A1c Target Research Articles

Glycated Hemoglobin and Blood Pressure Levels in Adults With Type 2 Diabetes: How Many Patients Are on Target?

ObjectivesAchieving glycated hemoglobin (A1C) and blood pressure targets is an important strategy for preventing chronic vascular complications in diabetes. Our aim in this study was to determine the proportion of type 2 diabetes patients who meet the recommended A1C and arterial blood pressure targets and to identify the determinants of failure to do so. MethodsA cross-sectional study was conducted in an outpatient endocrine clinic at a university hospital. The A1C goal was 7% in general and 8% for patients with advanced chronic complications. Regarding blood pressure, the overall expected target was 140/90 mmHg. ResultsA total of 602 type 2 diabetes patients were analyzed: 62% were female, 14% self-reported as black, mean age was 63±11 years, mean diabetes duration was 17±9 years and median A1C was 8.0% (interquartile range, 7.0% to 9.5%). Macrovascular disease was present in 33% of the patients, diabetic retinopathy in 47%, peripheral neuropathy in 43% and diabetic kidney disease in 56%. Regarding metabolic control, 403 (67%) patients were not at the adjusted target A1C level, and being female, black, young and an insulin user were the main determinants of poor glycemic control. Regarding blood pressure, 348 (58%) patients were not at the recommended targets, and a more advanced age was the main associated factor. ConclusionsBecause more than half of type 2 diabetes outpatients do not meet the recommended A1C and blood pressure target values, there is a major call to overcome the therapeutic inertia and target treatment of patients on an individual basis.

Effective Initiation and Treatment With Basal Insulin in People With Type 2 Diabetes: Focus on Mitigating Hypoglycemia in Patients at Increased Risk: Executive Summary.

Many people with type 2 diabetes are treated with insulin with the goal of achieving a specific A1C target. The most prominent risk for people on insulin therapy is hypoglycemia. When basal insulin analogs are used appropriately, the risk of hypoglycemia can be reduced while still achieving individualized glycemic goals. In a series of short videos now available on the Clinical Diabetes website, the authors discuss approaches to optimizing basal insulin initiation and treatment in people with type 2 diabetes, including those at high risk such as individuals with renal impairment and older adults, with a focus on reaching A1C goals while mitigating the risk for hypoglycemia. This article is intended to briefly summarize those discussions, and readers are encouraged to view the videos in their entirety at https://clinical.diabetesjournals.org/content/basal-insulin-videos. ### Introduction (Available at https://bcove.video/2Q2Rb9b) Approximately 50% of people with type 2 diabetes have poorly controlled disease and are vulnerable to long-term micro- and macrovascular complications (1). As type 2 diabetes progresses, many patients will require insulin to maintain glycemic control. The appropriate use of insulin requires a balance between the need for tight glucose control and the potential risk for hypoglycemia. Definitions of hypoglycemia have evolved over time, and the American Diabetes Association (ADA) now uses a three-level classification of hypoglycemia severity (2). Mitigating the risk for hypoglycemia is crucial to the successful treatment of people with type 2 diabetes. In the following series of videos, the authors discuss the use of available insulin formulations in the context of hypoglycemia risk. ### Basal Insulin Therapy—Balancing Glycemic Control With Risk for Hypoglycemia (Available at https://bcove.video/3h3Y85h) The achievement of tight glycemic control reduces micro- and macrovascular complications, and adherence to treatment improves quality of life and decreases health care costs (3–9). The authors discuss the association between A1C reduction and microvascular complications, as reported in the UK …

Monitoring, treatment and control of blood glucose and lipids in Ontario First Nations people with diabetes.

Indigenous people worldwide are disproportionately affected by diabetes and its complications. We aimed to assess the monitoring, treatment and control of blood glucose and lipids in First Nations people in Ontario. We conducted a longitudinal population-based study using administrative data for all people in Ontario with diabetes, stratified by First Nations status. We assessed age- and sex-specific rates of completion of recommended monitoring for low-density lipoprotein (LDL) and glycated hemoglobin (A1c) from 2001/02 to 2014/15. We used data from 2014/15 to conduct a cross-sectional analysis of rates of achievement of A1c and LDL targets and use of glucose-lowering medications. The study included 22 240 First Nations people and 1 319 503 other people in Ontario with diabetes. Rates of monitoring according to guidelines were 20%-50% for A1c and 30%-70% for lipids and were lowest for younger First Nations men. The mean age- and sex-adjusted A1c level was higher among First Nations people than other people (7.59 [95% confidence interval (CI) 7.57 to 7.61] v. 7.03 [95% CI 7.02 to 7.03]). An A1c level of 8.5% or higher was observed in 24.7% (95% CI 23.6 to 25.0) of First Nations people, compared to 12.8% (95% CI 12.1 to 13.5) of other people in Ontario. An LDL level of 2.0 mmol/L or less was observed in 60.3% (95% CI 59.7 to 61.6) of First Nations people, compared to 52.0% (95% CI 51.1 to 52.9) of other people in Ontario. Among those aged 65 or older, a higher proportion of First Nations people than other Ontarians were using insulin (28.1% v. 15.1%), and fewer were taking no medications (28.3% v. 40.1%). As of 2014/15, monitoring and achievement of glycemic control in both First Nations people and other people in Ontario with diabetes remained suboptimal. Interventions to support First Nations patients to reach their treatment goals and reduce the risk of complications need further development and study.

Social factors associated with practice of self-monitoring of blood glucose among type-2 diabetic patients

Background: Self-monitoring of blood glucose (SMBG) is an effective self-management tool to achieve desirable haemoglobin A1c (HbA1c) targets and minimizing glucose variability, when the data is timely reviewed and acted upon by healthcare providers and diabetic patients to actively modify behaviour and/or adjust treatment. SMBG improves patient’s disease awareness and participation in disease management.Methods: This cross-sectional study was conducted at Basaveshwara Hospital, Chitradurga, to estimate percentage of type-2 diabetics practicing SMBG and to assess social factors associated with SMBG practice. Diabetic patients in age-group of 18-75 years were included in the study. Information was collected by interview technique, clinical examination and review of laboratory reports.Results: A 21.5% patients were practicing SMBG. SMBG practice was significantly higher among patients who were urban-area residents (25.0%), with higher educational qualifications (42.2% of patients who studied up-to 12th standard and/or above), with better awareness of diabetes self-management (28.9%) and with better socio-economic status (35.3%). Majority of patients with longer duration of diabetes (4.9±1.5 years), relatively older age group (57.3±2.5 years), with associated co-morbid conditions (26.8%) were found to be practicing SMBG. HbA1c levels were significantly lower among SMBG practicing group (6.6±0.7%).Conclusions: Better health literacy, higher educational qualifications, financial stability, easier access to specialized anti-diabetic health-care are favourable factors for SMBG practice. Study also highlighted favourable effect of SMBG practice on effective achievement of target HbA1c levels.

Risk factor control among Black and White adults with diabetes onset in older adulthood: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study

The objective of this study was to determine whether attainment of clinical and lifestyle targets varied by race and sex among adults with diabetes onset in older adulthood.This study included 1420 black and white adults from the REGARDS study without diabetes at baseline (2003–07) but with diabetes onset at the follow-up exam (2013–16). Attainment of clinical targets (A1c <8%; blood pressure < 140/90 mmHg; and statin use) and lifestyle targets (not smoking; physical activity≥ 4 times/week; and moderate/no alcohol use) was assessed at the follow-up exam. Modified Poisson regression was used to obtain prevalence ratios (PR) for meeting clinical and lifestyle targets stratified by race and sex, separately.The mean age was 71.5 years, 53.6% were female, and 46.1% were black. The majority were aware of their diabetes status (85.7%) and used oral or injectable hypoglycemic medications (64.8%). Overall, 39.4% met all 3 clinical targets and 18.8% met all 3 lifestyle targets. Meeting A1c and blood pressure targets were similar by race and sex. Statin use was more prevalent for men than women among white adults (PR = 1.13; 95% CI = 0.99–1.29) and black adults (PR = 1.23; 95% CI = 1.06–1.43). For lifestyle factors, the non-smoking prevalence was similar by race and sex, while white men were more likely than white women to be physically active.Although the attainment of each clinical and lifestyle target separately was generally high among adults with diabetes onset in older adulthood, race and sex differences were apparent. Comprehensive management of clinical and lifestyle factors in people with diabetes remains suboptimal.

Primary and Secondary Cardiovascular Prevention Among First Nations Peoples With Type 2 Diabetes in Canada: Findings From the FORGE AHEAD Program

BackgroundFirst Nations (FN) peoples in Canada face spiraling rates of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). Data on the extent of CVD risk-factor management in FN peoples with T2DM in Canada are scarce. MethodsA T2DM registry with data from 7 FN communities in Canada was utilized to identify individuals eligible for primary and secondary CVD prevention. Proportions of individuals meeting clinical practice guideline–specified targets (hemoglobin A1c ≤7.0%; blood pressure ≤130/80 mm Hg; low-density lipoprotein ≤2 mmol/L) were calculated. Prescription of recommended cardioprotective medications (antithrombotic medication, lipid-lowering agents, renin-angiotensin-aldosterone system inhibitors, and beta-blockers) among those with CVD was assessed. χ2 tests were employed to evaluate differences between CVD prevention groups and sexes. ResultsOf the 2098 individuals in the registry, 18% had documented CVD (female: male = 1.12). Overall, <10% met all 3 clinical practice guideline targets. Attainment of hemoglobin A1c and blood pressure targets was comparable between primary and secondary CVD prevention groups, with<50% achieving targets. A greater proportion of the secondary prevention group met low-density lipoprotein targets compared to those without CVD (61.6% vs 40.9%, P < 0.01). In the secondary prevention group, beta-blockers were prescribed to only 20%, and <60% were prescribed antithrombotics, lipid-lowering medications, or agents targeting the renin-angiotensin-aldosterone system; <2% were prescribed medications from all 4 classes of cardioprotective medications. ConclusionsPrimary and secondary CVD prevention recommendations for individuals with T2DM are not being met for an alarmingly high proportion of FN peoples. These findings serve as an urgent call for proactive measures to reduce CVD events and related mortality in this high-risk population.

Improving Clinical Outcomes in Newly Diagnosed Pediatric Type 1 Diabetes: Teamwork, Targets, Technology, and Tight Control-The 4T Study.

Many youth with type 1 diabetes (T1D) do not achieve hemoglobin A1c (HbA1c) targets. The mean HbA1c of youth in the USA is higher than much of the developed world. Mean HbA1c in other nations has been successfully modified following benchmarking and quality improvement methods. In this review, we describe the novel 4T approach—teamwork, targets, technology, and tight control—to diabetes management in youth with new-onset T1D. In this program, the diabetes care team (physicians, nurse practitioners, certified diabetes educators, dieticians, social workers, psychologists, and exercise physiologists) work closely to deliver diabetes education from diagnosis. Part of the education curriculum involves early integration of technology, specifically continuous glucose monitoring (CGM), and developing a curriculum around using the CGM to maintain tight control and optimize quality of life.

1398-P: Mortality Implications of Comorbid Health Status in Older Adults with Diabetes: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: In older adults with diabetes, the potential risks of tight glycemic control are a major concern. The 2020 American Diabetes Association (ADA) guidelines suggest different A1C targets in older adults based on comorbid health status. However, the association of A1C levels with mortality by ADA health status categories is uncharacterized. Methods: We conducted a prospective analysis of 2068 older participants (mean age 76±5; 57% women, 30% black) with diabetes in the ARIC Study (baseline, 2011-13). We categorized health status based on ADA criteria (see Table) and evaluated mortality risk overall and by A1C categories. Results: In older adults with diabetes, 45% were classified as healthy, 39% were complex/intermediate, and 15% had very complex/poor health. Over 6 years of follow-up, those with complex/intermediate or very complex/poor health had higher mortality risk than those classified as healthy (Table). Regardless of health status, older adults with A1C &amp;lt;7% were not at significantly higher risk of mortality than those with A1C 7-&amp;lt;8%. Conclusions: There were substantial differences in mortality based on the ADA health status categories but, within categories, those meeting more stringent A1C goals (&amp;lt;7%) were not at substantially elevated risk. Our results suggest that certain patients may safely achieve lower A1C goals even in older age. Disclosure M.R. Rooney: None. O. Tang: None. B. Windham: None. J.B. Echouffo Tcheugui: None. P. Lutsey: None. M. Grams: Other Relationship; Self; DCI. E. Selvin: None. Funding National Heart, Lung, and Blood Institute (T32HL007024)

1323-P: Frequency of Diabetes Team Contacts in Children and Adolescents Using Insulin Pumps

Type 1 diabetes (T1D) management has become increasingly technologically advanced with the use of insulin pumps, continuous glucose monitoring and diabetes data management software. These technologies are underutilized although there is evidence for improvement in A1C when adults review blood glucose trends with their diabetes team in between clinic visits. The primary objective of this study was to assess if a correlation exists between A1C within target (≤ 7.5%) and frequency of contact of pediatric patients with the diabetes team between clinic visits. Secondary objectives included determining barriers to contact and change in A1C from baseline to end of study. T1D patients using an insulin pump for one year or more were approached to participate. Participants completed a questionnaire to assess diabetes management over the past year. A1C and contact with the diabetes team between clinic visits for insulin adjustments in the past year were collected. One hundred and seventy six participants were enrolled, 46% female, with a mean age of 12.9 (± 3.8) years. Mean duration of T1D was 6.7 (± 3.7) years with a mean duration of pump use of 4.5 (± 3.1) years. Mean A1C at baseline was 8.1% (± 1). One hundred and sixteen (66%) patients contacted the diabetes team for insulin adjustments between clinic visits with a mean of 1.2 (± 1.7) contacts, 90% by e-mail. There was no significant relation between target A1C and frequency of contact (p&amp;gt;0.05). Decreased frequency of contact was associated with increased age (r=0.20, p = 0.01) and longer duration of pump use (r=0.17, p = 0.02). Barriers to contact included being too busy (41%) and technical problems with software (39%). In conclusion, there was no significant relationship between frequency of contact of pediatric patients with the diabetes team and A1C. The low frequency of contact raises the importance of defining strategies to increase patient contact which has the potential to improve diabetic control. Disclosure F. Babalola: None. A. Ens: None. P.H. Gallego: None. R.I. Stein: None. C. Clarson: None.

1038-P: Insulin Glargine 300 U/ml (Gla-300) vs. First-Generation Standard-of-Care Basal Insulin Analogs (SOC-BI) in Insulin-Naïve Patients with Type 2 Diabetes (T2D): Impact of Renal Function on the Outcomes of the Randomized Pragmatic Real-Life Achieve Control S

In the 12-month ACHIEVE Control study, significantly more insulin-naive patients with T2D treated with Gla-300 vs. SOC-BI (glargine 100 U/mL or detemir) achieved the primary composite endpoint of individualized HEDIS A1c target attainment at 6 months without documented symptomatic (≤70 mg/dL) or severe hypoglycemia. This post-hoc analysis explored outcomes in subgroups with estimated glomerular filtration rate (eGFR) of &amp;lt;60, 60 to &amp;lt;90, and ≥90 mL/min/1.73 m2. Patients with eGFR &amp;lt;60 mL/min/1.73 m2 were older and had longer T2D duration. Within each eGFR subgroup, baseline characteristics were generally balanced between treatment groups. Within subgroups, odds ratios for clinical outcomes generally showed trends favoring Gla-300 vs. SOC-BI, consistent with the overall study population (Figure). In patients with eGFR &amp;lt;60 mL/min/1.73 m2, the odds ratio point estimates for absence of documented symptomatic (≤70 mg/dL and &amp;lt;54 mg/dL) or severe hypoglycemia at 6 and 12 months strongly favored Gla-300 (&amp;gt;1.40). The results suggest a potential benefit of Gla-300 vs. SOC-BI for avoiding hypoglycemia in patients with compromised renal function that warrants further evaluation in prospective studies. Disclosure L. Meneghini: Advisory Panel; Self; Novo Nordisk Inc., Sanofi US. Consultant; Self; Applied Therapeutics, Sanofi US. A. Cheng: Advisory Panel; Self; Abbott, AstraZeneca, Boehringer Ingelheim (Canada) Ltd., Boehringer Ingelheim International GmbH, Eli Lilly and Company, HLS Therapeutics, Inc., Janssen Pharmaceuticals, Inc., Medtronic, Merck &amp; Co., Inc., Novo Nordisk A/S, Sanofi. Research Support; Self; Applied Therapeutics, Sanofi. Speaker’s Bureau; Self; Abbott, AstraZeneca, Boehringer Ingelheim (Canada) Ltd., Boehringer Ingelheim International GmbH, Eli Lilly and Company, Insulet Corporation, Janssen Pharmaceuticals, Inc., mdBriefCase, Medtronic, Merck &amp; Co., Inc., Merck Sharp &amp; Dohme Corp., Novo Nordisk A/S, Sanofi. P. Evenou: Employee; Self; Sanofi. J. Gill: Other Relationship; Self; Sanofi US. A. Mohamed: None. G.E. Umpierrez: None. Funding Sanofi US

1084-P: Postmarketing Real-World Effectiveness of Hydroxychloroquine (HCQ) in Treatment of Patients with T2D

Real-world data is important in providing evidence of treatment effectiveness in clinical practice. This real-world analysis included 1523 patients of T2D uncontrolled (A1c≥7%) on metformin-SU combination to additionally receive HCQ 400 mg/day for 24 weeks. Mean age of patients was 51.3 years and 53.25% were males. Of the 1523 enrolled patients, 1297 patients who completed 24 weeks of therapy were analyzed for effectiveness. Treatment with HCQ resulted in significant reduction in A1c (change from baseline at Week 12 and 24 was 1.10% and -1.41%, respectively; p&amp;lt;0.0001) and other glycemic and lipid parameters. At Week 24, 81% and 62% of patients reported a fall of ≥0.5% and ≥1% in A1c, respectively. Target A1c of &amp;lt;7% and &amp;lt;8% was achieved by 34% and 73% of patients, respectively at Week 24. Overall, HCQ was well tolerated. Majority of the 148 AEs were GI related (25%), mild in intensity (85%) and unlikely related (66%) to HCQ. Ten patients reported hypoglycemia; all were ADA Level 1. Nine NPDR cases were reported, all were mild and 8 were unlikely related to HCQ. Of 8 SAEs reported, 7 were not related to HCQ. Causality was assessed by investigator. Low-grade inflammation is a common feature in T2D. HCQ, an anti-inflammatory agent, significantly improved glycemic profile (comparable to other OHAs) with added benefits on lipids. Thus, HCQ could be an effective and well-tolerated therapeutic option for treatment of T2D. Disclosure A. Pareek: Employee; Self; Ipca Laboratories. S. Dharmadhikari: Employee; Self; Ipca Laboratories. R.T. Mehta: Employee; Self; Ipca Laboratories. K.B. Naidu: Employee; Self; Ipca Laboratories. Funding Ipca Laboratories Limited

Lessons From a Diabetes Clinic: Achieving Glycemic Goals and Clinical Use of Antidiabetic Agents in Patients With Type 2 Diabetes.

The proportion of patients with type 2 diabetes who achieve their glycemic goals remains low. We examined medical records and A1C results from patient visits to our referral diabetes center between 21 March to 20 July 2018. After stratifying patients into four groups-monotherapy, dual therapy, triple therapy, or insulin therapy-we found that the target A1C of ≤7.0% was achieved by 86% of patients and that A1C was uniformly low across the treatment categories. Our individualized approach, which included high use of glucagon-like peptide-1 receptor agonists and low use of sulfonylureas, may have contributed to these results.

Outcomes in adults with systolic blood pressure between 130 and 139 mmHg in Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial and Systolic Blood Pressure Intervention Trial.

Patients with stage 1 systolic hypertension have increased risk of cardiovascular disease (CVD) events. Using Cox models, we assess the effect of targeting an intensive SBP goal of less than 120 mmHg compared with standard SBP goal of less than 140 mmHg on the risk of CVD events in adults with stage 1 systolic hypertension with diabetes mellitus enrolled in Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial (ACCORD BP) (n = 1901) and without diabetes mellitus enrolled in Systolic Blood Pressure Intervention Trial (SPRINT) (n = 3484) that used identical SBP goal interventions. In ACCORD BP, the primary composite CVD outcome was the first occurrence of myocardial infarction, stroke, or CVD mortality. In SPRINT, the primary composite CVD outcome was the first occurrence of myocardial infarction, other acute coronary syndrome, stroke, heart failure, or CVD mortality. In SPRINT, targeting an intensive SBP goal significantly reduced the risk of the primary CVD outcome [hazard ratio 0.75 (95% confidence interval, 0.58-0.98); events 1.78 vs. 2.37%/year]. In ACCORD BP, the relationships of SBP goal with the primary CVD outcome was modified by the glycemia goal intervention (interaction P = 0.039). In the standard glycemia subgroup (A1c target 7-7.9%), intensive SBP goal significantly reduced the risk of the primary CVD outcome [hazard ratio 0.61 (0.40-0.94); events 1.63 vs. 2.56%/year]. In the intensive glycemia subgroup (A1c target <6%), the risk of the primary CVD outcome was not significantly different between groups [hazard ratio 1.20 (0.76-1.89); events 1.91 vs. 1.60%/year]. Targeting an intensive SBP goal significantly reduced the risk of CVD events in patients with stage 1 systolic hypertension without diabetes and with diabetes on standard glycemia goal.

Time in suboptimal glycemic control over 10 years for patients newly diagnosed with type 2 diabetes

ObjectiveTo estimate time in suboptimal glycemic control among patients with incident type 2 diabetes (T2D) over 10 years. MethodsWe calculated percent of time in suboptimal glycemic control using three A1C thresholds (8%, 7.5%, 7%) following T2D diagnosis. Stratified analyses were conducted based on age and A1C levels at T2D diagnosis. ResultsWe identified 28,315 patients with incident T2D. Percent of time in suboptimal glycemic control increased with T2D duration. Mean percent time in suboptimal A1C control in the first 2 years following diagnosis was 30%, 34% and 40% for the 8%, 7.5%, and 7% thresholds, respectively. In the 6–10 years following T2D diagnosis, the percent time in suboptimal A1C control increased to 39%, 48% and 61%, for the 8%, 7.5%, and 7% thresholds, respectively. Time in suboptimal glycemic control was longer among younger patients aged 20–44 versus ≥65 years and those with higher A1C (>8%) versus lower A1C (<7%) at diagnosis. ConclusionsOver 10 years following diagnosis, T2D patients spent one-third to over one-half of their time in suboptimal glycemic control. Reducing time spent above desired A1C targets could lower risk of microvascular and macrovascular complications.

Early Combination Therapy with Linagliptin and Metformin in People with Type 2 Diabetes Improves Glycemic Control to HbA1c ≤ 6.5% without Increasing Hypoglycemia: Pooled Analysis of Two Randomized Clinical Trials.

IntroductionClinical guidelines suggest a glycated hemoglobin A1c (HbA1c) target of ≤ 6.5% for type 2 diabetes patients with short duration of disease, few comorbidities and/or long life expectancy—provided this goal can be achieved safely. We explored whether initial combination treatment with the dipeptidyl peptidase-4 inhibitor linagliptin and metformin could provide better glycemic control (HbA1c ≤ 6.5%) than metformin alone without increasing hypoglycemia.MethodsWe pooled and analyzed individual patient data from two randomized clinical trials of early combination therapy with linagliptin and metformin versus metformin monotherapy. The primary outcome in both trials was the change in HbA1c from baseline to week 24. We evaluated the percentage of patients who achieved HbA1c ≤ 6.5% at week 24 and the incidence of adverse events.ResultsMost (> 70%) of the 1160 patients analyzed were treatment naive, and more than half had had diabetes for ≤ 1 year; mean baseline HbA1c was approximately 8.7%. Combination therapy with linagliptin and metformin resulted in more patients achieving HbA1c ≤ 6.5% than metformin alone, both for a metformin dose of 500 mg (40.1 vs. 22.9%, respectively, odds ratio [OR] 2.84, 95% confidence interval [CI] 1.87–4.32) and 1000 mg (49.5 vs. 35.4%, respectively, OR 2.28, 95% CI 1.54–3.40). Hypoglycemia occurred in < 3% of patients, with a comparable incidence between treatment groups. Other adverse events were also balanced between groups.ConclusionEarly combination treatment with linagliptin and metformin can improve the chances of achieving tight glycemic control (HbA1c ≤ 6.5%) without increasing the risk of hypoglycemia or other adverse events.Trial RegistrationClinicalTrials.gov, NCT00798161 and NCT01708902.

Continuous glucose monitoring: Musing on our progress in memory of Dr Andrew Jay Drexler

Continuous glucose monitoring: Musing on our progress <i>in memory of Dr Andrew Jay Drexler</i>

Evaluating the impact of onsite diabetes education teams in primary care on clinical outcomes

BackgroundTo evaluate the impact of integrating diabetes education teams in primary care on glycemic control, lipid, and blood-pressure management in type 2 diabetes patients.MethodsA historical cohort design was used to assess the integration of teams comprising nurse and dietitian educators in 11 Ontario primary-care sites, which delivered individualized self-management education. Of the 771 adult patients with A1C ≥ 7% recruited, 487 patients attended appointments with the diabetes teams, while the remaining 284 patients did not. The intervention’s primary goal was to increase the proportion of patients with A1C ≤7%. Secondary goals were to reduce mean A1C, low-density lipoprotein, total cholesterol-high density lipoprotein, and diastolic and systolic blood pressure, as recommended by clinical-practice guidelines.ResultsAfter 12 months, a higher proportion of intervention-group patients reached the target for A1C, compared with the control group. Mean A1C levels fell significantly among all patients, but the mean reduction was larger for the intervention group than the control group. Although more intervention-group patients reached targets for all clinical outcomes, the between-group differences were not statistically significant, except for A1C.ConclusionsNurse and dietitian diabetes-education teams can have a clinically meaningful impact on patients’ ability to meet recommended A1C targets. Given the study’s historical cohort design, results are generalizable and applicable to day-to-day primary-care practice. Longer follow-up studies are needed to investigate whether the positive outcomes of the intervention are sustainable.

Type 2 Diabetes in Older Adults in Long-Term Care Homes: An Educational Intervention to Improve Diabetes Care

ObjectivesOver 25% of nursing home residents have diabetes. Nurses (registered nurses and registered practical nurses), registered dietitians and personal support workers (PSWs) provide the bulk of diabetes care in long-term care (LTC) homes, but their self-rated diabetes knowledge is poor. In this study, we evaluated the impact of an educational intervention on comfort with, and knowledge of, diabetes management among frontline LTC staff. MethodsWe implemented an educational intervention in 2 LTC homes in Ontario that targeted nurses and dietitians, PSWs and physicians. A self-assessment questionnaire and a knowledge test were administered to nurses and dietitians and PSWs before and after the intervention. We also measured pre- and postintervention glycated hemoglobin levels, use of sliding scale insulin and type and dose of diabetes medications prescribed. ResultsAfter the intervention, both the nurses and dietitians and PSWs groups demonstrated increased comfort with diabetes management and improved self-appraised knowledge. Among PSWs, knowledge of foot care improved the most, and the nurses and dietitians group had the greatest improvement in knowledge of blood glucose monitoring. In addition, there was reduced use of sliding scale insulin, and in the number of residents requiring renal-based dose reductions of glucose-lowering medications. This intervention was innovative as it targeted different LTC health-care providers; it demonstrated the potential to increase LTC health-care providers’ confidence in diabetes management. Future studies could assess the clinical benefits of an educational intervention on rates of hypoglycemia and improving A1C targets. ConclusionsAn educational intervention can improve knowledge and comfort of diabetes management of frontline LTC staff.

Targets for blood glucose: What have the trials told us.

The challenges of diabetes treatment are to prevent or delay microangiopathic complications and macrovascular disease. Early, effective and sustained glycaemic control is advocated by all diabetes guidelines to mitigate the risks of prolonged hyperglycaemia. The post-hoc analyses of the large randomised glucose intervention trials and the long-term results of these trials have shown clearly that intensive glycaemic control may have more favourable cardiovascular effects when initiated earlier in the course of diabetes, particularly among in patients without cardiovascular disease. Based on the intervention trials a haemoglobin A1c level of less than 7.0% (<53 mmol/mol) is a generally accepted target to reduce microvascular disease and should be initiated early in the course of the diabetes. However, haemoglobin A1c targets should be individualised. Achieving a good glycaemic control without detrimental effect and preferably with benefit to the cardiovascular system and to renal function is an important challenge. When targeting a tight glycaemic control, avoidance of hypoglycaemia is crucial particularly in patients with coronary artery disease and in patients with heart failure. The cardiovascular outcomes trials performed to test the cardiovascular safety of the new glucose-lowering therapies offer compelling evidence in favour of the role of these drugs for cardiovascular prevention. Thus, both the glycaemic target and the choice of therapies should now be defined on an individual basis.

The use of longitudinal hemoglobin A1c values to predict adverse obstetric and neonatal outcomes in pregnancies complicated by pregestational diabetes

Although an elevated early pregnancy hemoglobin A1c has been associated with both spontaneous abortion and congenital anomalies, it is unclear whether A1c assessment is of value beyond the first trimester in pregnancies complicated by pregestational diabetes. We sought to investigate the prognostic ability of longitudinal A1c assessment to predict obstetric and neonatal adverse outcomes based on degree of glycemic control in early and late pregnancy. This was a retrospective cohort study of all pregnancies complicated by pregestational diabetes from January 2012 to December 2016 at The Ohio State University Wexner Medical Center with both an early A1c (<20 weeks' gestation) and late A1c (>26 weeks' gestation) available for analysis. Patients were categorized by good (early and late A1c <6.5%), improved (early A1c >6.5% and late A1c <6.5%) and poor (late A1c >6.5%) glycemic control. A multivariate regression model was used to calculate adjusted odds ratios (aOR) for each identified obstetric and neonatal outcome, controlling for maternal age, body mass index, race/ethnicity, type of diabetes, and gestational age at delivery compared to good control as the referent group. A total of 341 patients met inclusion criteria during the study period. The median A1c values improved from early to late gestation in the good (5.7% [interquartile range [IQR], 5.4-6.1%] versus 5.4%; [IQR 5.2-5.7%]), improved (7.5% [IQR, 6.7-8.5] versus 5.9% [IQR, 5.6-6.1%]) and poor (8.3% [IQR, 7.1-9.6%] versus 7.3% [IQR, 6.8-7.9%]) glycemic control groups. There were no statistically significant differences in the rate of adverse outcomes between the goodand improved groups except for an increased rate of neonatal intensive care unit admissions in the improved group (aOR, 3.7; confidence interval [CI], 1.9-7.3). In contrast, the poor control group hadanincreased rate of shoulder dystocia (aOR, 6.8; CI, 1.4-34.0), preterm delivery (aOR, 3.9; CI, 2.1-7.3), neonatal intensive care unit admission (aOR, 2.8; CI, 1.4-5.3), respiratory distress syndrome (aOR, 3.0; CI, 1.1-8.0), hypoglycemia (aOR, 3.2; CI, 1.5-6.9), large for gestational age weight at birth (aOR, 2.7; CI, 1.5-4.9), neonatal length of stay >4 days (aOR, 3.1; CI, 1.6-6.0) and preeclampsia (aOR, 2.4; CI, 1.2-4.6). There were no differences in rates of cesarean delivery, umbilical artery pH <7.1, or Apgar score <7 at 5 minutes after regression analysis. Antenatal hemoglobin A1c values are useful for objective risk stratification of patients with pregestational diabetes. Strict glycemic control throughout pregnancy with a late pregnancy A1c target of <6.5% leads to reduced rates of obstetric and neonatal adverse outcomes independent of early pregnancy glucose control.