cross-sectional study, we assessed beta-cell function and insulin sensitivity index (ISI) with hyperglycemic clamps (10 mmol/l) in 24 subjects with impaired fasting glycemia (IFG, fasting plasma glucose [FPG] between 6.1 and 7.0 mmol/l), 15 type 2 diabetic subjects (FPG >7.0 mmol/l), and 280 subjects with normal fasting glycemia (NFG, FPG <6.1 mmol/l). First-phase insulin release (0-10 min) was lower in IFG (geometric mean 541 pmol/l.10 min; 95% confidence interval [CI] 416-702 pmol/l.10 min) and in type 2 diabetes (geometric mean 376 pmol/l.10 min; 95% CI 247-572 pmol/l.10 min) than NFG (geometric mean 814 pmol/l.10 min; 95% CI 759-873 pmol/l.10 min) (P < 0.001). Second-phase insulin secretion (140-180 min) was also lower in IFG (geometric mean 251 pmol/l; 95% CI 198-318 pmol/l; P = 0.026) and type 2 diabetes (geometric mean 157 pmol/l; 95% CI 105-235 pmol/l; P < 0.001) than NFG (geometric mean 295 pmol/l; 95% CI 276-315 pmol/l). IFG and type 2 diabetic subjects had a lower ISI (0.15 plus minus 0.02 and 0.16 plus minus 0.02 micromol/kg fat-free mass [FFM]/min/pmol/l, respectively) than NFG (0.24 plus minus 0.01 micromol/kg FFM/min/pmol/l, P < 0.05). We found a stepwise decline in first-phase (and second-phase) secretion in NFG subjects with progressive decline in oral glucose tolerance (P < 0.05). IFG subjects with impaired glucose tolerance (IGT) had lower first-phase secretion than NFG subjects with IGT (P < 0.02), with comparable second-phase secretion and ISI. NFG and IFG subjects with a diabetic glucose tolerance (2-h glucose >11.1 mmol/l) had a lower ISI than their respective IGT counterparts (P < 0.05). We conclude that the early stages of glucose intolerance are associated with disturbances in beta-cell function, while insulin resistance is seen more markedly in later stages.