XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Diabetes mellitus is associated with a considerably increased risk of premature atherosclerotic cardiovascular disease. Intensive glycemic control has essentially failed to significantly improve cardiovascular outcomes in clinical trials. Dyslipidemia is common in diabetes and there is strong evidence that cholesterol lowering improves cardiovascular outcomes, even in patients with apparently unremarkable lipid profiles. Here, the authors review the pathophysiology and implications of the alterations in lipoproteins observed in both type 1 and type 2 diabetes, the effect of medications commonly used in the management of diabetes on the lipid profile, the evidence for lifestyle and pharmaceutical interventions, and national and international recommendations for the management of dyslipidemia in patients with diabetes.

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Diabetes Dyslipidemia

The role of type 2 diabetes in neurodegeneration

Background Type 2 diabetes is increasingly common and associated with substantial morbidity and mortality. Methods We conducted descriptive analyses of cross-sectional data using the IMS Health National Disease and Therapeutic Index, a nationally representative audit of ambulatory physician practices in the US. We focused on visits for diabetes among patients 35 years or older. We used the IMS Health National Prescription Audit of pharmacy dispensing to derive information about drug expenditures. Results Ambulatory diabetes visits increased from 23 million [M] treatment visits in 1997 (95% confidence intervals [CI], 21-25M) to 35M (CI 32-37M) in 2007 and declined to 31M visits by 2012 (CI 27-31M). Between 1997 and 2012 biguanide use increased, from 23% (20-26%) to 53% (50-56%) of treatment visits. Glitazone use grew from 6% (CI 4-8%) in 1997 to 41% (CI 39-43%) of all visits in 2005, but declined to 16% (CI 8-12%) by 2012. Since 2005, DPP-4 inhibitor use increased steadily, representing 21% (CI 18-23%) of treatment visits by 2012. GLP-1 agonists accounted for 4% of treatment visits in 2012. Visits where two or more drug compounds were used increased nearly 40% from 1997 to 2012. Between 2008 and 2012, drug expenditures increased 61%, driven primarily by use of insulin glargine and DPP-4 inhibitors. Conclusions Declining sulfonylurea and glitazone use has been offset by increases in DPP-4 inhibitor use and, to a lesser degree, use of GLP-1 agonists. Treatment of diabetes has grown in complexity while older treatments continue to be replaced or supplemented by newer therapies.

https://care.diabetesjournals.org/content/diacare/early/2013/11/06/dc13-2097.full.pdf

Ambulatory Treatment of Type 2 Diabetes in the U.S., 1997–2012

Alzheimer's disease (AD) is an age-related neurodegenerative disease leading over the course of decades to the most common form of dementia. Many of its pathologic features and cognitive deficits may be due in part to brain insulin resistance recently demonstrated in the insulin receptor→insulin receptor substrate-1 (IRS-1) signaling pathway. The proximal cause of such resistance in AD dementia and amnestic mild cognitive impairment (aMCI) appears to be serine inhibition of IRS-1, a phenomenon likely due to microglial release of inflammatory cytokines triggered by oligomeric Aβ. Studies on animal models of AD and on human brain tissue from MCI cases at high risk of AD dementia have shown that brain insulin resistance and many other pathologic features and symptoms of AD may be greatly reduced or even reversed by treatment with FDA-approved glucagon-like peptide-1 (GLP-1) analogs such as liraglutide (Victoza). These findings call attention to the need for further basic, translational, and clinical studies on GLP-1 analogs as promising AD therapeutics.

The nature, significance, and glucagon-like peptide-1 analog treatment of brain insulin resistance in Alzheimer’s disease

OBJECTIVETo discuss the controversy surrounding selection of second-line type 2 diabetes mellitus (T2DM) therapy by reviewing available data regarding secondary effects of glucagon-like peptide-1 receptor (GLP-1) agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors, which include low hypoglycemia risk, weight loss, and cardiovascular (CV) and β-cell function benefits.DATA SOURCESA MEDLINE search (1966–March 2013) was conducted using the following key terms: β-cell protection, blood pressure, DPP-4 inhibitors, exena tide, exenatide extended-release, GLP-1 agonists, hypoglycemia, lina glip tin, lipid, liraglutide, pancreatitis, saxagliptin, sitagliptin, and type 2 diabetes.STUDY SELECTION AND DATA EXTRACTIONIdentified articles published in English were evaluated for inclusion, with priority given to randomized controlled trials in humans receiving incretin monotherapy or incretin combination therapy with metformin. References identified in these articles were reviewed for additional trials.DATA SYNTHESISM...

Evaluating Second-Line Treatment Options for Type 2 Diabetes: Focus on Secondary Effects of GLP-1 Agonists and DPP-4 Inhibitors:

Insulin is the mainstay of current treatment for patients with type 1 diabetes mellitus (T1DM). Due to increasing insulin resistance, insulin doses are often continually increased, which may result in weight gain for patients. Medications currently approved for the treatment of type 2 diabetes offer varying mechanisms of action that can help to reduce insulin resistance and prevent or deter weight gain. A MEDLINE search was conducted to review literature evaluating the use of metformin, alpha-glucosidase inhibitors, pioglitazone, glucagon-like peptide 1 agonists, dipeptidyl peptidase, and sodium-dependent glucose transporter 2 inhibitors, in patients with T1DM. Varying results were found with some benefits including reductions in hemoglobin A1c, decreased insulin doses, and favorable effects on weight. Of significance, a common fear of utilizing multiple therapies for diabetes treatment is the risk of hypoglycemia, and this review displayed limited evidence of hypoglycemia with multiple agents.

Alternative Agents in Type 1 Diabetes in Addition to Insulin Therapy: Metformin, Alpha-Glucosidase Inhibitors, Pioglitazone, GLP-1 Agonists, DPP-IV Inhibitors, and SGLT-2 Inhibitors.

Objective. To determine if an educational intervention in a doctor of pharmacy (PharmD) degree program increases pharmacy students’ ability to identify plagiarism.

Methods. First-year (P1), second-year (P2), and third-year (P3) pharmacy students attended an education session during which types of plagiarism and methods for avoiding plagiarism were reviewed. Students completed a preintervention assessment immediately prior to the session and a postintervention assessment the following semester to measure their ability.

Results. Two hundred fifty-two students completed both preintervention and postintervention assessments. There was a 4% increase from preintervention to postintervention in assessment scores for the overall student sample (p<0.05). The mean change was greatest for P1 and P2 students (5% and 4.8%, respectively).

Conclusion. An educational intervention about plagiarism can significantly improve students’ ability to identify plagiarism.

Michelle DeGeeter

Papers

Evaluating Second-Line Treatment Options for Type 2 Diabetes: Focus on Secondary Effects of GLP-1 Agonists and DPP-4 Inhibitors:

Alternative Agents in Type 1 Diabetes in Addition to Insulin Therapy: Metformin, Alpha-Glucosidase Inhibitors, Pioglitazone, GLP-1 Agonists, DPP-IV Inhibitors, and SGLT-2 Inhibitors.

Pharmacy students' ability to identify plagiarism after an educational intervention.

Preceptor perceptions of fourth year student pharmacists’ abilities regarding patient counseling on therapeutic lifestyle changes

Student pharmacist perceptions of therapeutic lifestyle change (TLC) counseling abilities and personal health status