American Diabetes Association Treatment Goals Research Articles

Late Diabetes Relapse After Sleeve Gastrectomy Compared with Long-Term Remission: Characteristics and Cardiometabolic Outcomes.

Background: Studies of the relapse of type 2 diabetes mellitus (T2D) after laparoscopic sleeve gastrectomy (LSG) are scarce. We assessed the rate of relapse 5 years after LSG, compared relapsed patients to their baseline and to those with remission, and explored the independent predictors of relapse. Methods: Retrospective analysis of 103 adults who underwent primary LSG at our institution between 2011 and 2015. Data retrieved comprised 23 pre-/postoperative demographic, anthropometric, biochemical, and clinical characteristics. Univariate and multivariate analyses assessed the predictors of relapse. Results: In total, 54% of our patients experienced relapse. Nevertheless, their anthropometric and metabolic profiles significantly improved compared to the values before surgery, reflecting better weight, glycemic, clinical, and biochemical control (P values ranged from 0.012 to <0.0001). These improvements were mirrored by significant increase in the proportion of relapsed patients meeting the American Diabetes Association treatment goals of hemoglobin A1c (HbA1c), blood pressure, high-density lipoprotein, and triglyceride at 5 years compared with the proportion before surgery (P = 0.027-0.008). In addition, the anthropometric and metabolic profiles of relapsed patients were not different compared to those of patients with long-term remission (P = 0.075-0.686), except for a significantly higher prevalence of dyslipidemia and number of diabetes medications among the relapsed group (P = 0.008 and <0.0001, respectively). Multivariate analysis showed that most of the predictors tested operated in the appropriate direction but fell short of statistical significance. Weight regain at 3 years did not predict relapse at 5 years. Conclusions: Relapse of T2D per se should not undervalue the overall long-term health benefits of LSG. Long-term monitoring of glycemic status after LSG is recommended.

Are Patients with Type 2 Diabetes Mellitus at a University Hospital in Jeddah Achieving Treatment Goals?

Background: Diabetes mellitus is one of the most prevalent chronic diseases worldwide and is very debilitating. Studies have shown that adherence to treatment recommendations are rewarded with a decrease in diabetes mellitus - related morbidity and mortality. The aim of this study is to assess adherence to the American Diabetes Association treatment goals in patients with type 2 diabetes mellitus.&#x0D; Methods: This was a retrospective chart review study, between February and April, 2013, of patients with type 2 diabetes mellitus who attended outpatient clinics at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. We included patients provided they were adults (≥ 18 years) with type 2 diabetes mellitus who were regularly followed up at the outpatient clinics, and they have had the disease for more than one year.&#x0D; Results: We included 201 patients between 27 – 96 years old. Most patients had their blood pressure and creatinine levels measured during each visit, and close to half had their HbA1c levels measured twice in the last year of follow up. Approximately 55.10% of the patients achieved an LDL level &lt; 2.6 mmol/L. A relatively small proportion of the patients had blood pressure measurements and HbA1c levels within the recommended guidelines (29.03% and 24.53%, respectively).&#x0D; Conclusion: Diabetes mellitus is not very well controlled. This could be attributed to physicians’ factors and patients’ factors. Further studies to assess this issue are recommended.&#x0D;

Do Cinnamon Supplements Have a Role in Glycemic Control in Type 2 Diabetes? A Narrative Review

Cinnamon (Cinnamomum sp) has been suggested to help patients with type 2 diabetes mellitus (T2DM) achieve better glycemic control, although conclusions from meta-analyses are mixed. To evaluate whether the use of cinnamon dietary supplements by adults with T2DM had clinically meaningful effects on glycemic control, as measured by changes in fasting plasma glucose (FPG) or hemoglobin A1c (HbA1c), a comprehensive PubMed literature search was performed. Eleven randomized controlled trials were identified that met our inclusion criteria that enrolled 694 adults with T2DM receiving hypoglycemic medications or not. In 10 of the studies, participants continued to take their hypoglycemic medications during the cinnamon intervention period. Studies ranged from 4 to 16 weeks in duration; seven studies were double-blind. Cinnamon doses ranged from 120 to 6,000 mg/day. The species of cinnamon used varied: seven used Cinnamomum cassia or Cinnamomum aromaticum, one used Cinnamomum zeylanicum, and three did not disclose the species. Because of the heterogeneity of the studies, a meta-analysis was not conducted. All 11 of the studies reported some reductions in FPG during the cinnamon intervention, and of the studies measuring HbA1c very modest decreases were also apparent with cinnamon, whereas changes in the placebo groups were minimal. However, only four studies achieved the American Diabetes Association treatment goals (FPG <7.2 mmol/L [130 mg/dL] and/or HbAlc <7.0). We conclude that cinnamon supplements added to standard hypoglycemic medications and other lifestyle therapies had modest effects on FPG and HbA1c. Until larger and more rigorous studies are available, registered dietitian nutritionists and other health care professionals should recommend that patients continue to follow existing recommendations of authoritative bodies for diet, lifestyle changes, and hypoglycemic drugs.

Evaluation of the Impact of a Pharmacist-Led Telehealth Clinic on Diabetes-Related Goals of Therapy in a Veteran Population.

Telemedicine has been offered as a way to ensure that all patients, including those who live in rural areas, have access to the same health care. This study was performed to evaluate the benefit of a real-time, clinic-based video telehealth (Clinical Video Telehealth [CVT]) program and the impact of a pharmacist-led CVT clinic for chronic disease state management. The primary objective was to evaluate changes from baseline values, in veterans referred by primary care providers to this clinic. This was a single-center, prospective, pre-post pilot study that also included a post-patient satisfaction survey. The study was conducted at the Tennessee Valley Healthcare System, which is composed of two medical centers and 12 community-based outpatient clinics (CBOCs) located away from the two main facilities. Fifteen clinical pharmacy specialists (CPSs)-seven at the two main facilities and eight at the CBOCs-provide disease state management clinical pharmacy services. One of the seven CPSs at the main facilities works via telemedicine and provides services to the CBOCs where on-site clinical pharmacy services did not exist. The primary outcomes were changes from baseline in A1C, LDL level, systolic blood pressure, and diastolic blood pressure after 6 months of CVT services by the CPS. Secondary outcomes were the percentages of patients meeting American Diabetes Association treatment goals for hemoglobin A1c (A1C), low-density lipoprotein level, and blood pressure, both individually and in combination after attending a pharmacist-led CVT program; the level of patient satisfaction with pharmacists' care and with CVT as a method of receiving chronic disease management, specifically for diabetes; and medication additions or changes made by the pharmacist. Twenty-six patients completed the 6-month evaluation. A significant decrease in A1C of 2% from baseline was observed (p=0.0002), and the percentage of patients meeting goal A1C significantly increased from 0% at baseline to 38% at 6 months (p=0.0007). Overall patient satisfaction scores were also high, with a median score 39.5 (interquartile range 36-40) of a maximum score of 40. Six months of CVT clinic attendance significantly improved A1C values and the overall percentage of patients meeting their goal A1C values in this veteran population. In addition, patient satisfaction scores also indicated a high level of satisfaction with the pharmacist-led CVT service.

Impact of Clinical Pharmacist Intervention on Diabetes-Related Outcomes in a Military Treatment Facility

Clinical pharmacist management of patients with diabetes has been well justified, but there is a lack of research that evaluates the impact of pharmacist-managed diabetes care versus standard medical care on American Diabetes Association (ADA) treatment goals other than hemoglobin A(1c) (A1C). To evaluate the reduction in A1C, blood pressure, and low-density lipoprotein cholesterol (LDL-C) for patients with diabetes whose care was managed by a clinical pharmacist and compare these values to those of a cohort of patients whose care was managed by primary care providers. The difference in percentage of patients attaining ADA treatment goals between the 2 groups was also evaluated. This retrospective chart review identified 98 diabetic patients managed by a clinical pharmacist with at least 2 A1C measurements between September 15, 2008, and March 15, 2011. The Military Health System Population Health Portal was used to identify a similar group of patients with diabetes managed by their primary care provider (N = 90). The Armed Forces Health Longitudinal Technology Application was used to collect baseline data and the most recent measurements for A1C, blood pressure, LDL-C, and documented immunizations. The pharmacist group saw positive improvements in all primary end points, including a 1.6% reduction in A1C, a 9-mm Hg and 1.4-mm Hg reduction in systolic and diastolic blood pressure, respectively, and a 16.3-mg/dL reduction in LDL-C. Conversely, the control group had an increase of 0.8% in A1C and 1.5 mm Hg in diastolic blood pressure. Reductions in systolic blood pressure and LDL-C were much less robust than in the pharmacist group (1.6 mm Hg and 5.2 mg/dL, respectively). Overall, patients in the pharmacist group were more likely to achieve ADA treatment goals. Pharmacist management of patients with diabetes significantly reduces A1C and allows more patients to meet ADA treatment goals. A clinical pharmacist-run diabetes clinic can provide numerous clinical benefits to patients.

An Evaluation of Diabetes-Related Measures of Control After 6 Months of Clinical Pharmacy Specialist Intervention

Purpose: To evaluate the effectiveness of a pharmacist management regarding the percentages of patients meeting American Diabetes Association (ADA) treatment goals for diabetes and specific Veterans Health Administration (VA) performance measures individually and in combination after 6 months of intervention. Methods: We retrospectively evaluated the electronic medical record of all new patients seen between October 1, 2007 and March 31, 2009, with an A1c >7%. Primary objectives included the percentages of patients meeting ADA treatment goals individually and in combination after 6 months in addition to the percentage meeting the 3 VA performance goals individually and in combination. Results: One-hundred and ninety-seven patients met inclusion criteria. There were 6% of patients who met all ADA goals and 79% who met all VA performance measure goals at study end. Individual goal analyses revealed 43% of patients at a goal A1c of <7%, 55% of patients were at low-density lipoprotein (LDL) goal, 45% of patients at systolic blood pressure (SBP) goal, and 51% of patients at diastolic blood pressure (DBP) goal. Evaluation for VA performance measures showed that 91% patients at goal for A1c, 55% at LDL goal, 70% at systolic BP goal, and 87% met diastolic BP goal. Conclusions: Six months of pharmacist intervention resulted in improvement in patients achieving ADA and VA performance measure goals individually and in combination.

Managing Type 2 Diabetes: Going Beyond Glycemic Control

Aggressive management of type 2 diabetes is necessary to achieve glycemic and nonglycemic treatment goals. Attainment of treatment goals is associated with a decreased risk of diabetes-related complications, costs, and health care utilization. To review the advantages and disadvantages of different glucose-lowering agents, with an emphasis on the role of thiazolidinediones (TZDs). Diabetes has become increasingly prevalent, particularly among younger age groups in the United States, accounting for approximately 15% of health care expenditures by managed care organizations. Reducing a patient's glycated hemoglobin (A1C) has been shown to decrease the risk of diabetes-related complications, as well as reduce medical costs and health care utilization. Despite this knowledge, achievement of the American Diabetes Association (ADA) goal A1C of < 7% is suboptimal, and < 1 in 10 patients also reach the ADA targets for cholesterol (low-density lipoprotein < 100 mg per dL) and blood pressure (< 130/80 mm Hg). To ensure that all ADA treatment goals are met, clinicians need to closely monitor patients and adjust therapy as needed, taking into consideration both a drug's glycemic and nonglycemic effects when selecting medication therapy. Four basic defects contribute to type 2 diabetes: insulin resistance, decreased insulin secretion, increased hepatic glucose production, and reduced glucagon-like peptide-1 levels. Unlike metformin, sulfonylureas, and insulin that address only 1 or 2 physiologic defects, TZDs uniquely address 3 of these defects at the adipocyte. Metformin is recommended for initial drug therapy; TZDs, sulfonylureas, and insulin are useful options as add-on therapy for patients whose A1C levels remain >or= 7% despite treatment with metformin and lifestyle interventions. It has been suggested that TZDs, when used either as add-on therapy or when appropriate as monotherapy, may conserve pancreatic beta-cell function over an observed 3- to 5-year period of time and sustain a decrease in A1C ranging from 0.5%-1.5%. Although rarely associated with hypoglycemia, TZDs may cause total body weight gain that is most commonly caused by volume expansion, which may manifest as new or worsened heart failure in susceptible individuals. Pioglitazone and rosiglitazone, the 2 TZDs available in the United States, contain black box label warnings about their potential to cause or exacerbate congestive heart failure; additional data have suggested a link to ischemic cardiac events. Recent data also suggest that TZDs may reduce bone density. Conversely, pioglitazone may have some vasculoprotective effect related to elevation of high-density lipoprotein and lessened progression of carotid intima-media thickness; however, any effect on macrovascular clinical outcomes is unknown. Other drug options are available for the treatment of type 2 diabetes, such as incretin-based therapies. Yet despite their favorable effects on glycemia, they have not been included to date in the ADA treatment algorithm. Proper glycemic control and attainment of other nonglycemic management targets (e.g., blood pressure, lipids, body weight) are essential to the prevention of long-term complications of diabetes and to reduction of overall disease management costs. Therefore, patients with diabetes should be followed closely to ensure that they achieve and maintain both glycemic and nonglycemic treatment goals. Most patients will not sustain an adequate level of control using nondrug or single-drug therapeutic approaches. When choosing among treatment options, consideration should be given to the nonglycemic as well as glycemic effects of various glucose-lowering agents.

Prevalence of Patients with Type 2 Diabetes Mellitus Reaching the American Diabetes Association’s Target Guidelines in a University Primary Care Setting

The success with which primary care physicians are able to meet American Diabetes Association (ADA) clinical goals is unknown. Charts of 218 randomly sampled type 2 diabetic patients were abstracted to assess the attainment of six ADA treatment goals and receipt of four ADA-recommended health services. The mean number of ADA goals attained was 4.9 (SD, 1.6). Only one patient had attained all 10 goals. Most patients had attained ADA goals for triglycerides, diastolic blood pressure, hemoglobin A1c, low-density lipoprotein cholesterol, and diabetic education. Most patients had not received an annual eye examination or urine microalbuminuria screening, most were not taking daily aspirin, and most had not attained treatment goals for high-density lipoprotein or systolic blood pressure. ADA treatment goals may be quite difficult to attain in the primary care setting. Further studies are needed to understand the barriers to diabetes control.