January 20, 2018 : Issue #921

• How To Overcome The Complexities of Treatment Decisions For Patients With Type 2 Diabetes, Part 2: Costs vs. Outcomes for Patients With Type 2 Diabetes
• Semaglutide Shows Superiority Over Exenatide ER in Head-to-Head Trial
• Non-adherence to Metformin Versus Therapeutic Failure: When is it Appropriate to Switch to Second-Line Therapies?
• Controversy Between SGLT-2 Inhibitors and GLP-1 Agonists as Preferred Second-Line Therapy
• Is Insulin Secretion and Sensitivity Contingent upon BMI Fluctuations?
• Stroke and Dementia Risks With Sugars and Artificial Sweeteners: Fact or Fiction?
• Exclusive: Mark Peyrot on the Psycho-Social Guidelines for Diabetes

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We have continued to add new and more effective medications for diabetes focusing on different defects in metabolism. These additions have actually put the drugs in the weird position of competing with each other and working together at the same time.

This week, our newsletter is full of examples of how these conflicts and cooperations can affect care. However, through it all, cost and prescription coverage really dictate what our patients get treated with.

This week, we have Part 2 of our special feature on how to work through the complexities and make the right choices.

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We can make a difference!

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Dave Joffe

Editor-in-chief

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Which CGM system do you prefer?

1) Dexcom C5
2) Abbott Freestyle Libre
3) Medtronic Elite
4) Either
5) None

Follow the link to see how you and your colleagues compare.

For patients who suffer from acute and chronic wounds, a novel device has been developed – the dermaPACE, by Sanuwave. The mechanism of action is based on shockwave technology, which has been used for nearly 30 years in orthopedic treatments and lithotripsy procedures (destruction of kidney stones). These early devices also provided evidence that there was an effect on wound healing. Pulsed Acoustic Cellular Expression (PACE) Technology was developed based on this evidence, and the dermaPACE device is the first to utilize PACE specific proprietary protocols for wound treatment. DermaPACE is CE marked for the application of pulsed acoustic waves on acute and chronic defects of the skin and subcutaneous soft tissues, to treat post-operative wound healing defects, post-traumatic wounds, deep-partial thickness burns, decubitus ulcers, diabetic ulcers, arterial ulcers and venous ulcers. To learn more, see video: http://www.sanuwave.com/template_files/946/sanuwave/files/video/Biofilm8.mp4

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Mark Peyrot is Professor of Sociology at Loyola University Maryland and Professor of Health and Social Sciences at Bergen University College (Norway). He formerly was a faculty member in the departments of Sociology and Medicine at the University of Kentucky and Medicine at Johns Hopkins University.

A 51-year-old patient returns to your office for a follow-up visit. She is currently taking metformin and glipizide after being diagnosed with type 2 diabetes 8 years ago. She shows you her self-care logs that indicate she has been eating a healthy diet and walking daily. She has been maintaining her weight (BMI 26kg/m2). Despite her excellent efforts, her A1C is 7.8%, above her target of A1C<7.0%. When you start to discuss adding a basal insulin dose to her regimen, she bursts into tears. All of the following are common barriers to insulin therapy initiations EXCEPT: A. Fear that hyperglycemia will make her ill. B. Fear others will treat her differently because she needs regular injections. C. Fear of needles or that insulin injections are painful. D. Fear that insulin causes death or complications. Follow the link to see the answer.

Diabetes affects mortality and cognitive functioning. It is not known how diabetes influences life expectancy (LE) with or without cognitive impairment. The study set out to examine age at onset of cognitive impairment and life expectancy (LE) with or without cognitive impairment by diabetes status among middle- and older-aged Americans. The results of the study indicates that older adults with diabetes have a higher chance of cognitive impairment and a shorter life expectancy compared with those without. A recent estimate suggests that diabetes is associated with a 40% increase in the odds of dementia among older Americans. The precise physiologic pathways linking diabetes and cognitive impairment remain largely undetermined. Given that cognitive impairment is a major cause of loss of independence, presents a barrier to medication adherence and results in extremely high care costs, policies aimed at improving outcomes among those with diabetes should be informed by the level of cognitive impairment in this population. Researchers studied age at onset of cognitive impairment and life expectancy with and without cognitive impairment by diabetes status among middle- and older-aged adults. The total sample included 13,687 individuals aged 50 to 74 years who contributed 136,367 person-years of follow-up from 2000 to 2012. They calculated age at onset of cognitive impairment and life expectancy with and without cognitive impairment by diabetes status at age 50 years. The results show diabetes as a strong indicator of increased mortality and cognitive decline. For men and women, and for most ages, those with diabetes had a higher prevalence of cognitive impairment than those without. The researchers found that the average cognition score for people with diabetes was 1.7 points lower and the prevalence of cognitive impairment was more than 10% higher compared with those without diabetes (25% vs. 14%; P .01).  From age 50 years, men and women with diabetes had a first incidence of cognitive impairment 3 and 4 years earlier, respectively, than those without diabetes. Diabetes decreased total life expectancy by 5 to 7 years and cognitively healthy life expectancy by 4 to 6 years. Compared with individuals without diabetes, those with diabetes lived approximately 1 year less with poor cognitive health. Furthermore, although education was strongly protective of cognitive health, diabetes was linked to lower age at cognitive impairment onset and fewer cognitive healthy years lived across all educational groups.  Diaz-Venegas C, et al. PLOS One. 2017;doi:10.1371/journal.pone.0190488, January 5, 2018.

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Costs vs. Outcomes for Patients With Type 2 Diabetes: The issue of cost in healthcare is a central point in the discussion of the future of medicine. While much is made of the cost of end-of-life care, many of the dollars spent yearly are focused on the treatment of chronic diseases like diabetes. The estimated yearly cost of diabetes care was $245 billion in the U.S. in 2012, the last year for which numbers have been reported. $50 billion of that was related to prescription drug purchases.

Battle between two GLP-1 receptor agonists proves semaglutide achieves favorable HbA1c levels, decreased mean body weight.

Patients who skipped initial treatment with metformin and were instead started on second-line antihyperglycemic medication more likely to need dual therapy or insulin to control T2.

Patient specific considerations have to be taken into account prior to choosing GLP-1 agonist or SGLT2 inhibitor as second-line anti-hyperglycemic agent.

Patients projected to have increase in body mass index also likely to develop increased plasma glucose levels and have diminished insulin response.

Researchers use data from large ongoing cohort study to look for connection. In a recent study, researchers concluded that sugar and artificially sweetened beverage intake have been linked to cardiometabolic risk factors, which increase the risk of cerebrovascular disease and dementia. The study examined whether sugar or artificially sweetened beverage consumption was associated with the …

Quote of the Week!

‘Tis not enough to help the feeble up, but to support them after.”

…William Shakespeare

Diabetes in Control gratefully acknowledges the assistance of the following pharmacy doctoral candidates in the preparation of this week’s newsletter:

Lamija Zimic, Doctor of Pharmacy Candidate 2018, USF College of Pharmacy

Your Friends in Diabetes Care
Steve and Dave
Diabetes In Control
810 Bear Tavern Road Suite 102
Ewing, NJ, 08628
USA
www.diabetesincontrol.com

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