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Roy Chowdhury S, Sadouki F, Collins E, Keen F, Bhagi R, Lim YSJ, Cozma SL, Bain SC. Real-World Use of Oral and Subcutaneous Semaglutide in Routine Clinical Practice in the UK: A Single-Centre, Retrospective Observational Study. Diabetes Ther 2024; 15:869-881. [PMID: 38427165 PMCID: PMC10951141 DOI: 10.1007/s13300-024-01551-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/07/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Semaglutide, the only glucagon-like peptide-1 receptor agonist (GLP-1 RA) available in subcutaneous and oral formulation for treatment of type 2 diabetes (T2D), has demonstrated clinically significant improvements in glycaemic control and weight in clinical trials. This study aimed to gain insights into the use of both formulations and evaluate their clinical effectiveness in a secondary care clinic in Wales. METHODS This was a retrospective observational analysis of adults with T2D initiated on oral or subcutaneous semaglutide. Changes from baseline in glycated haemoglobin (HbA1c), weight and other metabolic parameters were evaluated. RESULTS At baseline, participants (n = 103) had a mean age of 57.3 years, mean HbA1c of 79.1 mmol/mol (9.38%), mean weight of 111.8 kg and body mass index (BMI) of 39.6 kg/m2 (no statistically significant differences between oral and subcutaneous groups). At 6-month follow-up, statistically significant improvements in HbA1c (- 19.3 mmol/mol [- 1.77%] and - 20.8 mmol/mol [- 1.90%]), body weight (- 9.0 kg and - 7.2 kg), and BMI (- 3.3 kg/m2 and - 2.5 kg/m2) were observed for oral and subcutaneous semaglutide, respectively. No statistically significant differences between the formulations were observed, and safety profiles were comparable. CONCLUSIONS Both formulations of semaglutide provided clinically and statistically significant reductions in HbA1c and weight in real-world practice. Oral GLP-1 RA may offer a practical and effective option for the management of T2D.
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Affiliation(s)
| | | | | | - Frederick Keen
- Department of Diabetes and Endocrinology, Princess of Wales Hospital, Bridgend, CF31 1RQ, UK
| | - Ridhi Bhagi
- Department of Diabetes and Endocrinology, Princess of Wales Hospital, Bridgend, CF31 1RQ, UK
| | - Yuan S J Lim
- Department of Diabetes and Endocrinology, Princess of Wales Hospital, Bridgend, CF31 1RQ, UK
| | - Silviu L Cozma
- Department of Diabetes and Endocrinology, Princess of Wales Hospital, Bridgend, CF31 1RQ, UK
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Куркин ДВ, Бакулин ДА, Морковин ЕИ, Стрыгин АВ, Горбунова ЮВ, Волотова ЕВ, Робертус АИ, Макаренко ИЕ, Сапарова ВБ, Драй РВ, Петров ВИ. [Fixed ratio combinations GLP-1RA and basal insulin: literature review]. PROBLEMY ENDOKRINOLOGII 2024; 70:91-99. [PMID: 38433545 PMCID: PMC10926250 DOI: 10.14341/probl13312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/06/2023] [Accepted: 08/10/2023] [Indexed: 03/05/2024]
Abstract
The progressive nature of type 2 diabetes mellitus leads to the need for insulin therapy in a significant proportion of patients. Very often start of insulin therapy in type 2 diabetes mellitus (T2DM) is associated with weight gain and a significant increase of hypoglycemia's risk. However, innovative options, such as fixed ratio combinations of glucagon-like peptide 1 receptor agonists (GLP-1RA) and basal insulin, minimize weight gain and hypoglycemia risks and allow a greater proportion of patients to achieve individual glycemic control goals without compromising safety parameters. This review includes a description of the randomized clinical trials, as well as the results of real clinical practice of the use of two currently existing fixed ration combinations of GLP-1RA and basal insulin - iDegLira and iGlarLixi.
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Affiliation(s)
- Д. В. Куркин
- Российский университет медицины; Волгоградский государственный медицинский университет
| | | | | | - А. В. Стрыгин
- Волгоградский государственный медицинский университет
| | | | | | | | | | | | | | - В. И. Петров
- Волгоградский государственный медицинский университет
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Wong WJ, Nguyen T, Fortin M, Harrison C. Prevalence and patterns of comorbidities in older people with type 2 diabetes in Australian primary care settings. Australas J Ageing 2024. [PMID: 38343287 DOI: 10.1111/ajag.13282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 03/02/2024]
Abstract
OBJECTIVE The aim of this study was to identify the prevalence and patterns of comorbidity in community-dwelling older people with type 2 diabetes mellitus (T2DM) attending general practice settings in Australia. METHODS This study involved a cross-sectional analysis using the Bettering the Evaluation and Care of Health (BEACH) sub-study data. In a series of sub-studies, a representative sample of general practitioners was asked to record all diagnosed chronic conditions for patients at 40 consecutive encounters using structured paper-based recording forms. The dataset was analysed with descriptive analyses, and exploratory factor analyses were applied to examine comorbidity patterns. RESULTS Of the 14,042 patients aged 65 years or older, 2688 had a diagnosis of T2DM (19%). Of the 2688 patients with T2DM, hypertension was present in 67% (95% CI: 64.6-70.0), followed by arthritis 52% (95% CI: 48.8-54.8), hyperlipidaemia 45% (95% CI: 41.8-47.9), ischemic heart disease, 23% (95% CI: 20.7-24.9), depression 16% (95% CI: 48.8-54.8), atrial fibrillation 10% (95% CI: 8.9-11.6), congestive heart failure 7% (95% CI: 6.0-8.1), stroke/cerebrovascular accident 7% (95% CI: 5.4-8.2) and peripheral vascular disease 5% (95% CI: 4.4-6.2). We identified two comorbidity patterns among older people with T2DM. The first were psychological and musculoskeletal conditions and the second were cardiovascular conditions and chronic renal failure. CONCLUSIONS The prevalence of cardiovascular and non-cardiovascular comorbidities in community-dwelling older people with T2DM was high. Adequate primary care strategies should be in place to support the long-term care for this population.
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Affiliation(s)
- Wei Jin Wong
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- School of Pharmacy, Monash, University Malaysia, Subang Jaya, Selangor, Malaysia
| | - Tu Nguyen
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Martin Fortin
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Saguenay, Quebec, Canada
| | - Christopher Harrison
- The Menzies Centre for Health Policy and Economics, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Alhindi Y, Avery A. The efficacy and safety of oral semaglutide for glycaemic management in adults with type 2 diabetes compared to subcutaneous semaglutide, placebo, and other GLP-1 RA comparators: A systematic review and network meta-analysis. Contemp Clin Trials Commun 2022; 28:100944. [PMID: 35812819 PMCID: PMC9260263 DOI: 10.1016/j.conctc.2022.100944] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 05/26/2022] [Accepted: 06/07/2022] [Indexed: 01/16/2023] Open
Abstract
Aim Semaglutide is a long-acting glucagon-like peptide-1 receptor agonist (GLP-1 RA) indicated for glycaemic management in adults with type 2 diabetes (T2D). Oral semaglutide administration can help decrease glycated haemoglobin (HbA1c) and body weight in people with uncontrolled T2D. We evaluated the efficacy and safety of oral semaglutide compared to that of subcutaneous semaglutide, placebo, and other GLP-1 RAs in the treatment of T2D. Methods Randomised controlled trials of subcutaneous and oral semaglutide for glycaemic control in adults with T2D were selected from the Cochrane Central Register of Controlled Trials and PubMed. Mean differences (MDs) and risk ratios with 95% confidence intervals (CIs) were used to synthesise the results, and oral and subcutaneous semaglutide formulations were indirectly compared using mixed treatment comparisons. Results Twelve studies were included in this review (6840 participants). Oral semaglutide (14.0 mg) significantly reduced HbA1c (MD, −1.30% [95%CI: -1.44, −1.16], P < 0.05) and body weight (MD, −3.17 kg [95%CI: -3.89, −2.45], P < 0.05) compared to placebo (MD, HbA1c: -0.32% [95%CI: -0.49, −0.15], P < 0.05; MD body weight: -2.56 kg [95%CI: -3.41, −1.71], P < 0.05), liraglutide (1.2 mg), exenatide ER (2.0 mg), and dulaglutide (1.5 mg). Oral semaglutide was slightly less effective than subcutaneous semaglutide in reducing HbA1c levels (MD: -0.26% [95%CI: -0.44, −0.07], P < 0.05) and body weight (MD: -1.08 kg [95%CI: -2.04, −0.12], P < 0.05). Oral semaglutide increased the incidence of adverse events (nausea, diarrhoea, dyspepsia, and vomiting) compared to placebo, liraglutide (1.2 mg), exenatide (ER, 2.0 mg), and dulaglutide 1.5 mg but not compared to subcutaneous semaglutide. Conclusion Oral semaglutide was non-inferior to subcutaneous semaglutide and superior to placebo and another GLP-1 RA in reducing HbA1c and body weight. It was superior to subcutaneous semaglutide and inferior to other GLP-1 RA comparators and placebo in terms of the incidence of adverse events. Thus, oral semaglutide provides a convenient administration route for patients who prefer oral treatments over injectable therapies.
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Affiliation(s)
- Yousef Alhindi
- Division of Food, Nutrition & Dietetics, University of Nottingham, UK
- Division of Applied Medical Sciences, University of Hail, Saudi Arabia
- Corresponding author. Nottinghamshire, Nottingham, NG1 1AS, UK.
| | - Amanda Avery
- Division of Food, Nutrition & Dietetics, University of Nottingham, UK
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Cantor JC, Chakravarty S, Farnham J, Nova J, Ahmad S, Flory JH. Impact of a Provider Tele-mentoring Learning Model on the Care of Medicaid-enrolled Patients With Diabetes. Med Care 2022; 60:481-487. [PMID: 35191424 PMCID: PMC9172896 DOI: 10.1097/mlr.0000000000001696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Project ECHO (Extension for Community Healthcare Outcomes), a tele-mentoring program for health care providers, has been shown to improve provider-reported outcomes, but there is insufficient research on patient-level outcomes. OBJECTIVES To evaluate the impact of primary care provider (PCP) participation in Project ECHO on the care of Medicaid enrollees with diabetes. RESEARCH DESIGN New Jersey Medicaid claims and encounter data and difference-in-differences models were used to compare utilization and spending between Medicaid patients seen by PCPs participating in a Project ECHO program to those of matched nonparticipating PCPs. SUBJECTS A total of 1776 adult Medicaid beneficiaries (318 with diabetes), attributed to 25 participating PCPs; and 9126 total (1454 diabetic) beneficiaries attributed to 119 nonparticipating PCPs. MEASURES Utilization and spending for total inpatient, diabetes-related inpatient, emergency department, primary care, and endocrinologist services; utilization of hemoglobin A1c tests, eye exams, and diabetes prescription medications among diabetics, and total Medicaid spending. RESULTS Participation in Project ECHO was associated with decreases of 44.3% in inpatient admissions (P=0.001) and 61.9% in inpatient spending (P=0.021) among treatment relative to comparison patients. Signs of most other outcome estimates were consistent with hypothesized program effects but without statistical significance. Sensitivity analyses largely confirmed these findings. CONCLUSIONS We find evidence that Project ECHO participation was associated with large and statistically significant reductions of inpatient hospitalization and spending. The study was observational and limited by a small sample of participating PCPs. This study demonstrates the feasibility and potential value of quasi-experimental evaluation of Project ECHO patient outcomes using claims data.
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Affiliation(s)
| | | | | | | | - Sana Ahmad
- Center for State Health Policy
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - James H. Flory
- Endocrinology Service, Department of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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6
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Hammerman A, Moore CM, Aboalhasan E, Azuri J, Arbel R. Oral versus subcutaneous semaglutide for prevention of major adverse cardiovascular events: cost per outcome analysis of SUSTAIN-6 and PIONEER-6. Postgrad Med 2022; 134:654-658. [PMID: 35701876 DOI: 10.1080/00325481.2022.2090794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Semaglutide, a glucagon-like peptide-1 receptor agonist (GLP1a), reduces the risk of major adverse cardiovascular events (MACE) in patients with Type 2 diabetes mellitus (T2DM). An oral version of semaglutide is now available, and patients may prefer it over the subcutaneous form. Our objective was to compare the value for money of the two modalities by assessing the cost needed to treat (CNT) to prevent MACE. METHODS The CNT to prevent MACE was figured by multiplying the one-year number needed to treat (NNT) with either oral or subcutaneous semaglutide by the annual cost of therapy. Efficacy estimates and the resulting NNT figures were extracted from the published results of the SUSTAIN-6 and the PIONEER-6 trials for the injectable and oral versions of semaglutide, respectively. Drug costs were estimated as 75% of the United States national average drug acquisition cost listing in June 2021. We performed a scenario analysis to mitigate the primary differences between the populations in the two trials. Sensitivity analysis was performed to evaluate the effect of price changes of the interventions. RESULTS The CNT to prevent one MACE with subcutaneous semaglutide in SUSTAIN-6 was $966,693 ($594,888-$5,035,302) compared to $948,689 ($463,465-∞) with oral semaglutide in PIONEER-6. The scenario analysis demonstrated a 17% lower CNT for oral semaglutide. The difference between CNTs was sensitive to price fluctuations of the two interventions. CONCLUSIONS Oral and subcutaneous semaglutide prescribed to prevent MACE in patients with T2DM provide similar value for money. The choice between both therapies should be guided mainly by patient preferences.
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Affiliation(s)
- Ariel Hammerman
- Community Medical Services, Clalit Health Services Headquarters, Tel Aviv, Israel
| | - Candace Makeda Moore
- Research Software department, Netherlands eScience Center, Amsterdam, The Netherlands
| | - Enis Aboalhasan
- Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel
| | - Joseph Azuri
- Maccabi Healthcare Services, Diabetes Clinic, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Arbel
- Community Medical Services, Clalit Health Services Headquarters, Tel Aviv, Israel.,Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel
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7
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Joshi SR, Rajput R, Chowdhury S, Singh AK, Bantwal G, Das AK, Unnikrishnan AG, Saboo BD, Kesavadev J, Ghosal S, Mohan V. The role of oral semaglutide in managing type 2 diabetes in Indian clinical settings: Addressing the unmet needs. Diabetes Metab Syndr 2022; 16:102508. [PMID: 35653929 DOI: 10.1016/j.dsx.2022.102508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 11/26/2022]
Abstract
AIMS Despite their established benefits, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) remain underutilized for type 2 diabetes mellitus (T2DM) management, which indicates that subcutaneous injection is an unfavorable mode of delivery from the patient's perspective. This review summarizes existing challenges related to medication adherence and the use of antihyperglycemia injectables, revisits the established safety and efficacy of oral semaglutide, and explores its features and considerations for use among the Indian T2DM population. METHODS We performed a literature search using MEDLINE and the National Institutes of Health Clinical Trials Registry from July 1, 2016, to July 1, 2021, to identify publications on oral semaglutide approval, T2DM treatment guidelines, and clinical evidence for oral drug formulation. RESULTS Oral semaglutide is the first oral GLP-1 RA approved for T2DM patients based on phase 3, randomized PIONEER trials. The multitargeted action of this drug offers glycemic control, weight control, and cardiovascular, renal, and additional benefits, including patient convenience and enhanced medication adherence. In addition to achieving glycemic control, the cost of semaglutide is reported to be lower than other GLP-1 RA in the West, thus potentially mitigating the economic burden that appears to be high among the Indian population. CONCLUSIONS Currently, there is no data available on oral semaglutide in Indian clinical settings. However, significant improvements in glycemic control, cardiac and renal benefits, as well as weight loss across clinical trials should encourage clinicians to prioritize oral semaglutide over other antidiabetic agents.
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Affiliation(s)
- Shashank R Joshi
- Grant Medical College and Consulting Endocrinologist, Lilavati Hospital, Mumbai, India.
| | - Rajesh Rajput
- Department of Endocrinology, PGIMS, Rohtak, Haryana, India.
| | | | - Awadhesh K Singh
- G. D. Hospital & Diabetes Institute, Kolkata, West Bengal, India.
| | | | - Ashok K Das
- Department of General Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India.
| | | | | | | | | | - Viswanathan Mohan
- Dr. Mohan's Diabetes Specialties Centre & Madras Diabetes Research Foundation, Chennai, India.
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8
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Predictors of Clinical Inertia and Type 2 Diabetes: Assessment of Primary Care Physicians and Their Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084436. [PMID: 35457303 PMCID: PMC9031531 DOI: 10.3390/ijerph19084436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/03/2022] [Accepted: 04/05/2022] [Indexed: 11/24/2022]
Abstract
With the growing prevalence and complex pathophysiology of type 2 diabetes, many patients fail to achieve treatment goals despite guidelines and possibilities for treatment individualization. One of the identified root causes of this failure is clinical inertia. We explored this phenomenon, its possible predictors, and groups of patients affected the most, together with offering potential paths for intervention. Our research was a cross-sectional study conducted during 2021 involving 52 physicians and 543 patients of primary healthcare institutions in Belgrade, Serbia. The research instruments were questionnaires based on similar studies, used to collect information related to the factors that contribute to developing clinical inertia originating in both physicians and patients. In 224 patients (41.3%), clinical inertia was identified in patients with poor overall health condition, long diabetes duration, and comorbidities. Studying the changes made to the treatment, most patients (53%) had their treatment adjustment more than a year ago, with 19.3% of patients changing over the previous six months. Moreover, we found significant inertia in the treatment of patients using modern insulin analogues. Referral to secondary healthcare institutions reduced the emergence of inertia. This assessment of primary care physicians and their patients pointed to the high presence of clinical inertia, with an overall health condition, comorbidities, diabetes duration, current treatment, last treatment change, glycosylated hemoglobin and fasting glucose measuring frequency, BMI, patient referral, diet adjustment, and physician education being significant predictors.
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9
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Seidu S, Cos X, Brunton S, Harris SB, Jansson SPO, Mata-Cases M, Neijens AMJ, Topsever P, Khunti K. 2022 update to the position statement by Primary Care Diabetes Europe: a disease state approach to the pharmacological management of type 2 diabetes in primary care. Prim Care Diabetes 2022; 16:223-244. [PMID: 35183458 DOI: 10.1016/j.pcd.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 12/12/2022]
Abstract
Type 2 diabetes and its associated comorbidities are growing more prevalent, and the complexity of optimising glycaemic control is increasing, especially on the frontlines of patient care. In many countries, most patients with type 2 diabetes are managed in a primary care setting. However, primary healthcare professionals face the challenge of the growing plethora of available treatment options for managing hyperglycaemia, leading to difficultly in making treatment decisions and contributing to treatment and therapeutic inertia. This position statement offers a simple and patient-centred clinical decision-making model with practical treatment recommendations that can be widely implemented by primary care clinicians worldwide through shared-decision conversations with their patients. It highlights the importance of managing cardiovascular disease and elevated cardiovascular risk in people with type 2 diabetes and aims to provide innovative risk stratification and treatment strategies that connect patients with the most effective care.
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Affiliation(s)
- S Seidu
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, United Kingdom.
| | - X Cos
- Sant Marti de Provenҫals Primary Care Centres, Institut Català de la Salut, University Research Institute in Primary Care (IDIAP Jordi Gol), Barcelona, Spain
| | - S Brunton
- Primary Care Metabolic Group, Winnsboro, SC, USA
| | - S B Harris
- Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - S P O Jansson
- School of Medical Sciences, University Health Care Research Centre, Örebro University, Örebro, Sweden
| | - M Mata-Cases
- La Mina Primary Care Centre, Institut Català de la Salut, University Research Institute in Primary Care (IDIAP Jordi Gol), CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - A M J Neijens
- Praktijk De Diabetist, Nurse-Led Case Management in Diabetes, QOL-consultancy, Deventer, The Netherlands
| | - P Topsever
- Department of Family Medicine, Acibadem Mehmet Ali Aydinlar University School of Medicine, Kerem Aydinlar Campus, 34752 Atasehir, Istanbul, Turkey
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, United Kingdom
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10
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Coke LA, Deedwania PC, Hinnen D, Magwire M, Miller NH. GLP-1 receptor agonists and cardiovascular outcomes in patients with type 2 diabetes: Clinical evidence and best practice. J Am Assoc Nurse Pract 2022; 34:418-440. [PMID: 35120085 DOI: 10.1097/jxx.0000000000000661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 09/02/2021] [Indexed: 12/13/2022]
Abstract
ABSTRACT Cardiovascular disease (CVD) is a major cause of death and disability among people with type 2 diabetes (T2D), presenting a significant impact on longevity, patient quality of life, and health care costs. In the United States, attainment of recommended glycemic targets is low and T2D-related cardiovascular complications remain a significant burden. Many glucose-lowering treatment options are available, but glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 (SGLT-2) inhibitors are recommended in recent guidelines as the preferred add-on therapy to metformin to improve glycemic control. This is particularly the case for patients with T2D and established atherosclerotic CVD, at high risk of atherosclerotic CVD, and/or with chronic kidney disease. Recommendations were based on GLP-1RA and SGLT-2 inhibitor cardiovascular outcomes trials (CVOTs), which consistently showed that these agents pose no additional cardiovascular risk compared with placebo. Three GLP-1RAs (liraglutide, dulaglutide, and subcutaneous semaglutide) demonstrated significantly lower major adverse cardiovascular events versus placebo and are now approved for this indication. However, to realize improvement in outcomes in the clinical setting, organized, systematic, and coordinated approaches to patient management are also needed. For example, nurse-led diabetes self-management education and support programs have been shown to be effective. This article explores T2D management with emphasis on cardiovascular risk and CVOTs performed to date and reviews the clinical experience with GLP-1RAs for managing hyperglycemia and their impact on cardiovascular risk. In addition, practical guidance is given for key health care providers involved in the care of patients with T2D with cardiovascular risk outside of diabetes clinics/endocrinology centers.
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Affiliation(s)
- Lola A Coke
- Kirkhof College of Nursing, Grand Valley State University, Allendale, Michigan
| | | | - Debbie Hinnen
- University of Colorado Health, Diabetes Clinic, Colorado Springs, Colorado
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11
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Azri N, Norsa'adah B, Hassan NB, Naing NN. Insulin Adherence and Associated Factors in Patients with Type 2 Diabetes Mellitus Treated in Klang Primary Health Care Centres. Malays J Med Sci 2022; 28:76-87. [PMID: 35002492 PMCID: PMC8715880 DOI: 10.21315/mjms2021.28.6.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/10/2021] [Indexed: 11/05/2022] Open
Abstract
Background Insulin therapy is necessary for patients with type 2 diabetes mellitus (T2DM) to reach the targeted glycaemic level and prevent complications. This study aimed to determine the proportion of adherence to insulin therapy and the associated factors in patients with T2DM. Methods A cross-sectional study was conducted among 249 patients with T2DM who had been on insulin therapy for at least 2 months in primary care centres of the Ministry of Health in Klang, Malaysia. A validated insulin adherence questionnaire for diabetes mellitus (DM) was used to assess insulin adherence. Data on the sociodemographic characteristics, disease-related factors, treatment-related factors and clinical parameters were extracted from medical records and interviews with patients. Results The adherence to insulin therapy was 8.43%. The factors associated with insulin adherence were self-monitoring of blood glucose (SMBG) (adjusted odds ratio [AOR]: 5.39; 95% confidence interval (CI): 1.20, 24.13; P = 0.028), exercise (AOR: 3.38; 95% CI: 1.37, 10.03; P = 0.029) and the number of daily insulin injections (AOR: 1.63; 95% CI: 1.09, 2.44; P = 0.017). Conclusion The adherence to insulin therapy in primary health care centres in Malaysia was very poor. Patients who practiced SMBG, exercised and frequent daily insulin injections were significantly more adherent to insulin therapy.
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Affiliation(s)
- Nasruddin Azri
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.,National Pharmaceutical Regulatory Division, Ministry of Health Malaysia, Petaling Jaya, Selangor, Malaysia
| | - Bachok Norsa'adah
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Norul Badriah Hassan
- Department of Pharmacology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Nyi Nyi Naing
- Faculty of Medicine, Universiti Sultan Zainal Abidin, Medical Campus, Kuala Terengganu, Terengganu, Malaysia
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12
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Seidu S, Cos X, Brunton S, Harris SB, Jansson SPO, Mata-Cases M, Neijens AMJ, Topsever P, Khunti K. A disease state approach to the pharmacological management of Type 2 diabetes in primary care: A position statement by Primary Care Diabetes Europe. Prim Care Diabetes 2021; 15:31-51. [PMID: 32532635 DOI: 10.1016/j.pcd.2020.05.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/30/2020] [Accepted: 05/11/2020] [Indexed: 12/31/2022]
Abstract
Type 2 diabetes and its associated comorbidities are growing more prevalent, and the complexity of optimising glycaemic control is increasing, especially on the frontlines of patient care. In many countries, most patients with type 2 diabetes are managed in a primary care setting. However, primary healthcare professionals face the challenge of the growing plethora of available treatment options for managing hyperglycaemia, leading to difficultly in making treatment decisions and contributing to therapeutic inertia. This position statement offers a simple and patient-centred clinical decision-making model with practical treatment recommendations that can be widely implemented by primary care clinicians worldwide through shared-decision conversations with their patients. It highlights the importance of managing cardiovascular disease and elevated cardiovascular risk in people with type 2 diabetes and aims to provide innovative risk stratification and treatment strategies that connect patients with the most effective care.
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Affiliation(s)
- S Seidu
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, United Kingdom.
| | - X Cos
- Sant Marti de Provençals Primary Care Centres, Institut Català de la Salut, University Research Institute in Primary Care (IDIAP Jordi Gol), Barcelona, Spain
| | - S Brunton
- Primary Care Metabolic Group, Los Angeles, CA, USA
| | - S B Harris
- Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - S P O Jansson
- School of Medical Sciences, University Health Care Research Centre, Örebro University, Örebro, Sweden
| | - M Mata-Cases
- La Mina Primary Care Centre, Institut Català de la Salut, University Research Institute in Primary Care (IDIAP Jordi Gol), CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - A M J Neijens
- Praktijk De Diabetist, Nurse-Led Case Management in Diabetes, QOL-consultancy, Deventer, The Netherlands
| | - P Topsever
- Department of Family Medicine, Acibadem Mehmet Ali Aydinlar University School of Medicine, Kerem Aydinlar Campus, Atasehir 34752, Istanbul, Turkey
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, United Kingdom
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Seidu S, Mellbin L, Kaiser M, Khunti K. Will oral semaglutide be a game-changer in the management of type 2 diabetes in primary care? Prim Care Diabetes 2021; 15:59-68. [PMID: 32826189 DOI: 10.1016/j.pcd.2020.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 01/21/2023]
Abstract
GLP-1 receptor agonists (GLP-1RAs) are recommended for patients with type 2 diabetes (T2D), particularly those at high cardiovascular risk. Oral semaglutide is the first oral GLP-1RA. In clinical trials, oral semaglutide 14 mg reduced mean HbA1c by approximately 1.1-1.5% and reduced body weight by up to 5 kg. These changes were significantly greater compared with empagliflozin, sitagliptin and liraglutide (p < 0.05 for estimated treatment differences at 52 weeks in patients on treatment without rescue medication use). The most common side effects were gastrointestinal, mainly mild-to-moderate and transient nausea. Oral semaglutide may change the paradigm of T2D treatment in primary care.
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Affiliation(s)
- Samuel Seidu
- Leicester Diabetes Centre, University of Leicester, Leicester, UK.
| | - Linda Mellbin
- Department of Medicine, Karolinska Instiutet Solna, Stockholm, Sweden
| | - Marcel Kaiser
- Practice for Internal Medicine and Diabetology, Frankfurt, Germany
| | - Kamlesh Khunti
- Leicester Diabetes Centre, University of Leicester, Leicester, UK
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Mehta R, Pichel D, Chen-Ku CH, Raffaele P, Méndez Durán A, Padilla F, Arango Alvarez JJ, Esteban Costa Gil J, Esteban Gómez Mesa J, Giorgi M, Lahsen R, Sposito AC. Latin American Expert Consensus for Comprehensive Management of Type 2 Diabetes from a Metabolic-Cardio-Renal Perspective for the Primary Care Physician. Diabetes Ther 2021; 12:1-20. [PMID: 33325006 PMCID: PMC7843679 DOI: 10.1007/s13300-020-00961-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/27/2020] [Indexed: 11/29/2022] Open
Abstract
Growing scientific evidence from studies on type 2 diabetes (T2D) has recently led to a better understanding of the associated metabolic-cardio-renal risks. The large amount of available information makes it essential to have a practical guide that summarizes the recommendations for the initial management of patients with T2D, integrating different aspects of endocrinology, cardiology, and nephrology. The expert consensus presented here does not attempt to summarize all the evidence in this regard but rather attempts to define practical summary recommendations for the primary care physician to improve the clinical prognosis and management of patients with T2D, while ensuring economic sustainability of health systems, beyond glycemic control.
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Affiliation(s)
- Roopa Mehta
- Metabolic Diseases Research Unit (UIEM), National Institute of Medical Sciences and Nutrition Salvador Zubirán (INCMNSZ), Vasco De Quiroga 15, Belisario Dominguez, Tlalpan, 14200, Mexico.
| | - Daniel Pichel
- Department of Medicine/Cardiology, Hospital Paitilla, Calle 53, Ave Balboa, Urb. Marbella, Panama City, 00134, Panama
| | - Chih Hao Chen-Ku
- Clínica Los Yoses, San Pedro Montes de Oca, San José, Costa Rica
| | - Pablo Raffaele
- Department of Nephrology, Fundación Favaloro University Hospital, Buenos Aires, 1093, Argentina
| | - Antonio Méndez Durán
- Coordinacion de Planeacion de Infraestructura Medica, Instituto Mexicano del Seguro Social, C.P. 6700, Mexico City, Mexico
| | - Francisco Padilla
- Cardiología Clínica e Intervencionista, 44670, Guadalajara, Jalisco, Mexico
| | | | | | | | - Mariano Giorgi
- Cardiology Section, Cardiovascular Prevention Unit, CEMIC, Buenos Aires, Argentina
| | - Rodolfo Lahsen
- Centro de Diabetes Adultos, Clinica Las Condes, 7591047, Santiago, Chile
| | - Andrei C Sposito
- Department of Cardiology, State University of Campinas (Unicamp), Campinas, Brazil
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15
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Marjanović M, Bralić Lang V, Đido V. Total and partial clinical inertia of general physicians with type 2 diabetes mellitus patients in Central Bosnia Canton. Prim Care Diabetes 2020; 14:622-627. [PMID: 32173293 DOI: 10.1016/j.pcd.2020.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/07/2020] [Accepted: 02/25/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The goal of this study was to determine the frequency and predictive factors of partial (PCI) and total clinical inertia (TCI) of general physicians (GPs) in Central Bosnia Canton in the care of type 2 diabetes mellitus patients. MATERIAL AND METHODS A longitudinal study was conducted with a prospective data collection. Total of 541 subjects of over 40 years of age with type 2 diabetes mellitus of both genders were included in the study. Total of 532 subjects completed the study. Questionnaires for physicians and patients and the Perceived Stress Scale were used, as well as anthropometric measurements and measurements of the glucose level in plasma, HbA1c, triglycerides, AST, ALT, creatinine and eGFR, which were examined on the day of study entry, after 6 months and after one year. RESULTS TCI was 5.8% and PCI was 25.6%. Patients with poorly regulated glycaemia and elevated triglyceride levels had the highest probability of PCI and TCI. Patients with an unaccomplished targeted level of blood pressure were more likely to experience PCI. Patients treated by both an internist and a general physician were more likely to have TCI as compared to patients treated only by an internist. CONCLUSIONS Patients with poor glycemic control experience PCI and TCI more often. In our study, referring to a diabetologist was observed as a non-inert procedure, which resulted in lower PCI and TCI, compared to studies where clinical inertia was defined only as non-intensification of medication therapy.
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Affiliation(s)
- Marijan Marjanović
- Faculty of Health Care, University "Vitez "in Vitez, Bosnia and Herzegovina.
| | - Valerija Bralić Lang
- Private Family Physician Office affiliated to University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Vedran Đido
- Faculty of Health Studies, University of Sarajevo, Bosnia and Herzegovina
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16
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Brunton SA. Introducing a novel therapy for type 2 diabetes to primary care. Postgrad Med 2020; 132:1-2. [DOI: 10.1080/00325481.2020.1798686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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17
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Brunton SA, Mosenzon O, Wright EE. Integrating oral semaglutide into clinical practice in primary care: for whom, when, and how? Postgrad Med 2020; 132:48-60. [PMID: 32815453 DOI: 10.1080/00325481.2020.1798162] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Oral semaglutide is the first US Food and Drug Administration-approved oral glucagon-like peptide-1 receptor agonist (GLP-1RA) for the treatment of type 2 diabetes (T2D). Prior articles within this supplement reviewed the PIONEER trial program, which demonstrated that oral semaglutide reduced glycated hemoglobin and body weight when given to patients with uncontrolled T2D on various background therapies, and had a safety profile consistent with subcutaneous GLP-1RAs. This article provides guidance on integrating oral semaglutide into clinical practice in primary care. Patient populations with T2D who may gain benefit from oral semaglutide include those with inadequate glycemic control taking one or more oral glucose-lowering medication (e.g. after metformin), patients for whom weight loss would be beneficial, patients at risk of hypoglycemia, those who would historically have been considered for treatment with a subcutaneous GLP-1RA, and those receiving basal insulin who require treatment intensification. Like other GLP-1RAs, oral semaglutide is contraindicated in those with personal/family history of medullary thyroid carcinoma, and in those with multiple endocrine neoplasia syndrome type 2, as noted in a boxed warning in the prescribing information. Oral semaglutide has not been studied in those with a history of pancreatitis, is not recommended in patients with suspected/confirmed pancreatitis, and is not indicated in type 1 diabetes. When initiating oral semaglutide, gradual dose escalation is recommended to minimize the risk of gastrointestinal adverse events. As food and excess liquid reduce oral semaglutide absorption, patients should swallow the tablet with up to 4 fl oz/120 mL of water on an empty stomach upon waking, and should wait at least 30 minutes before eating, drinking, or taking other oral medications. Those managing patients should be aware of the potential impact of these dosing conditions on concomitant medications. When counseling patients, it is important to discuss these administration instructions, realistic therapeutic expectations, and strategies for mitigation of gastrointestinal events. Oral semaglutide provides a new option for add-on to initial T2D therapy (or later in the treatment paradigm), with the potential to enable more patients to benefit from the improvements in glycemic control, reductions in body weight, and low risk of hypoglycemia afforded by GLP-1RAs.
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Affiliation(s)
| | - Ofri Mosenzon
- Faculty of Medicine, Hebrew University of Jerusalem , Jerusalem, Israel.,Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center , Jerusalem, Israel
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Lavernia F, Blonde L. Clinical review of the efficacy and safety of oral semaglutide in patients with type 2 diabetes compared with other oral antihyperglycemic agents and placebo. Postgrad Med 2020; 132:15-25. [DOI: 10.1080/00325481.2020.1798638] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
| | - Lawrence Blonde
- Department of Endocrinology, Ochsner Medical Center, New Orleans, LA, USA
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19
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Brunton SA, Wysham CH. GLP-1 receptor agonists in the treatment of type 2 diabetes: role and clinical experience to date. Postgrad Med 2020; 132:3-14. [DOI: 10.1080/00325481.2020.1798099] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Cos X, Seidu S, Brunton S, Harris SB, Jansson SPO, Mata-Cases M, Neijens AMJ, Topsever P, Khunti K. Impact on guidelines: The general practitioner point of view. Diabetes Res Clin Pract 2020; 166:108091. [PMID: 32105769 DOI: 10.1016/j.diabres.2020.108091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 01/15/2023]
Abstract
Primary care physicians are uniquely placed to offer holistic, patient-centred care to patients with T2DM. While the recent FDA-mandated cardiovascular outcome trials offer a wealth of data to inform treatment discussions, they have also contributed to increasing complexity in treatment decisions, and in the guidelines that seek to assist in making these decisions. To assist physicians in avoiding treatment inertia, Primary Care Diabetes Europe has formulated a position statement that summarises our current understanding of the available T2DM treatment options in various patient populations. New data from recent outcomes trials is contextualised and summarised for the primary care physician. This consensus paper also proposes a unique and simple tool to stratify patients into 'very high' and 'high' cardiovascular risk categories and outlines treatment recommendations for patients with atherosclerotic cardiovascular disease, heart failure and chronic kidney disease. Special consideration is given to elderly/frail patients and those with obesity. A visual patient assessment tool is provided, and a comprehensive set of prescribing tips is presented for all available classes of glucose-lowering therapies. This position statement will complement the already available, often specialist-focused, T2DM treatment guidelines and provide greater direction in how the wealth of outcome trial data can be applied to everyday practice.
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Affiliation(s)
- X Cos
- Sant Marti de Provenҫals Primary Care Centres, Institut Català de la Salut, University Research Institute in Primary Care (IDIAP Jordi Gol), Barcelona, Spain.
| | - S Seidu
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, United Kingdom
| | - S Brunton
- Primary Care Metabolic Group, Los Angeles, CA, United States
| | - S B Harris
- Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - S P O Jansson
- School of Medical Sciences, University Health Care Research Centre, Örebro University, Örebro, Sweden
| | - M Mata-Cases
- La Mina Primary Care Centre, Institut Català de la Salut, University Research Institute in Primary Care (IDIAP Jordi Gol), CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - A M J Neijens
- Praktijk De Diabetist, Nurse-Led Case Management in Diabetes, QOL-consultancy, Deventer, the Netherlands
| | - P Topsever
- Department of Family Medicine, Acibadem Mehmet Ali Aydinlar University School of Medicine, Kerem Aydinlar Campus, 34752 Atasehir, Istanbul, Turkey
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, United Kingdom
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MacIsaac RJ. Dulaglutide and Insulin: How Can the AWARD Studies Help Guide Clinical Practice? Diabetes Ther 2020; 11:1627-1638. [PMID: 32564337 PMCID: PMC7376989 DOI: 10.1007/s13300-020-00863-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Indexed: 01/20/2023] Open
Abstract
The glucagon-like peptide 1 receptor agonist (GLP-1RA) dulaglutide has many characteristics to recommend it both as a second-line agent and as an alternative to or in combination with insulin. This commentary summarises recent updates to diabetes management guidelines regarding the use of GLP-1RAs such as dulaglutide, both as a second-line agent and as a first-line injectable agent in type 2 diabetes (T2D). It also examines how the Assessment of Weekly AdministRation of LY2189265 [dulaglutide] in Diabetes (AWARD) studies with dulaglutide and insulin may help to guide clinical practice for the use of dulaglutide as an alternative to basal insulin or in combination with insulin.Individualising glucose-lowering therapy is important in patients with T2D, especially given patients' heterogeneity in terms of age, lifestyle, disease duration, level of hyperglycaemia and comorbidities. Choice of therapy should be guided by clinical considerations (e.g. high risk or existing cardiovascular [CV] disease, heart failure, chronic kidney disease, risk of hypoglycaemia), side effect profile, contraindications, patient preferences and cost. The recently updated American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) guidelines now recommend adding a GLP-1RA with proven CV benefit to metformin in patients with T2D and indicators of high risk or established atherosclerotic CV disease. The AWARD studies demonstrate that dulaglutide provides effective glucose lowering together with sustained weight loss and a low incidence of hypoglycaemia when used as the first injectable option and when used in combination with titrated basal insulin or prandial insulin, providing a valid treatment option across a wide range of patients with T2D, including those with chronic kidney disease.
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Morales J, Shubrook JH, Skolnik N. Practical guidance for use of oral semaglutide in primary care: a narrative review. Postgrad Med 2020; 132:687-696. [PMID: 32643514 DOI: 10.1080/00325481.2020.1788340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
As the cornerstone of type 2 diabetes (T2D) management within the community, primary care providers are now faced with the challenge of not only managing diabetes itself, but also preventing hypoglycemia and weight gain associated with intensive disease management, and reducing cardiovascular risk. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are well established as efficacious treatments for T2D, and the safety/tolerability profile of this drug class is well defined. However, despite their beneficial effects, GLP-1RAs are under-utilized, highlighting the need for novel approaches to increase their use in primary care. Oral semaglutide is the first oral GLP-1RA approved for the treatment of T2D, offering glucose lowering and body weight loss, a low risk of hypoglycemia, and no increase in cardiovascular risk. Oral semaglutide represents an additional treatment option for patients not achieving their glycemic goal despite treatment with metformin, either alone or with other hypoglycemic agents. Oral semaglutide has the potential to increase usage of GLP-1RAs in the primary care setting by addressing clinician and patient concerns about injections, and may facilitate earlier initiation of GLP-1RA therapy in T2D. Due to the formulation of oral semaglutide, clinicians need to be aware of specific considerations in order to ensure optimal use. Such considerations include dosing conditions and use of concomitant medications. This article provides practical guidance on the use of oral semaglutide in the primary care setting, based on evidence from clinical studies, including the phase 3a PIONEER program, and the authors' clinical experience.
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Affiliation(s)
- Javier Morales
- Department of Medicine, Donald and Barbara Zucker School of Medicine, Hofstra/Northwell University , New York, NY, USA
| | - Jay H Shubrook
- Primary Care Department, College of Osteopathic Medicine, Touro University California , Vallejo, CA, USA
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Zhu NA, Harris SB. Therapeutic Inertia in People With Type 2 Diabetes in Primary Care: A Challenge That Just Won't Go Away. Diabetes Spectr 2020; 33:44-49. [PMID: 32116453 PMCID: PMC7026753 DOI: 10.2337/ds19-0016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Therapeutic inertia is a prevalent problem in people with type 2 diabetes in primary care and affects clinical outcomes. It arises from a complex interplay of patient-, clinician-, and health system-related factors. Ultimately, clinical practice guidelines have not made an impact on improving glycemic targets over the past decade. A more proactive approach, including focusing on optimal combination agents for early glycemic durability, may reduce therapeutic inertia and improve clinical outcomes.
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Affiliation(s)
- Nemin Adam Zhu
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Stewart B Harris
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Ali SN, Dang-Tan T, Valentine WJ, Hansen BB. Evaluation of the Clinical and Economic Burden of Poor Glycemic Control Associated with Therapeutic Inertia in Patients with Type 2 Diabetes in the United States. Adv Ther 2020; 37:869-882. [PMID: 31925649 PMCID: PMC7004420 DOI: 10.1007/s12325-019-01199-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Indexed: 01/10/2023]
Abstract
Introduction Therapeutic inertia refers to the failure to initiate or intensify treatment in a timely manner and is widespread in type 2 diabetes (T2D) despite the well-established importance of maintaining good glycemic control. The aim of this analysis was to quantify the clinical and economic burden associated with poor glycemic control due to therapeutic inertia in patients with T2D in the USA. Methods The IQVIA CORE Diabetes Model was used to simulate life expectancy, costs associated with diabetes-related complications, and lost workplace productivity in US patients. Baseline glycated hemoglobin (HbA1c) levels were 7.0% (53 mmol/mol), 9.0% (75 mmol/mol), 11.0% (97 mmol/mol) 13.0% (119 mmol/mol), or 15.0% (140 mmol/mol), with targets of 6.5% (48 mmol/mol), 7.0% (53 mmol/mol), 8.0% (64 mmol/mol), or 9.0% (75 mmol/mol) depending on baseline HbA1c, across several delayed intensification scenarios (values above target were defined as poor control). The burden associated with intensification delays of 1, 2, 3, 5, and 7 years was estimated over time horizons of 1–30 years. Future costs and clinical benefits were discounted at 3% annually. Results In a population of 13.4 million patients with T2D and baseline HbA1c of 9.0% (75 mmol/mol), delaying intensification of therapy by 1 year was associated with a loss of approximately 13,390 life-years and increased total costs of US dollars (USD) 7.3 billion (1-year time horizon). Longer delays in intensification were associated with a greater economic burden. Delaying intensification by 7 years was projected to cost approximately 3 million life-years and USD 223 billion over a 30-year time horizon. Conclusion Therapeutic inertia is common in routine clinical practice and makes a substantial contribution to the burden associated with type 2 diabetes in the USA. Initiatives and interventions aimed at preventing therapeutic inertia are needed to improve clinical outcomes and avoid excess costs. Electronic Supplementary Material The online version of this article (10.1007/s12325-019-01199-8) contains supplementary material, which is available to authorized users.
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