Oral Diabetes Medications Research Articles

Initiation of Basal Insulin in Patients with Uncontrolled Type 2 Diabetes Mellitus

Type 2 diabetes mellitus is a growing health problem, characterized by insulin resistance progressing to beta cell dysfunction and insulin deficiency, most of these patients will need intensification of treatment and initiation of insulin to delay or prevent diabetic complications. Glycemic control is the most important aspect of management, and in reducing morbidity and mortality of the diseases. Control of plasma glucose in patients with diabetes can be assessed by HbA1c, FPG, PPG, but still HbA1c% remains the gold standard for assessment of glycemic control and follow up of diabetic patients. The aim of this study is to assess HbA1c% in patients on oral anti-diabetic drugs, with poor glycemic control before and after adding basal insulin, with titration of the dose of insulin depending on fasting blood sugar. 82 patients with uncontrolled type 2 diabetes (43.9% male, 56.1% female), with HbA1c more than 9%, on two types of oral diabetic medication or more, were started on basal insulin (glargine, lantus) and followed for three to six months. Overall 82 patients with type 2 diabetes mellitus were included in the study. The mean age of the study population was 58.4 years, the mean duration of the disease range was 13.4 years. All patients with HbA1c more than 9%, without organ failure, were included in the study. The mean HbA1c overall had decreased from mean of 11.15% before starting basal insulin to the mean of 8.43% within 3 to 6 month, after initiating basal insulin, this difference was significant at p ive type 2 diabetic patients resulted in significant improvement of glycemic control, with improved HbA1c level, without adverse effects.

Impact of Community Pharmacist Interventions With Managed Care to Improve Medication Adherence

Background: Nonadherence to medications is a concern due to adverse outcomes and higher costs of care. The Centers for Medicare and Medicaid Services has made adherence a key measurement for Star ratings. Objective: To evaluate the impact of a collaborative pilot program between a third-party payer, local pharmacy organization, and academic institution focusing on improving medication adherence with community pharmacies. Methods: Twenty-five community pharmacies implemented adherence-based interventions in patients ≥65 years old, who were Medicare Advantage Plan members, taking targeted medications (statins, oral diabetic medications, angiotensin-converting enzyme inhibitors [ACE-Is] and angiotensin receptor blockers [ARBs]). Outcome measures were (1) pharmacy intervention completion rate, (2) type of adherence interventions, (3) change in the proportion of days covered (PDC) following pharmacist intervention based on adherence group, and (4) nonadherence barriers. Results: A total of 1263 interventions met the eligibility criteria, and common interventions included explaining the benefit of the medication (n = 453, 35.9%) and provider follow-up (n = 109, 8.6%). Among nonadherent subjects who became adherent, the mean PDC increased by 14% (74%-88%, P < .0001), with a 12% decrease in mean PDC score in the nonadherent who remained nonadherent group (71%-58%, P < .0001). Common patient barriers for nonadherence were forgetfulness (n = 451, 35.7%) and denial (n = 84, 6.7%). System and therapeutic barriers included complexity (n = 155, 12.3%) and adverse side effects (n = 42, 3.3%). Conclusion: This collaborative effort successfully implemented a community pharmacist-led adherence intervention in 25 independent pharmacies. Our findings highlight increased interactions with patients and in some cases improved adherence measures. Future research must include implementation outcomes in order to effectively implement these interventions in the community pharmacy setting.

The Effect of Reduced Drug Copayments on Adherence to Oral Diabetes Medications Among Childless Adults in Wisconsin Medicaid.

Medication adherence is an indicator of the quality of drug use, which is associated with better health outcomes and reduced health care expenditures. Drug cost sharing can be a barrier to adherence, especially for low-income individuals with chronic conditions. Most of the existing studies in a Medicaid population have evaluated the effects of increasing drug copayments, but few studies have evaluated the effects of reducing drug copayments on medication adherence. Medicaid coverage for low-income childless adults in Wisconsin was expanded on April 1, 2014, which included reductions in drug copayments and monthly caps on out-of-pocket spending. To evaluate changes in adherence to oral diabetes medications using proportion of days covered (PDC) among Medicaid childless adults with type 2 diabetes after the 2014 Medicaid drug copayment reduction. A difference-in-differences design was used to compare the changes in medication adherence between childless adults (treatment group) and parents/caretakers (control group). Wisconsin Medicaid's administrative enrollment records, pharmacy claims, and medical claims data were analyzed. Medication adherence was evaluated for 4 commonly used oral diabetes drug classes (i.e., biguanides, sulfonylureas, dipeptidyl peptidase-IV inhibitors, and thiazolidinediones) by adapting the medication adherence quality measures endorsed by the Pharmacy Quality Alliance. The PDC for all diabetes drugs was calculated among patients who filled ≥ 2 prescriptions for any of the 4 drug classes. PDC for each drug class was also measured among patients who had ≥ 2 drug fills for each drug class. The proportion of adherent patients was evaluated using a threshold of PDC ≥ 0.80. Average PDC for all diabetes drugs was 0.87 in the childless adults at baseline and significantly increased by 0.02 (P = 0.025) relative to the parents/caretakers after the copayment reduction. The baseline proportion of adherent patients (PDC ≥ 0.80) among the childless adults was 76% and significantly increased by 6.2 percentage points (P = 0.003) relative to the control group. The odds of adherence to oral antidiabetic drugs increased by 47%, resulting in the proportion of adherent patients in the childless adults group reaching almost 80% after the coverage expansion. In the per class analyses, a significant effect was found for biguanides; the proportion of adherent patients increased by 5.5 percentage points in childless adults compared with the control group (P = 0.022). This program evaluation found that a reduction of drug copayments in Wisconsin Medicaid improved the quality of medication use by increasing adherence to oral antidiabetic drugs among childless adults. This study was conducted as part of a larger study funded by the Wisconsin Department of Health Services. The authors are solely responsible for the content of this study. The authors report an evaluation contract with the Wisconsin Department of Health Services, unrelated to this study. An earlier version of this paper was presented at the AcademyHealth Annual Research Meeting; June 23-24, 2018; Seattle, WA.

Initiation of Basal Insulin in Patients with Uncontrolled Type 2 Diabetes Mellitus

Type 2 diabetes mellitus is a growing health problem, characterized by insulin resistance progressing to beta cell dysfunction and insulin deficiency, most of these patients will need intensification of treatment and initiation of insulin to delay or prevent diabetic complications. Glycemic control is the most important aspect in management, and in reducing morbidity and mortality of the diseases. Control of plasma glucose in patients with diabetes can be assessed by HbA1c, FPG, PPG, but still HbA1c% remains the gold standard for assessment of glycemic control and follow up of diabetic patients. The aim of this study is to assess HbA1c% in patients on oral anti-diabetic drugs, with poorly glycemic control before and after adding basal insulin, with titration of the dose of insulin depending of fasting blood sugar. 82 patients with uncontrolled type 2 diabetes (43.9% male, 56.1% female), with HbA1c more than 9%, on two types of oral diabetic medication or more, were started on basal insulin (glargine, lantus) and followed for three to six months. Overall 82 patients with type2 diabetes mellitus were included in the study. The mean age of the study population was 58.4 years, the mean duration of the disease range was 13.4 years. All patients with HbA1C more than 9%, without organ failure, were included in the study. The mean HbA1c overall had decreased from mean of 11.15% before starting basal insulin to the mean of 8.43% within 3 to 6 month , after initiating basal insulin , this difference was significant at p &lt; 0.000 .There was no adverse effect to this medication in any of the study group. The addition of basal insulin to oral anti- diabetic medication in uncontrolled insulin-naïve type 2 diabetic patients resulted in significant improvement of glycemic control, with improved HbA1c level, without adverse effects.

The association between diabetes medication and weight change in a non-surgical weight management intervention: an intervention cohort study.

To compare weight change in a lifestyle-based weight management programme between participants taking weight-gaining, weight-neutral/loss and mixed diabetes medications. Electronic health records for individuals (≥18 years) with Type 2 diabetes who had been referred to a non-surgical weight management programme between February 2008 and May 2014 were studied. Diabetes medications were classified into three categories based on their effect on body weight. In this intervention cohort study, weight change was calculated for participants attending two or more sessions. All 998 individuals who took oral diabetes medications and attended two or more sessions of weight management were included. Some 59.5% of participants were women, and participants had a mean BMI of 41.1kg/m2 (women) and 40.2kg/m2 (men). Of the diabetes medication combinations prescribed, 46.0% were weight-neutral/loss, 41.3% mixed and 12.7% weight-gaining. The mean weight change for participants on weight-gaining and weight-neutral/loss diabetes medications respectively was -2.5kg [95% confidence interval (CI) -3.2 to -1.8) and -3.3kg (95% CI -3.8 to -2.9) (P = 0.05) for those attending two or more sessions (n = 998). Compared with those prescribed weight-neutral medications, participants prescribed weight-gaining medication lost 0.86kg less (95% CI 0.02 to 1.7; P=0.045) in a model adjusted for age, sex, BMI and socio-economic status. Participants on weight-neutral/loss diabetes medications had a greater absolute weight loss within a weight management intervention compared with those on weight-gaining medications. Diabetes medications should be reviewed ahead of planned weight-loss interventions to help ensure maximal effectiveness of the intervention.

Oral diabetes medication and risk of dementia in elderly patients with type 2 diabetes

AimTo examine the effect of oral diabetes medication on the risk of dementia in an elderly cohort with type 2 diabetes. MethodsThis was a population-based cohort study using the Korean National Health Insurance claims data from 2002 to 2013. Elderly subjects (60 years of age or older) with and without type 2 diabetes were included; patients with new-onset type 2 diabetes were further divided into the oral diabetes medication group and no-medication group. ResultsAmong 278,290 patients with type 2 diabetes, 56,587 developed dementia (20.3%) over 11 years of follow-up. Type 2 diabetes was associated with a 1.69-fold increased risk of dementia (95% CI 1.66–1.72). Among patients with newly diagnosed type 2 diabetes, the risk of dementia was lower in the oral diabetes medication group than in the no-medication group (adjusted hazard ratio [aHR], 0.79; 95% CI 0.77–0.81). Lower risk of dementia was particularly noticeable in all of the combination therapy groups and especially lower in the combination therapy group treated with dipeptidyl peptidase 4 inhibitor (aHR 0.48, 95% CI 0.45–0.51). ConclusionOverall, the use of oral diabetes medication in type 2 diabetes patients significantly decreased the risk of dementia.

The Impact of Implementing the Pharmacists’ Patient Care Process on Medication Adherence in Type 2 Diabetes Patients in a Community Setting

Research suggests differential effects for somatic and cognitive-affective depressive symptoms in predicting health outcomes. This study evaluated differential relations with medication non-adherence among disadvantaged, and predominantly immigrant adults with sub-optimally controlled type 2 diabetes (T2D).Health plan members taking oral diabetes medication and who had A1c ≥ 7.5% were recruited for a trial of telephonic self-management support. A subset (n = 376; age, M = 55.6 ± 7.2 years; A1c M = 9.1% ± 1.6) completed the Patient Health Questionnaire-8 (PHQ-8). Diabetes medication adherence was measured by self-report and claims-based records. Multivariable logistic regression modeled depressive symptoms and odds of non-adherence using pre-intervention data.A positive PHQ-8 screen (OR = 2.72 [95%CI: 1.56–4.73]) and each standard deviation increase in PHQ-8 score (OR = 1.40 [95%CI: 1.11–1.75]) were associated with non-adherence, with no independent effects for somatic versus cognitive-affective symptoms. Exploration of individual symptoms identified three significantly associated with non-adherence in covariate-adjusted models; after adjustment for likely presence of clinical depression, only fatigue was independently associated with non-adherence (OR = 1.71 [95%CI: 1.06–2.77]).Findings support depression symptom severity as a significant correlate of medication non-adherence among disadvantaged adults with T2D. Support was limited for differential associations for symptom dimensions, but findings suggest that fatigue may be associated with non-adherence independent of the likely presence of depression.

Comparison of Medication Therapy Management Services and Their Effects on Health Care Utilization and Medication Adherence.

Medication therapy management (MTM) programs are designed to improve clinical outcomes and enhance appropriate medication use. Comprehensive medication reviews (CMRs) and targeted medication reviews (TMRs) are 2 broad interventions defined within MTM services. While MTM services have been extensively researched, there are few comparisons of CMR versus non-CMR interventions. Given the variability in MTM interventions and lack of a consistent TMR definition in the literature, this study sought to compare CMRs and TMRs that were clearly defined based on Centers for Medicare & Medicaid Services (CMS) criteria. To (a) compare acute inpatient admissions and emergency department (ED) visits between patients participating in MTM services (CMR, TMR, or both) and eligible nonparticipating patients and (b) examine the effect of receiving TMR services on medication adherence. This was a retrospective cohort study of patients with Medicare Part D coverage who received MTM services and a 1:1 propensity score-matched control group. Participants had to be eligible for MTM services in 2014 or 2015 based on CMS requirements. CMRs were offered to all MTM-eligible patients, while TMRs were completed based on clinical rules that helped identify medication-related problems (MRPs). The date of MTM intervention, or eligibility for the control group, was considered the index date. Participants had to be continuously enrolled in a Medicare Advantage plan that included prescription drug coverage during the study period and have at least 6 months of data before and after the index date. Medical and pharmacy claims were assessed to examine trend-adjusted inpatient admissions and ED visits from pre-index to post-index date for participants and matched controls. In 2014 and 2015, receipt of TMR interventions was associated with statistically significant reductions in acute inpatient admissions. In 2014, there were 55.2 fewer admits per 1,000 individuals (95% CI = 29-81) and 30.8 fewer admits per 1,000 individuals in 2015 (95% CI = 20-42). Receipt of CMR-only interventions was associated with fewer acute inpatient admissions only when coupled with preidentification of MRPs (36.8 [95% CI = 25-49] fewer admits per 1,000 individuals). In 2015, there were significant reductions in ED visits for participants receiving TMR-only interventions or TMR/CMR interventions (26.1 [95% CI = 11-41] and 12.0 [95% CI = 1-23] fewer ED visits per 1,000 individuals, respectively). In both years, a larger percentage (0.4% for oral diabetes medications; 7.7% for antihypertensives; 3.0% for statins) of MTM participants had greater improvements in medication adherence in the post-index period compared with controls. Receiving MTM services targeted at resolution of MRPs (TMR or CMR/TMR) resulted in positive reductions in health care utilization and increases in medication adherence. Given the importance of optimal medication utilization, this study highlights the need for additional focus on resolution of MRPs through TMRs and CMRs that can support improved clinical outcomes. No outside funding supported this study. Researchers completed the work as part of their employment with Humana. All authors are or were employees of Humana at the time of the study. There are no other conflicts of interest to disclose. This study was previously presented at AMCP Nexus 2017 on October 16, 2017, in Dallas, TX.

1228-P: Sodium-Glucose Cotransporter 2 Inhibitors and Risk of Genital Mycotic and Urinary Tract Infections: A Population-Based Study of Older Women and Men with Diabetes

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are the newest class of oral diabetes medications. There are concerns of an increased risk of genitourinary infections based on trial data, however this risk at a population level is understudied. We conducted a population-based study using linked administrative databases in Ontario of women and men with diabetes over the age of 66 who were incident users of SGLT2i from Jan-Dec 2016. We quantified the association between SGLT2i and each of genital mycotic infection and urinary tract infection within 30 days of drug initiation using a retrospective cohort design. The comparator group were new users of a DPP-4i. We identified 21,444 incident SGLT2i users and 22,463 DPP-4i users. Among SGLT2i users, 41% were women and the mean age at index was 71.8 ± 5 years. After adjusting for propensity score, age, sex, and recent UTI, there was a 2.47 fold increased risk of a genital mycotic infection with SGLT2i (adjusted hazard ratio (HR), 2.47; 95% CI 2.08-2.92, p &amp;lt; 0.001) within 30 days. For UTI, the adjusted HR was 0.89 (95% CI 0.78-1.00, p=0.05) overall. Incident SGLT2i use among older women and men is associated with an increased risk of genital mycotic infections within 30 days; there is no associated increased risk of UTI. These findings from a real-world setting provide evidence of the potential harms of SGLT2i. Disclosure I.C. Lega: None. S. Bronskill: None. M.A. Campitelli: None. J. Guan: None. N.M. Stall: None. K. Lam: None. L.M. McCarthy: None. A. Gruneir: None. P.A. Rochon: None. Funding Canadian Institutes of Health Research (PJT153060)

Oral Hypoglycemics in Patients with type 2 Diabetes and Peripheral Artery Disease

Worldwide, in 2010, 202 million people were living with PAD, with a prevalence between 3-12 percent. The prevalence of PAD is three times greater in diabetic patients compared to those with normal glycaemia. PAD of the limbs is associated with increased cardiovascular morbidity and mortality, as well as major adverse limb events including acute limb ischemia and amputation. These risks are particularly high in patients who smoke and/or have type 2 diabetes. The goal of treatment in diabetic patients with PAD is to prevent cardiovascular events and prevent further peripheral artery stenosis leading to limb ischemia, and amputation. Poor glycemic control contributes to atherosclerotic progression; however, no randomized control trial evidence exists that demonstrates improved glycemic control reduces the risk of PAD. Oral diabetic medications are designed to lower glucose levels, reduce symptoms and the microvascular complications of diabetes without the inconvenience of daily injections. However, the data supporting benefit of these medications in diabetic populations with concurrent PAD are limited. We review the evidence for oral hypoglycemic agents in the treatment of patients with concurrent PAD and diabetes.

PDG12 EFFECTS OF MEDICAID EXPANSION ON ADHERENCE TO ORAL HYPOGLYCEMIC MEDICATIONS IN LOW-INCOME POPULATIONS

The Affordable Care Act created provisions to expand Medicaid coverage to all individuals with incomes at or below 138 percent of the poverty line ($16,243 for an individual and $33,465 for a family of four in 2015). However, nearly three million low-income individuals in 19 states across the nation remain without health insurance following the Supreme court decision that yielded Medicaid expansion non-compulsory for states. Several studies have determined that states the that have adopted the expansion have had largely positive impacts on coverage, access to care and utilization, as well as economic outcomes. No study to date, however, has investigated the impact of Medicaid expansion on adherence to oral hypoglycemic medications. This investigation is crucial because adherence to diabetic medications can in many cases postpone or prevent the damaging and costly complications associated with the progression of diabetes. Medicaid provides access to essential medical services and prescription drugs for millions of low-income individuals, many of whom would not have health insurance otherwise and whom experience diabetes associated complications at a higher rate. This study will evaluate pharmacy claims from the Medical Expenditure Panel Survey to determine whether Medicaid expansion has, in fact, had an effect on adherence to oral hypoglycemic diabetic medications for low-income individuals. The analysis will compare pre-expansion (2013) and post-expansion (2015) adherence estimates among Medicaid expansion and non-Medicaid expansion states utilizing the difference-in-differences statistical model

Factors Impacting Adherence to Diabetes Medication Among Urban, Low Income Mexican-Americans with Diabetes.

Mexican-Americans carry a high burden of type 2 diabetes and are disproportionately affected by diabetes related mortality and morbidity. Poor adherence to medication is an important barrier to achieving metabolic control and contributes to adverse health outcomes and health disparities. Little is known about barriers and facilitators to medication adherence among Mexican-Americans with diabetes. This is a qualitative study of semi-structured interviews with a sample of 27 adults (25 Mexican-Americans and 2 Latinos of other origin) with self-reported type 2 diabetes who were recruited as part of a church-based, randomized controlled trial for diabetes self-management education in a low-income, immigrant neighborhood of Chicago. Face-to-face, in-depth interviews were conducted (one in English and 26 in Spanish), audio-recorded, transcribed verbatim, and professionally translated. Systematic qualitative methods were used to analyze interviews. All 27 participants were Latino, and 25 were of Mexican descent. Participants' mean age was 57 years, 81% were female, 69% had an annual income less than $20,000 and 48% had no health insurance. Mean A1C level was 8.6% and mean systolic blood pressure was 125mmHg. The majority of participants (85%) reported using oral diabetes medication and 35% reported taking insulin. 76% reported being affiliated with one of the two partnering catholic churches based in the South Lawndale neighborhood of Chicago, also known as Little Village. Concerns regarding effectiveness and negative impact of diabetes medication were prevalent and expressed by 13 (48%) of 27 participants. Dissatisfaction with ineffective provider communication and not being able to pay for medication were other important barriers to adherence and were expressed by 7% and 11% of participants, respectively. Family support, for example, family members assisting in organizing medications in boxes and reminding participants to take them, was reported by 15% of participants and emerged as an important facilitator to medication adherence. There is a gap in research on factors influencing adherence to diabetes medication among Mexican-Americans. Our study suggests that concerns regarding negative impact of diabetes medication and concerns regarding effectiveness are prevalent barriers to adherence. These barriers can be addressed through educational efforts targeting patients and clinicians by specifically including content on beliefs that lead to poor adherence in diabetes self-management interventions for patients and continuing medical education for providers and by developing interventions that engage family members as a support system for medication adherence.

Diabetes and elevated preoperative HbA1c level as risk factors for postoperative delirium after cardiac surgery: an observational cohort study.

IntroductionPostoperative delirium (POD) is a common complication of cardiac surgery associated with increased mortality, morbidity, and long-term cognitive dysfunction. Diabetic patients, especially those with poor diabetes control and long-standing hyperglycemia, may be at risk of developing delirium. The aim of this study was to analyze whether the occurrence of POD in cardiac surgery is associated with diabetes or elevated preoperative glycated hemoglobin (HbA1c) level.Materials and methodsWe performed a cohort analysis of prospectively collected data from a register of cardiac surgery department of a university hospital. Delirium assessment was performed twice a day during the first 5 days after the operation based on Diagnostic Statistical Manual of Mental Disorders, fifth edition criteria.ResultsWe analyzed a cohort of 3,178 consecutive patients, out of which 1,010 (31.8%) were diabetic and 502 (15.8%) were diagnosed with POD. Patients with delirium were more often diabetic (42.03% vs 29.86%, P<0.001) and on oral diabetic medications (34.66% vs 24.07%, P<0.001), no difference was found in patients with insulin treatment. Preoperative HbA1c was elevated above normal (≥6%) in more delirious than nondelirious patients (44.54% vs 33.04%, P<0.001), but significance was reached only in nondiabetic patients (20.44% vs 14.86%, P=0.018). In univariate analysis, the diagnosis of diabetes was associated with an increased risk of developing POD (OR: 1.703, 95% CI: 1.401–2.071, P<0.001), but only for patients on oral diabetic medications (OR: 1.617, 95% CI: 1.319–1.983, P<0.001) and an association was noted between HbA1c and POD (OR: 1.269, 95% CI: 1.161–1.387, P<0.001). Multivariate analysis controlled for diabetes showed that POD was associated with age, heart failure, preoperative creatinine, extracardiac arteriopathy, and preoperative HbA1c level.ConclusionMore diabetic patients develop POD after cardiac surgery than nondiabetic patients. Elevated preoperative HbA1c level is a risk factor for postcardiac surgery delirium regardless of the diagnosis of diabetes.

Discontinuation and Nonadherence to Medications for Chronic Conditions after Hematopoietic Cell Transplantation: A 6-Year Propensity Score-Matched Cohort Study.

Hematopoietic cell transplantation (HCT) is an established curative option for patients with hematological malignancies and other life-threatening conditions. Evidence on nonpersistence and nonadherence to oral medications for chronic conditions among patients following HCT is lacking. This study aims to examine patterns of oral medication use for chronic conditions following HCT in the U.S. Nonpersistence and nonadherence to oral medications for diabetes, hypertension, and dyslipidemia among HCT recipients were assessed in a cohort that included 1382 autologous and 650 allogeneic HCT recipients with hematological malignancies using the Truven Health MarketScan Research Database between 2009 and 2014. Recipients of HCT were compared to propensity score-matched cancer patients receiving chemotherapy without transplantation. Multivariable Cox proportional hazards models and generalized estimating equations were used to determine characteristics associated with nonpersistence and nonadherence to oral chronic medications, respectively. Recipients of HCT had higher risks of discontinuing medication for diabetes mellitus (allogeneic HCT hazard ratio [HR]=1.93, 95% confidence interval [CI] 1.10-3.39; autologous HCT HR=1.49, 95% CI 1.04-2.15); hypertension (allogeneic HCT HR=1.75, 95% CI 1.21-2.53; autologous HCT HR=1.32, 95% CI 1.07-1.62), and dyslipidemia (allogeneic HCT HR=2.02, 95% CI 1.39-2.93; autologous HCT, HR=1.26, 95% CI 0.98-1.61) compared to patients treated with only chemotherapy. Lower odds of adherence to antihypertensive medications (odds ratio [OR]=0.58, 95% CI 0.38-0.89) and to lipid-lowering medications (OR=0.38, 95% CI 0.22-0.65) were observed in allogeneic HCT recipients compared with propensity score-matched patients who underwent chemotherapy only. Poor medication persistence and adherence to chronic disease medications are common after HCT. Further research to improve long-term outcomes following HCT should include management of medication therapy for chronic comorbid conditions.

Initiation of Basal Insulin in Patients with Uncontrolled Type 2 Diabetes Mellitus

Type 2 diabetes mellitus is a growing health problem, characterized by insulin resistance progressing to beta cell dysfunction and insulin deficiency, most of these patients will need intensification of treatment and initiation of insulin to delay or prevent diabetic complications. Glycemic control is the most important aspect in management, and in reducing morbidity and mortality of the diseases. Control of plasma glucose in patients with diabetes can be assessed by HbA1c, FPG, PPG, but still HbA1c% remains the gold standard for assessment of glycemic control and follow up of diabetic patients. The aim of this study is to assess HbA1c% in patients on oral anti-diabetic drugs, with poorly glycemic control before and after adding basal insulin, with titration of the dose of insulin depending of fasting blood sugar. 82 patients with uncontrolled type 2 diabetes (43.9% male, 56.1% female), with HbA1c more than 9%, on two types of oral diabetic medication or more, were started on basal insulin (glargine, lantus) and followed for three to six months. Overall 82 patients with type2 diabetes mellitus were included in the study. The mean age of the study population was 58.4 years, the mean duration of the disease range was 13.4 years. All patients with HbA1C more than 9%, without organ failure, were included in the study. The mean HbA1c overall had decreased from mean of 11.15% before starting basal insulin to the mean of 8.43% within 3 to 6 month , after initiating basal insulin , this difference was significant at p < 0.000 .There was no adverse effect to this medication in any of the study group. The addition of basal insulin to oral anti- diabetic medication in uncontrolled insulin-naive type 2 diabetic patients resulted in significant improvement of glycemic control, with improved HbA1c level, without adverse effects.

Adherence to quality of care measurements among 58,182 patients with new onset diabetes and its association with mortality.

ObjectivesDisease registry for diabetes care encourages transparency and benchmarking of quality of care (QoC) measurements for all service providers and seems to improve diabetes care. This study evaluate changes over time in QoC measurement performance in a large diabetes registry among newly diagnosed diabetics and it association with mortality.MethodsRetrospective cohort study of patients in a large health maintenance organization diabetes registry from years 2000 to 2013. We identified 58,182 patients diagnosed with diabetes from 2000–2008 and examined the level of performance for seven QoC measurements (HbA1c, LDL, albumin-creatinine-ratio, fundus/foot examinations, BMI and Blood-pressure) at diagnosis year. We also searched data regarding visits to dietitians or endocrinologists, and purchase of diabetes and statin medications. We used Mantel-Haenszel's χ2 test to assess QoC performance and mortality rate by calendar year of entry into the registry, and Cox regression to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality up to 5 years from diagnosis adjusted for age, gender, socio-economic status and comorbidities.ResultsThe total QoC measurements improved from a mean of 2.71 tests performed in 2000 to 5.69 in 2008 (p<0.001). The mortality rate dropped from 7.7% in 2000 to 5.7% in 2008 (p<0.001). Patients with more QoC measurements performance who visited a dietitian and purchased statin medications had a lower mortality risk (HRs (95% CIs) 0.89 (0.87–0.92), 0.83 (0.76–0.91) and 0.70(0.65–0.75) respectively). Visits to endocrinologists and purchases of oral diabetes medication and insulin were associated with a higher risk of mortality (HRs (95% CIs) 1.20(1.07–1.35), 1.35(1.26–1.46) and 3.36(2.92–3.87) respectively).ConclusionPerformance of QoC measurements including visiting a dietitian and purchase of statin medications were associated with lower mortality in patients with diabetes. It may be that the early active involvement of the patients in their care plays a protective role in long term mortality.

Depressive symptom dimensions and medication non-adherence in suboptimally controlled type 2 diabetes

AimsResearch suggests differential effects for somatic and cognitive-affective depressive symptoms in predicting health outcomes. This study evaluated differential relations with medication non-adherence among disadvantaged, and predominantly immigrant adults with sub-optimally controlled type 2 diabetes (T2D). MethodsHealth plan members taking oral diabetes medication and who had A1c ≥ 7.5% were recruited for a trial of telephonic self-management support. A subset (n = 376; age, M = 55.6 ± 7.2 years; A1c M = 9.1% ± 1.6) completed the Patient Health Questionnaire-8 (PHQ-8). Diabetes medication adherence was measured by self-report and claims-based records. Multivariable logistic regression modeled depressive symptoms and odds of non-adherence using pre-intervention data. ResultsA positive PHQ-8 screen (OR = 2.72 [95%CI: 1.56–4.73]) and each standard deviation increase in PHQ-8 score (OR = 1.40 [95%CI: 1.11–1.75]) were associated with non-adherence, with no independent effects for somatic versus cognitive-affective symptoms. Exploration of individual symptoms identified three significantly associated with non-adherence in covariate-adjusted models; after adjustment for likely presence of clinical depression, only fatigue was independently associated with non-adherence (OR = 1.71 [95%CI: 1.06–2.77]). ConclusionsFindings support depression symptom severity as a significant correlate of medication non-adherence among disadvantaged adults with T2D. Support was limited for differential associations for symptom dimensions, but findings suggest that fatigue may be associated with non-adherence independent of the likely presence of depression.

The durability of oral diabetic medications: Time to A1c baseline and a review of common oral medications used by the primary care provider

Cost of generic medications has risen more in the past few years than any other time in history. While medical insurance covers much of these costs, health care professionals can better provide medications that have the longest duration of action when compared to placebo-treated controls. This will save health care costs and improve prescribing accuracy. Papers in PubMed were identified with keywords placebo. The study must be at least 2 years in length to evaluate the change in A1c over time. The primary endpoint was time to A1c neutrality (return of A1c to baseline at a maximum dose of single oral agent). A medication would be considered at neutrality if the 95% CI crossed baseline. Time to neutrality was averaged for each medication within the class and each summarized for class effect. Effective therapy for the DPP-4 and sulfonylurea classes of medications are 3-4 years as compared to a 5-year time to A1c neutrality for metformin usage. In comparison, the projected time to A1c neutrality was approximately 6-8 years for rosiglitazone and pioglitazone. While only a few studies have been published in the SGLT-2 class of medication, the time to A1c neutrality was also 6-8 years with Canagliflozin and full dosage of Empagliflozin. Metformin appears to have a 5-year duration of effect before the A1c returns to baseline. The sulfonylureas and DPP-4 inhibitors class of medications have one of the shortest durability which ranges between 3.3 to 4.4 years. In contrast, the SGLT-2 class of medication and the TZD class of medications has a projected time to A1c neutrality from 6-8 years. Diabetic duration of therapy as compared to placebo should be listed with those medications tested so the provider can choose wisely.

Changes in diabetes medication regimens and glycemic control in adolescents and young adults with youth-onset type 2 diabetes: The SEARCH for diabetes in youth study.

The aim of this study was to describe recent medication patterns and changes in medication patterns and glycemic control in adolescents and young adults with incident type 2 diabetes (T2D). Using data from the SEARCH for Diabetes in Youth Study, we conducted a cross-sectional analysis of treatments for adolescents and young adults with incident T2D in 2 periods (2002-2005 vs 2008/2012), and a longitudinal analysis of medications and glycemic control for a subset with baseline and follow-up visits. Comparisons were performed using χ2 , Fisher's exact, or ANOVA. Of 646 individuals in the cross-sectional analysis, a majority in each period received metformin (64.9% vs 70.4%) and/or insulin (38.1% vs 38.4%), while fewer used sulfonylureas (5.6% vs 3.6%) with non-significant changes over time. There was a significant reduction in thiazolidinedione use (5.0% vs 2.0%, P < .05). In the longitudinal analysis, 322 participants were followed for 7 years, on average. Baseline metformin users had a lower A1C (6.4% [46.7 mmol/mol]) compared to insulin (8.4% [68.2 mmol/mol], P < .001) or insulin plus any oral diabetes medication (ODM) users (7.7% [60.4 mmol/mol], P < .001). Among baseline metformin users (n = 138), 29.7% reported metformin at follow-up, with the remainder adding (19.6%) or switching to insulin (8.0%), ODM (15.9%), or lifestyle only (26.8%). Of those receiving insulin (±ODM) (n = 129), 76% reported insulin use at follow-up. Overall, 35% were at A1C goal (<7.0%, 53 mmol/mol) at follow-up. Youth-onset T2D is still largely being treated with metformin and/or insulin. The majority treated were not at American Diabetes Association (ADA)-recommended goal 7 years after diagnosis.

Oral diabetes medication monotherapy and short-term mortality in individuals with type 2 diabetes and coronary artery disease

ObjectiveTo determine whether sulfonylurea use, compared with non-sulfonylurea oral diabetes medication use, was associated with 2-year mortality in individuals with well-controlled diabetes and coronary artery disease (CAD).Research design and methodsWe...