January 5, 2019 : Issue #971

• Special Feature — Pumps vs. Daily Injections: The Future of Insulin Delivery
• Brain Hormones and Relaxation to Lower Mental and Physical Stress
  • By Sheri R. Colberg, PhD, FACSM
• Common Diabetes Drugs Linked to Higher Risk of Heart Attack and Stroke
• Association Between Use of Sodium Glucose Cotransporter 2 Inhibitors and Serious Adverse Effects
• Time In Range Associated With Diabetic Retinopathy
• CGM for the Less-Intensive Patient Population
  • by David Kliff, Editor, Diabetic Investor

My wife is heading in to her first appointment with an endocrinologist. After 3 years of controlling her glucose with long acting insulin, a GLP-1 analog and an SGLT-2I, she had to go on meal time insulin. The use of meal time insulin forced her to check her glucose more often and she found glucose swings with no explanation. One of the first things that frustrated her was the effect exercising had on her glucose. On multiple days she would be great before breakfast and regardless of what she tried after her morning bike ride, her glucose would often go to 300mg/dl. This happened with little regard to her food choices.

Her main goal of the appointment is to get a CGM device. Based on her checking her glucose 6-8 times a day and injecting insulin as often, having a CGM device would definitely be warranted.

But what about our patients that don’t need to be as intensively managed; will they be candidates for CGM? This week our good friend, David Kliff, joins us with a special feature on the use of CGM devices in these less intensive patients. The nice thing about Dave’s commentary is his perspective. He is both a patient who has insulin dependent diabetes and a financial guru. His focus in the article is on the practicality of patients requiring less intensive management using CGM, and what the devices and protocols would look like. Check out item #6 to take you to the page.

And be sure to also check out the results of our exclusive survey on what patients and healthcare professionals think about insulin pumps vs smart pens vs multiple daily injections in item #1.

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We can make a difference!

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Dave Joffe

Editor-in-chief

Which insulin pump do you prefer for most of your patients? Medtronic, Tandem, or Omnipod? Follow the link to share your opinion.

Children’s Health Diabetes Advisor provides children and families with diabetes a mobile resource to complement the diabetes education programs at Children’s Health System of Texas (CHST), providing a one stop source for an Education library and Ketone Manager.

John S. is a 63-year-old Caucasian man with significant abdominal obesity, type 2 diabetes, hypertension, and dyslipidemia as well. On the basis of an exercise stress test, John was recently diagnosed with silent ischemia. John’s current medications include metformin, a DPP-4 inhibitor, an ACE inhibitor/HCTZ agent, a calcium channel blocker, a high-dose statin, and ezetimibe. John’s relevant physical exam and laboratory findings are as follows:

BMI 34.8 kg/m2
Blood pressure 140/86 mm Hg
HbA1C 7.2%
Total cholesterol 150 mg/dL
LDL-C 79 mg/dL
HDL-C 42 mg/dL
Triglycerides 145 mg/dL
non-HDL-C 118 mg/dL
eGFR 65 mL/min/1.73 m2
ACR 100 mg albumin/g creatinine

You explain John’s options for antihyperglycemic therapy. Which of the following answers most accurately describes the extraglycemic benefits of the different options?

A. The GLP-1 receptor agonists may improve endothelial function and reduce infarct size and the SGLT2 inhibitors are likely to improve arterial blood flow.
B. The DPP-4 inhibitors are not safe for people with cardiovascular disease, while the proven cardiovascular benefits of GLP-1 receptor agonists are consistent across the class.
C. DPP-4 inhibitors and SGLT2 inhibitors both reduce blood pressure, which accounts for their similar effects on heart failure.
D. The cardiovascular benefits of both the GLP-1 receptor agonists and SGLT2 inhibitors derive mainly from their effects on weight.

Follow the link for the answer.

The claims show that 15% of type 2 patients over test their blood sugars. Many of those who test too often are not on any medications that could cause hypoglycemia or not on any medications for diabetes at all. Endorsed by the American Academy of Family Physicians, this recommendation states that daily finger glucose monitoring has “no benefit” for these patients and is also accompanied by “small, but significant, patient harms.”  Among the patients considered to be self-monitoring needlessly, a median of two strips per day were used (IQR 1.2-2.4). Over the course of the year, this amounted to a median cost of $325.54 per patient (IQR $0-$534.76) in insurance claims for these unnecessary test strips. Patients’ copays for test strips averaged $18.14 per year/patient or over 80 million dollars a year. The study included claim information between 2013 and 2015 on beneficiaries of a large commercial health insurance and Medicare Advantage beneficiaries. Only patients who were not prescribed insulin were included in the analysis. One strategy to encourage more judicious use of self-monitoring of blood glucose might involve clinical decision support in electronic medical records with an alert for a test strip prescription in a patient taking nonhypoglycemia-inducing medications. — published online December 10 in JAMA Internal Medicine by Kevin D. Platt, MD, of the University of  Michigan, Ann Arbor, and colleagues.

New technologies have the potential to revolutionize diabetes care. But what are the advantages and disadvantages of insulin pumps, vs. daily injections? How widely will they be adopted, by patients with type 2 diabetes as well as type 1? What factors will make a difference for adoption – convenience, accuracy, costs?

In November, we asked you to help us examine the future of insulin delivery and find the answers to these questions. Now we’re sharing all the results with you, so that you can see for yourself how your fellow members of the diabetes community plan on using CGMs, now and in the future.

By Sheri R. Colberg, PhD, FACSM

At each dawn of a new year, many people make resolutions to be more physically active—only to fail in changing their lifestyle habits in a sustained manner. Don’t be one of the many who start exercising only to stop again a few months later. Read more about why daily release of feel-good brain hormones is so important and why you should learn how to relax more as well.

Even though most diabetes drugs can help in managing blood sugar levels, they can also be detrimental to the heart.

Study findings warrant cautious consideration and discussions about risk vs benefit when considering therapy.

Study compares enhanced patient care experience with standard shared medical appointments to determine if a significant benefit will result.

Guest Post by David Kliff, Editor, Diabetic Investor

Although we haven’t gotten there just yet, it’s no longer a question of if type 2’s start using CGM, but when they do and how they use it. CGM is not like an insulin pump when it comes to having a finite market size. CGM is a valuable tool regardless of whether the patient uses insulin.

Quote of the Week!

“If you change the way you look at things, the things you look at change.”

….Wayne Dyer

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

Michael Zaccaro, Pharm. D. Candidate 2019, LECOM School of Pharmacy

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