Effectiveness of an academic detailing service to support appropriate prescribing and care in patients with type 2 diabetes.

Type 1 Diabetes in Children and Adolescents

Comparative effectiveness of SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, and sulfonylureas on risk of major adverse cardiovascular events: emulation of a randomised target trial using electronic health records

Pharmacologic Glycemic Management of Type 2 Diabetes in Adults.

Time to Follow the Evidence: Glycemic Control and Cardiovascular Benefits of New Diabetes Medications

Background: Educational outreach programs that focus on safe opioid prescribing and awareness of state prescription monitoring programs may modify clinicians’ prescribing behavior. The objective of this study was to evaluate the secondary effects of an opioid-focused academic detailing (AD) program on non-opioid controlled substance prescribing in primary care. Methods: A quasi-experimental pre-post study of primary care clinicians exposed and unexposed to the AD program was conducted using data from the Illinois Prescription Monitoring Program from December 2017 to February 2019. Outcomes were mean monthly prescriptions for benzodiazepines (BZD), non-BZD sedative-hypnotics, and carisoprodol, per clinician. A difference-in-differences (DID) approach utilizing repeated-measures mixed-effects linear regression models was used to compare changes in outcomes six-months before and after the program. Results: Mean monthly BZD prescriptions declined in both groups of clinicians (AD-exposed n = 151; controls n = 399) after implementation of the AD program. Although the mean monthly number of BZD prescriptions decreased in both groups after the AD program, BZD prescribing in the AD-exposed group declined at a slower rate following the AD program (DID = 0.73; 95% CI: 0.14, 1.31). The AD-exposed group had a 0.06 (95% CI: −0.11, −0.01) lower rate of mean monthly carisoprodol prescriptions compared to the control group following the AD program. There was no change in the rate of mean monthly non-BZD sedative-hypnotic prescriptions between the two groups. Conclusions: The higher relative rate of BZD prescribing in the AD-exposed group compared to the control group following the AD program may be reflective of an unintended consequence of opioid-focused AD programs as clinicians learn to be cautious about opioid prescribing. Our findings may suggest the need for incorporation of targeted education on appropriate BZD prescribing into opioid-focused AD programs as a featured component. These findings warrant further consideration and investigation before large-scale implementation of opioid-focused educational outreach programs.

How Basal Insulin Analogs Have Changed Diabetes Care

Type 1 Diabetes in Children and Adolescents.

New Medications for the Treatment of Diabetes

Ethnic differences in outcomes of diabetes care and the role of self-management behavior

BackgroundThe aim of this study was to assess the impact that Academic Detailing (AD) had on General Practitioners' use of diagnostic imaging for shoulder complaints in general practice and their knowledge and confidence to manage shoulder pain.MethodsOne-to-one Academic Detailing (AD) for management of shoulder pain was delivered to 87 General Practitioners (GPs) in metropolitan Adelaide, South Australia, together with locally developed clinical guidelines and a video/DVD on how to examine the shoulder. Three months after the initial AD a further small group or an individual follow up session was offered. A 10-item questionnaire to assess knowledge about the shoulders was administered before, immediately after, and 3 months after AD, together with questions to assess confidence to manage shoulder complaints. The number of requests for plain film (X-ray) and ultrasound (US) imaging of the shoulder was obtained for the intervention group as well as a random comparison group of 90 GP's from the same two Divisions. The change in the rate of requests was assessed using a log Poisson GEE with adjustment for clustering at the practice level. A linear mixed effects model was used to analyse changes in knowledge.ResultsIn an average week 54% of GPs reported seeing fewer than 6 patients with shoulder problems. Mean (SD) GP knowledge score before, immediately after and 3-months after AD, was 6.2/10 (1.5); 8.6/10 (0.96) and; 7.2/10 (1.5) respectively (p < 0.0001). Three months after AD, GPs reported feeling able to take a more meaningful history, more confident managing shoulder pain, and felt their management of shoulder pain had improved. Requests for ultrasound imaging were approximately 43.8% higher in the period 2 years before detailing compared to six months after detailing (p < 0.0001), but an upward trend toward baseline was observed in the period 6 months to 1 year after AD. There was no statistically significant change in the rate of requests from before to after AD for plain-radiographs (p = 0.11). No significant changes in the rate of requests over time were observed in the control groups.ConclusionThese results provide evidence that AD together with education materials and guidelines can improve GPs' knowledge and confidence to manage shoulder problems and reduce the use of imaging, at least in the short term.

Patients with type 1 diabetes mellitus (T1DM) may have suboptimal glucose control and are interested in the use of adjuvant therapies. To determine, from the patients' perspective, the reasons for initiation of glucagon-like peptide 1 receptor agonist (GLP-1RA) and/or sodium glucose cotransporter 2 inhibitor (SGLT2i) in treating T1DM; perceived benefits/side effects, reasons for discontinuation, and willingness to reinitiate therapy. Retrospective chart review with structured telephone interviews. We identified patients with T1DM treated with a GLP-1RA and/or SGLT2i for >3 months at University of Texas Southwestern Medical Center (Dallas, TX, USA) and Poznan University (Poznan, Poland). We conducted structured telephone interviews regarding their experiences. We interviewed 68 participants treated with GLP-1RA and 82 with SGLT2i. Treatment was initiated for improving glycemic control (as reported by 61.8% versus 81.7% of GLP-1RA and SGLT2i users, respectively), weight loss/appetite suppression (51.4% versus 23.2%) and to reduce insulin requirement (13.2% versus 11%). Most participants (86.8% of GLP-1RA and 89.0% of SGLT2i users) reported ⩾1 benefit attributed to therapy. Reported benefits were improved glycemic control (reported by 58.8% versus 82.9% of GLP-1RA and SGLT2i users, respectively), weight loss/appetite suppression (63.2% versus 30.5%), and reduced insulin requirement (27.9% versus 34.1%). More GLP-1RA users reported side effects versus SGLT2i users (63.2% versus 36.6%); 22.6% discontinued GLP-1RA due to side effects versus 11.0% SGLT2i users. Diabetic ketoacidosis (DKA) was reported by 4.9% of SGLT2i users, but none in GLP-1RA users. Of those who discontinued medication, 60.7% of GLP-1RA versus 56.0% of SGLT2i prior users were willing to reinitiate treatment. Patients with T1DM report initiating adjuvant treatment with GLP-1RA and/or SGLT2i to improve glycemic control and lose weight; most patients reported perceived benefits from these therapies. Side effects (including DKA) are reported more commonly in real life than in clinical trials. Given patient interest in these medications, further studies should evaluate the long-term risk-benefits ratio in larger cohorts.

To investigate the association between physician participants' levels of engagement in a Web-based educational intervention and their patients' baseline diabetes measures. The authors conducted a randomized trial of online CME activities designed to improve diabetes care provided by family, general, and internal medicine physicians in rural areas of 11 southeastern states between September 2006 and July 2008. Using incidence rate ratios derived from negative binomial models, the relationship between physicians' engagement with the study Web site and baseline proportion of their patients having controlled diabetes (hemoglobin A1c < or = 7%) was explored. One hundred thirty-three participants (intervention = 64; control = 69) provided information for 1,637 patients with diabetes. In the intervention group, physicians in practices in the worst quartiles of A1c control were least engaged with the study Web site in nearly all dimensions. Total number of pages viewed decreased as quartile of A1c control worsened (137, 73, 68, 57; P = .007); similarly, for a given 10% increase in proportion of patients with controlled A1c, participants viewed 1.13 times more pages (95% CI: 1.02-1.26, P = .02). In the control group, engagement was neither correlated with A1c control nor different across quartiles of A1c control. Engagement in Web-based interventions is measurable and has important implications for research and education. Because physicians of patients with the greatest need for improvement in A1c control may not use online educational resources as intensely as others, other strategies may be necessary to engage these physicians in professional development activities.

The rising cost of insulins are significantly impacting health care expenditure, thereby limiting access to treatment for more people affected by diabetes. Fear and misunderstanding of insulin therapy have worsened with the emergence of biosimilar insulins. Biosimilars are not the same as generic medications. Generic medication contains identical ingredients to the reference, whereas biosimilar medication is highly comparable but not necessarily identical to the reference. There are five biosimilar insulins currently available in Canada: insulin glargine (U-100) as the biosimilar insulins, Basaglar® and Semglee®, insulin lispro (U-100) as the biosimilar insulin, Admelog® and insulin aspart (U-100) as the biosimilar insulins, Trurapi® and Kirsty ™. Recent clinical trials have demonstrated comparable efficacy, safety and immunogenicity for biosimilar insulins compared with reference insulins. The dosing of biosimilar insulins is also the same as the reference for initiating, switching (1:1) and titrating. Regulatory agencies, payors and clinical practice guideline committees are initiating biosimilar initiatives aimed at reducing costs, impacting more patients worldwide. While few studies have evaluated biosimilar insulin use in a real-world clinical practice setting, the descriptive patterns retrieved from the LMC Diabetes Registry reflect the Ontario Ministry of Health's changes in biologic drug policy that were implemented to promote the use of biosimilar insulins. Many health care providers are largely unfamiliar with biosimilar insulins. This limits the acceptance of biosimilar insulins by patients, as it is related to the comfort of health care providers in educating patients. Tailoring effective conversations to patient needs ensures the best possible therapeutic outcomes. This review article intends to review the efficacy and safety data from pivotal clinical trials with biosimilar insulins, as well as the regulatory and health economic considerations which underpin the safe and cost-effective use of biosimilar insulin therapy. Biosimilars are not the same as generic medications. Generic medication contains identical ingredients to the reference, whereas biosimilar medication is highly comparable but not necessarily identical to the reference. There are five biosimilar insulins currently available in Canada: insulin glargine (U-100) as the biosimilar insulins, Basaglar® and Semglee®, insulin lispro (U-100) as the biosimilar insulin, Admelog® and insulin aspart (U-100) as the biosimilar insulins, Trurapi® and Kirsty™. Data for biosimilars must be submitted in a stepwise approach to demonstrate similarity to the reference biologic under the following categories: structure & function, human clinical trials, comparative studies evaluating efficacy and safety and manufacturing quality control. Recent clinical trials have demonstrated comparable efficacy, safety and immunogenicity for biosimilar insulins compared with reference insulins. The dosing of biosimilar insulins is also the same as the reference for initiating, switching (1:1) and titrating. Health care providers are encouraged to stay up to date on the latest guidelines and recommendations regarding biosimilar insulin interchangeability to ensure safe and cost-effective use of these products. Regulatory agencies, payors and clinical practice guideline committees are initiating biosimilar initiatives aimed at reducing costs, impacting more patients worldwide. While few studies have evaluated biosimilar insulin use in a real-world clinical practice setting, the descriptive patterns retrieved from the LMC Diabetes Registry reflect the Ontario Ministry of Health's changes in biologic drug policy that were implemented to promote the use of biosimilar insulins. A summary of adults with diabetes from this registry showed 3.8% of individuals with T1D were prescribed Basaglar® before April 2023 compared to 12.0% after January 2024. For the T2D cohort, the use of basal biosimilar insulins, Basaglar® and Semglee®, similarly increased by approximately 10% and 2% after January 2024, respectively. The use of bolus biosimilar insulins also increased after January 2024 by approximately 28% in the T1D cohort and 60% in the T2D cohort using insulin therapy. Many health care providers are largely unfamiliar with biosimilar insulins. This limits the acceptance of biosimilar insulins by patients, as it is related to the comfort of health care providers in educating patients. People living with diabetes must have access to safe and effective treatment options, and they should be able to obtain appropriate medications at an affordable price and in a fair and timely manner.

For most adults without significant hypoglycemia, maintaining an HbA1c level below 7% is recommended. Despite guidelines and advancements in diabetes treatment, approximately half of the global diabetic population fails to meet glycemic targets. While lifestyle changes are crucial for the prevention and management of Type 2 Diabetes (T2D), most patients ultimately require pharmacotherapy to achieve effective blood glucose control. Purpose. This study aims to explore the key barriers preventing patients from achieving optimal glycemic levels by examining therapy structures in an outpatient setting. Methods. We evaluated a dataset of adult T2D patients (n=66) from general practice clinic No.1 in Aktobe, Kazakhstan. Measures included laboratory data, prescriptions, and patient and practice variables. The proportion of patients meeting clinical targets as of November 2023 was calculated, along with the proportion of T2D patients initiating monotherapy and polytherapy, and any changes in HbA1c levels. Results. The study found that 66.67% of patients did not achieve target treatment levels, with only one-third of participants demonstrating satisfactory diabetes control. Data analysis revealed a significant relationship between blood glucose levels and insulin therapy (χ2 = 5.500, df = 1, p ˂ 0.05), indicating that patients with glucose levels above 7 mmol/L are more likely to receive insulin. A notable correlation was also observed between glucose levels and the use of SGLT-2 inhibitors (Fisher's Exact Test, p ˂ 0.01), with higher glucose patients more frequently prescribed these drugs. Additionally, there was a substantial association between glucose levels and the chosen therapy structure (χ2 = 13.050, df = 2, p ˂ 0.001), suggesting that monotherapy is common in patients with glucose levels ≤7 mmol/L, whereas those with higher levels often require multi-drug treatment. Furthermore, a significant relationship was identified between elevated blood glucose levels (˃7 mmol/L) and the presence of endocrine diseases (Fisher's Exact Test, p = 0.004), indicating a higher incidence of these diseases among patients with elevated glucose levels. Conclusion. The study highlights the critical relationship between blood glucose levels and treatment strategies, emphasizing the need for personalized diabetes management. It points to the broader use of insulin and SGLT-2 inhibitors among patients with higher glucose levels and underscores the importance of individualized treatment planning. This approach to diabetes care necessitates a nuanced understanding of each patient's condition, advocating for tailored treatment regimens to effectively enhance patient outcomes. Keywords: Type 2 diabetes, glycemic control, antidiabetic therapy, treatment effectiveness

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