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More than one in 10 Americans today are living with diabetes (1). To prevent acute and chronic complications of diabetes, including death, patients with diabetes often require multiple medications and medication management supplies to enable effective, safe, and evidence-based control of hyperglycemia. These include insulin and noninsulin medications, technologies for glucose monitoring, and equipment for administration of injectable medications (both insulin and noninsulin injectables). Management of hyperglycemia is increasingly expensive for patients and the health care system, having increased 240% from the period 2005–2007 to 2015–2017, from $16.9 billion to $57.6 billion annually (2). Although the majority of these costs are borne by public and private payers (2), patients and caregivers increasingly report cost-related distress, nonadherence, and adverse health outcomes stemming from the costs of managing their disease (3–5). It is therefore vital for primary care clinicians, who care for the majority of people with diabetes (6), to be cognizant of the financial impact of diabetes management on their patients and to reduce it as much as possible. Insulin is just one component of comprehensive diabetes care, but it is the most critical for people who require it to live (i.e., people with type 1 diabetes and some with longstanding type 2 diabetes). In 2018, 18.6% of U.S. adults with diabetes were treated with insulin alone, and an additional 15.1% were treated with insulin and noninsulin glucose-lowering medications (7). The average list price of insulin in the United States rose by 15–17% each year between 2012 and 2016 (8). The greatest increase in insulin-related costs stems from greater use, and higher per-unit costs, of analog insulins (2). New insulin products such as ultra-long-acting or ultra-rapid-acting insulins offer important clinical and safety advantages to certain patients; however, these formulations are among the most expensive to obtain. Between the …

The proportion of patients with type 2 diabetes achieving recommended treatment goals remains suboptimal despite advances in diabetes care (1). Only 30% of patients with type 2 diabetes who use basal insulin achieve an A1C

More than 29 million Americans have diabetes. The Centers for Disease Control and Prevention predict that the prevalence of diabetes will increase from 9% to >30% in the next 35 years (1). More than 21 million medical office visits for diabetes are scheduled each year (2). A total of one in five dollars spent on health care in the United States (and one in three dollars spent through Medicare) are spent on people with diabetes (3). With this in mind, proper and accurate coding for diabetes is a necessity. The International Classification of Diseases, 10th Revision—Clinical Modification (ICD-10) is designed to accurately classify and categorize all illnesses and diseases seen in the U.S. health care setting. (4) The coding system was updated in October 2015 to its 10th revision because it was thought that the 9th revision (ICD-9) no longer accommodated all of the new codes submitted to the system, and the ICD-9 codes were not descriptive enough to accurately reflect the state of patients’ diseases. For example, the ICD-9 system had 13,000 three- to five-digit codes. This system was not able to take in new codes and did not include a way to designate laterality. The ICD-10 system has 68,000 codes that are three to seven digits each and has the capacity to expand. In general, ICD-10 codes can be up to seven characters long and are designed as follows: XXX.XXX.X (category.anatomic site/severity.extension). The first set of digits before the first decimal point describes the general disease or category. The next three digits after the first decimal point describe the etiology, anatomical site, severity, or clinical detail. Finally, some conditions will have a second decimal point, followed by a final digit that may define an initial or subsequent encounter, the laterality of a condition, or the number of weeks’ …

The chronic consequences of hyperglycemia in diabetes are well documented. There is evidence that aggressive glycemic control is beneficial in certain populations. Therapy optimization occurs when ineffective medications are adjusted or new medications are added to achieve target glucose levels with minimal adverse events, specifically, hypoglycemia. Therapy selection and glycemic goals vary depending on diabetes type, duration, and comorbidities. Insulin is paramount in reaching A1C goals for many patients with type 2 diabetes. Relying on sliding-scale insulin, a method in which the patient reactively takes a predetermined number of units of bolus insulin per blood glucose level in response to hyperglycemic self-monitored blood glucose readings, as an effective means of controlling blood glucose is not supported by evidence-based medicine. Often, basal insulin alone is not sufficient because of declining β-cell function. Establishing a basal-bolus insulin regimen can achieve glycemic control even with daily fluctuations in carbohydrate intake. There are numerous anecdotal methods for initiating such therapy, but no consensus has developed. Health care providers must review recent literature on methods of optimizing bolus insulin to assist their patients in reaching glycemic targets and reducing the risk of hypoglycemia. Five simple steps to optimize bolus insulin therapy, as discussed below and summarized in Table 1, may provide people with diabetes and their health care teams with a guide for success. View this table: TABLE 1. Five Steps of Bolus Insulin Optimization In the landmark U.K. Prospective Diabetes Study (UKPDS), people with newly diagnosed type 2 diabetes in the intensive therapy arm were treated with sulfonylurea, metformin, or insulin and attained an A1C of 7% compared to 7.9% with standard therapy. Obtaining a lower A1C reduced microvascular complications by 25% over a median period of 11 years (1). Additionally, a long-term cohort follow-up demonstrated reduced cardiovascular events in the intensive therapy group (2). Results from …

Diabetes is a clinically and genetically heterogeneous group of metabolic disorders manifested by abnormally high levels of glucose in the blood. This hyperglycemia results from either a deficiency of insulin secretion caused by pancreatic β-cell dysfunction or resistance to the action of insulin in liver and muscles, or both (1). Periodontal disease is one of the most common chronic inflammatory diseases and is characterized by gradual destruction of connective tissue surrounding the teeth, eventually leading to tooth loss. Periodontitis occurs primarily in adults, and its incidence increases with age (2). Type 2 diabetes and chronic periodontitis are both common in older age-groups. The relationship between both these diseases has been extensively studied. The prevalence of type 2 diabetes is increasing rapidly. According to World Health Organization estimates, the number of adults with diabetes worldwide will increase from 171 million in 2000 to 366 million by 2030 (3). India has been called “the diabetes capital of the world” because of its high diabetes rates; ∼41 million Indians have diabetes, accounting for one-fifth of all diabetes cases worldwide (4). The prevalence of periodontal disease in India is also alarming, with incidences of 296 million in 2000, 319 million in 2005, 341 million in 2010, and an estimated 363 million in 2015 (5). Both diabetes and periodontitis are more severe and progress more rapidly when these conditions occur simultaneously. Many studies have reported correlations between periodontal health and various diabetes-related factors such as A1C and duration of diabetes. In the U.S. Third National Health and Nutrition Examination Survey (2), adults with an A1C >9% had a significantly higher rate of severe periodontitis than those without diabetes. Periodontitis is considered a “sixth complication of diabetes” (6). A study by Williams and Mahan (7) involving 2,273 people with diabetes found a 60% prevalence of periodontal …

Gestational diabetes mellitus (GDM) is increasingly acknowledged as a public health problem in developing countries, resulting in both immediate and long-term health effects for mothers and their newborns (1,2). Maternal and fetal complications of GDM range from adaptation problems of the newborn (e.g., asphyxia, respiratory distress, and hypoglycemia) to major obstetric complications such as shoulder dystocia, prolonged or obstructed labor, preeclampsia, or postpartum hemorrhage (2,3). In low-resource settings, where shortages of health care providers as well as lack of skills to manage such complications prevail (4), untreated GDM and its associated conditions can endanger the life of mothers and their newborns. Screening and management of GDM often is not part of routine care in the majority of low-resource settings. Because of this, data on the prevalence of GDM and the incidence of related obstetric and newborn complications are scarce. Most of the research on GDM to date has been conducted in high-income countries where GDM screening is already an established part of antenatal care, and specific procedures are clearly defined in national guidelines. Such guidelines are often absent in low-resource settings where, until now, GDM has played a minor role in the shadow of more obvious determinants of maternal and perinatal morbidity and mortality. Where guidelines are available, they often are not standardized. In various GDM projects in low-resource settings, different guidelines have been used for screening and subsequently had to be adapted to fit into the local context (5). Based on the results of the Hyperglycemia and Adverse Pregnancy Outcome study (6), the World Health Organization (WHO) modified previously recommended criteria for the diagnosis of GDM (7) to serve as a basis for universal guidelines. This review will assess which criteria are applied by countries with routine screening for GDM in place and how congruent …