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Increased Risks of Infections in Diabetes According to Carey et al. ( Diabetes Care , doi.org/cjxp), individuals with diabetes, and especially those with type 1 diabetes, likely carry a substantially increased risk for infections in comparison to the general public. The authors say that the risk of infection attributable to diabetes likely represents a considerable burden for both patients and health care systems. They call for research to explore education and management strategies to reduce poor outcomes and point out that diabetes-related infection rates are only likely to go up as diabetes rates increase and the population ages. Notable for its large size, the study tracked infection rates and infection-related hospitalizations and mortality in just over 100,000 individuals with diabetes and just over 200,000 matched control individuals without diabetes in England between 2008 and 2015. The researchers then compared rates between individuals with and without diabetes and also between individuals with type 1 versus type 2 diabetes versus control individuals. Notably, they also adjusted the findings for a range of confounding factors such as smoking, BMI, and age—something that previous studies have not consistently accounted for. Compared to those without diabetes, patients with diabetes had higher rates of infections and hospitalization due to infection. Rate disparities were consistently greater in those with type 1 diabetes than in those with type 2 diabetes compared to control subjects. Bone and joint infections, sepsis, and cellulitis showed the largest disparities between individuals with type 2 diabetes and control subjects, whereas, for those with type 1 diabetes, bone and joint infections, sepsis, and endocarditis showed the greatest disparities versus control subjects. Adjusting for factors such as smoking, age, sex, BMI, and deprivation reportedly did not substantially change the outcomes. “People with diabetes, particularly type 1 diabetes, are at increased risk of serious infection, representing an important population burden,” the authors concluded. …

A patient who is overweight with type 2 diabetes and takes multiple oral antihyperglycemic agents has been informed that the current treatment plan is not providing adequate glycemic control and that adding insulin therapy is recommended. However, the patient is concerned about insulin causing weight gain or leading to hypoglycemia and is looking for a treatment that will avoid or reduce these issues. Taking all of these considerations into account, the health care provider recommends that the patient start insulin and a glucagon-like peptide 1 (GLP-1) receptor agonist given as fixed-ratio combination (FRC) therapy administered with a prefilled pen device that allows for both basal insulin and a GLP-1 receptor agonist to be delivered in a single daily injection. Basal insulin and GLP-1 receptor agonists have different but complementary modes of action. Basal insulin predominantly regulates blood glucose between widely spaced meals and overnight (1) through the movement of glucose from blood into certain cells of the body (including skeletal muscle) and the suppression of hepatic glucose production (2); GLP-1 receptor agonists affect glucose control through glucose-dependent insulin secretion, slowing gastric emptying, inducing satiety, and suppressing excess postprandial glucagon release (3). FRC therapies that contain both a basal insulin and a GLP-1 receptor agonist have been shown to improve glycemic control with a risk of hypoglycemia that is similar to that associated with the use of basal insulin alone (4,5). In addition, FRC therapies have been shown to mitigate insulin-induced weight gain and to reduce the likelihood of the gastrointestinal (GI) adverse events that are associated with the use of GLP-1 receptor agonists. This effect is the result of slower up-titration of the GLP-1 receptor agonist component of an FRC compared with the titration schedule recommended when a GLP-1 receptor agonist is used alone (6–8). …

IN BRIEF “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc. (ACP), and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an initiative to improve retinopathy screening rates at the pediatric diabetes clinic of a large academic teaching hospital in Canada.

Diabetes is the seventh leading cause of death in the United States (1). Furthermore, diabetes prevalence, diabetes-related hospital admissions and re-admissions, and risk factors are disproportionately higher in racial and ethnic minorities, indicating the need to focus efforts on reducing these disparities while also improving outcomes for all (2–4). Diabetes care and management vary significantly by race/ethnicity and insurance status and are less likely to be optimal in certain minority groups and the uninsured (5,6). Because most resources and barriers to diabetes management are present within the broader context in which patients carry out their daily lives, the ability to support self-management from within health care delivery systems is limited. Conversely, the capacity for health care systems to partner with community-based programs to manage diabetes is almost limitless. For example, an expert synthesis of strategies to reduce diabetes disparities concluded that community-based efforts and health information technology are the “new frontier” for eliminating diabetes disparities (7). Health care is shifting from volume to value, from treatment to prevention, from patients to populations, and from discrete clinical encounters to whole-person care. In this new model, collaborative partnerships to promote health and well-being within communities are increasingly relevant. Evidence suggests that chronic disease self-management support provided in the community setting improves outcomes in patients with complex chronic conditions (8–10). Previous studies on peer-led support have shown improvements in participant self-care (i.e., nutrition, physical activity, and glucose monitoring), psychosocial outcomes (i.e., quality of life, self-efficacy, and depression), and treatment and appointment engagement (8,11). Positive social support has been shown to influence diabetes self-management practices such as eating a healthy diet, exercising, and monitoring blood glucose (8). Peer-led diabetes social support in a community setting is gaining traction among people with diabetes (12). Pairing …

Mental health comorbidities are increasingly being recognized in children and adolescents with type 1 or type 2 diabetes (1–3). Several studies have found increased rates of depressive symptoms (1), clinical depression (2), and anxiety disorders (3) in pediatric patients with type 1 diabetes when compared to healthy peers. Some studies have also identified an association between poor glycemic control and more severe depression scores (4,5). Additional mental health and behavioral issues have been described in this population, including disordered eating behaviors and attention-deficit hyperactivity disorder (ADHD) (3,6). A wide variety of screening tools have been used in the diabetes population in attempts to identify patients with mental health comorbidities. These include the Patient Health Questionnaire-9 (4,7), the Children’s Depression Inventory (1), Beck’s Depression Inventory (5), and the Screen for Childhood Anxiety Related Emotional Disorders (5). However, a combination of several different screening tools is required to adequately identify the wide range of mental health and behavioral comorbidities that exist within the pediatric diabetes population. The Strengths and Difficulties Questionnaire (SDQ) has emerged as a more comprehensive tool for assessing mental health comorbidities in children with a variety of chronic diseases, including asthma, chronic kidney disease, primary antibody deficiency, and neurological disorders (8–10). The advantage of the SDQ is that it is a relatively short instrument that screens for a wider range of psychosocial and behavioral issues than other commonly used assessment tools, identifying symptoms of anxiety, depression, hyperactivity-inattention, conduct disorder, and peer relationship problems (11). The aim of this study was to examine the results of routine mental health and behavioral screening in children and adolescents with type 1 diabetes using the SDQ Self-Reported Version when compared to screening results from children without chronic disease. Clinically, the purpose …

Individuals with type 1 diabetes represent only ∼6% of all patients with diabetes in the United States and require characteristically complex treatment modalities (1). Autoimmune pancreatic β-cell destruction ultimately results in an absolute insulin deficiency, the presence of autoimmune markers, and little to no residual C-peptide (2,3). Additionally, pancreatic α-cell dysfunction is present, resulting in excess glucagon in both the fasting and postprandial states, and the gastric emptying rate is altered in many patients. Exogenous insulin serves as the foundation of therapy for type 1 diabetes and is commonly delivered via a multiple-dose regimen or an insulin pump. The two most common adverse effects associated with insulin use are hypoglycemia and weight gain. Recent data suggest that 68% of people with type 1 diabetes are overweight or obese and that severe hypoglycemia occurs at a rate of 9–20% (4). The latter complication is considered a limiting factor to achieving glycemic targets in the type 1 diabetes population. Indeed, the average A1C for adults ≥18 years of age with type 1 diabetes in the United States was 7.9% in 2015, a value well above the target of 7% recommended by the American Diabetes Association for most adult patients. Further complicating matters, diabetic ketoacidosis (DKA) occurs at a rate of 10% per year in some age-groups (4). Overall, these data suggest a need for adjunctive therapies for type 1 diabetes that reduce the risk for hypoglycemia and weight gain. While β-cell dysfunction is clearly a therapeutic focus for all types of diabetes, multiple other pathways of hyperglycemia present opportunities for alternate treatment modalities that may assist in achieving glycemic targets (5). The ideal pharmacotherapy regimen for a patient with type 1 diabetes would not only target the β-cell dysfunction, but also decrease blood glucose through hyperglycemic pathways independent of β-cell …

Canagliflozin is a member of the sodium–glucose cotransporter 2 (SGLT2) inhibitor class and is approved by the U.S. Food and Drug Administration (FDA) for use in patients with type 2 diabetes as an adjunct to diet and exercise to improve glycemic control. Canagliflozin works by inhibiting SGLT2 in the proximal renal tubules, causing a reduction of filtered glucose reabsorption, lowering of the renal threshold for glucose, and increasing urinary glucose excretion (1). The American Diabetes Association (ADA) Standards of Medical Care in Diabetes—2017 (2) and the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) (3) recommend SGLT2 inhibitors as add-on to metformin for patients with type 2 diabetes uncontrolled after 3 months of metformin use. The ADA lists the SGLT2 inhibitors as investigational agents for patients with type 1 diabetes because of the risk of diabetic ketoacidosis (DKA). Despite concerns for DKA in patients with type 2 diabetes treated with an SGLT2 inhibitor, a clinical review by an expert panel found that DKA occurred infrequently and recommended no change to their labeling (4). Although SGLT2 inhibitors are not FDA-approved for use in patients with type 1 diabetes, providers have prescribed these agents for off-label use in this patient population. Glycemic variability may be problematic in patients with type 1 diabetes; therefore, adding an SGLT2 inhibitor can assist in not only improving glycemic control but also reducing glycemic fluctuations. Although adding an SGLT2 inhibitor to insulin may increase the risk of hypoglycemia, the potential to reduce the need for increasing insulin doses may moderate this effect. Patients with type 1 diabetes uncontrolled with insulin therapy who are overweight/obese and have hypertension may benefit from the addition of an SGLT2 inhibitor because these medications help to lower A1C values and can reduce both weight and blood pressure. Several studies have …

Editor's Note: This article is adapted from the address Ms. Boucher delivered as the recipient of the American Diabetes Association’s (ADA’s) Outstanding Educator in Diabetes Award for 2018. She delivered the address in June 2018 at the association’s 78th Scientific Sessions in Orlando, Fla. A webcast of this speech is available for viewing at the ADA website (professional.diabetes.org/webcast/outstanding-educator-diabetes-award-lecture%E2%80%95connectedness%E2%80%94how-technology-and-social-networks).

Editor's Note: This article is adapted from the address Dr. Wysocki delivered as the recipient of the American Diabetes Association’s Richard R. Rubin Award for 2018. This award recognizes a behavioral researcher who has made outstanding, innovative contributions to the study and understanding of the behavioral aspects of diabetes in diverse populations. Dr. Wysocki delivered the address in June 2018 at the association’s 78th Scientific Sessions in Orlando, Fla.

IN BRIEF “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an effort to improve the safety of hyperglycemic crisis management at a Veterans Affairs Medical Center by making clinical pharmacy specialists available to the critical care team 24 hours/day.

The evolution of technologies to manage diabetes has led to improvements in patient adherence, technique, and monitoring. Insulin pens, for example, have distinct advantages over vials and syringes; they allow for more accurate dosing, improved adherence, less injection site pain, and greater patient satisfaction (1,2). As the population with diabetes grows internationally, second-generation insulin pens have been engineered with USB or Bluetooth features to enable closer monitoring of pharmacotherapy. Similarly, many devices for self-monitoring of blood glucose have also become integrated with Bluetooth to enable wireless transmission of data to a smartphone. As of 2016, the smart insulin pen market was valued at $59 million and is expected to increase to $123 million by 2023 in Latin America, the Middle East, and Africa (3). One report predicts that Europe will have the greatest smart insulin pen market growth, bringing in more than $2 million by 2027, based in part on high current utilization of such pen devices. The trend toward increased use of smart insulin pens can also be seen in North America; in fact, the same report estimates that, by 2027, the North American smart insulin pen market will have a continuous annual growth rate of 26.7% (4). The emergence of new technologies such as smart insulin pens, caps, attachments, and virtual platforms can help both patients and health care providers (HCPs) overcome problems such as poor insulin adherence, incorrect insulin initiation and titration, and medication errors. Adoption of such new devices may increase even further if clinical trials can show long-term cost-effectiveness (5). This review highlights the technologies now available on the market in the United States and internationally that are designed to improve insulin administration. A comprehensive literature review was conducted using manufacturer websites, press releases, commercial data resources, educational and training tools, …

IN BRIEF “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc. (ACP), and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an initiative to increase the use of basal-bolus insulin therapy for hyperglycemia in an inpatient setting and to evaluate its effects on patient outcomes compared to sliding-scale insulin therapy.

The 2017 Nobel Prize in Physiology and Medicine, awarded jointly to Jeffrey C. Hall, Michael Rosbash, and Michael W. Young for their discoveries of molecular mechanisms controlling the circadian rhythm, offered the opportunity to reflect on how clockwork mechanisms in the body affect the management of diabetes (1). Circadian rhythmicity relates to all cells in the human body and to the microbiome that coexists within its confines (2,3). Clock genes control intracellular metabolic processes, whereas tissue activity in aggregate is responsive to central clock rhythms entrained by circadian light/dark cycles (Figure 1) (2,3). The circadian system regulates energy homeostasis for the body and is vulnerable to disruption through aberrant feeding/fasting cycles (2,4). Metabolic dysfunction induced by such chrono-disruptive feeding behavior may be corrected by time-restricted feeding in synchronicity with our master resident pacemaker in the suprachiasmatic nucleus of the hypothalamus responsive to immutable celestial cues (2,5–7). FIGURE 1. The relationship of environmental (light and dark) cues with the central pacemaker and its effects on the periphery. SCN, suprachiasmatic nuclei. The liver is the central organ involved in nutrient processing and energy metabolism (7,8). It receives amino acids, monosaccharides, and free fatty acids from the gut, along with other trace elements and vitamins, and proceeds to discharge its duties, fabricating tissue and generating energy (7). This process is regulated by hormonal and neurological cues from other organs, most importantly the pancreas, adrenal glands, and gut, and is very much dependent on appropriate timing (3,7,9). Feeding not entrained to innate circadian rhythmicity results in metabolic aberrations and gut dysfunction (3,10,11). Metabolic aberrations are most frequently expressed as supraphysiologic glucose and triglyceride levels (3,7,10). These affect many organs …

I was embroiled in severe insulin pump burnout throughout 2017. My glucose management was relatively stable, but I struggled with technology management issues throughout the year. I had participated in more than half a dozen races, including 5-kilometer and 10-kilometer events and a couple of half marathons, culminating in a marathon. During each of these clutch athletic moments, I had pump failure issues. There was no consistency about when my pump died—only that it did die every single time I raced. Needless to say, I was frustrated. I have had diabetes for almost 23 years and have used an insulin pump for 14 of those years. For the past 9 years, I have used a leading-brand pump with relatively positive results in terms of both diabetes management and performance in endurance running/cycling/triathlon events. However, the headache of repeated pump failures led me to consider switching back to a multiple daily injection (MDI) regimen to give myself a reprieve from the nuances, and even more so the recent annoyances, of insulin pump therapy. But, I could not let go of my need, or at least my desire, for an automated “brain” that could help do the math calculations for me. Despite feeling that I had no great option, I took the plunge and switched back to an MDI regimen using disposable insulin pens. I also tried a variety of glucose-tracking mobile applications, such as mySugr (1) and Glucose Buddy (2), as I searched for a tool to help fill in the void left when I stopped using my pump. Although these apps are great for tracking glucose, none of the U.S.-based versions of them possesses the prized insulin-on-board (IOB) functionality I so desperately desired (3) to help me calculate doses. My despair ended, however, when I encountered the InPen. Produced by …

Glucagon-like peptide 1 (GLP-1) receptor agonists are relatively new additions to the treatment options available for type 2 diabetes. These agents provide glycemic control by increasing glucose-dependent insulin secretion, decreasing inappropriate glucagon secretion, slowing gastric emptying, and increasing satiety (1). The GLP-1 receptor agonists are an attractive treatment option because they are associated with weight loss and have a low risk of hypoglycemia. However, their use is limited in some patients because of gastrointestinal adverse effects (nausea, vomiting, diarrhea), cost, and their subcutaneous route of administration (1). There are currently six GLP-1 receptor agonists approved for use in the United States: exenatide (Byetta), 2005; liraglutide (Victoza), 2010; exenatide XR (Bydureon), 2012; albiglutide (Tanzeum), 2014; dulaglutide (Trulicity), 2014; and lixisenatide (Adlyxin), 2016. Many differences exist within this class of medications, including efficacy and safety profiles, dosing schedules, and preparation and administration requirements, making product selection and use potentially confusing for both health care professionals (HCPs) and patients. Dosing schedule is one important consideration when comparing GLP-1 receptor agonists. Whereas three of the GLP-1 receptor agonists are available in multi-use, disposable pen devices and are given either twice daily (exenatide) or once daily (liraglutide and lixisenatide), the other three GLP-1 receptor agonists are once-weekly formulations available in single-use, disposable pen devices (albiglutide [2], dulaglutide [3], and exenatide XR [4]). Once-weekly products may offer the advantage of better adherence and ease of use compared to once- or twice-daily medications. In clinical studies, adherence to treatment and treatment satisfaction significantly increased with once-weekly GLP-1 receptor agonists compared to once- or twice-daily GLP-1 receptor agonists (5–7). In comparing efficacy and safety of the once-weekly agents, meta-analyses and head-to-head trials demonstrate that dulaglutide showed the greatest reduction in A1C compared with other once-weekly GLP-1 receptor agonists, …

Human regular U-500 insulin (U-500), a fivefold concentrated form of U-100 regular human insulin, was introduced to address the insulin needs of patients with severe insulin resistance (1). Severe insulin resistance has historically been characterized by patients with total daily insulin dose (TDD) requirements exceeding 200 units/day (1). With the increasing prevalence of diabetes and obesity in the United States, severe insulin resistance has become more common, increasing the need for U-500. The safe and effective use of U-500 requires careful monitoring to optimize glycemic control while minimizing the risk of hypoglycemia. The elevated risk of medication errors associated with U-500 therapy and a lack of clear guidelines for its use may have been responsible for its underutilization by both patients and health care providers (HCPs). In a survey administered to internal medicine physicians and ward nurses evaluating the inpatient use of U-500, 47% of respondents said they were “very uncomfortable” with the use of U-500 (2). A 2013 article published by the Institute for Safe Medication Practices (ISMP) reported on an increasing number of medication error reports and complaints from HCPs related to the use of U-500 (3). To address these medication errors, innovations (i.e., a dedicated U-500 syringe and a U-500 pen delivery device) have been developed to help solve dosing confusion issues and potentially enhance HCP and patient comfort with U-500 therapy. Here, we review the available evidence for U-500 and the innovations for its delivery. When considering the use of U-500, patients and HCPs must be aware of the unique pharmacokinetic/pharmacodynamic (PK/PD) profile that distinguishes it from both basal insulins and prandial insulins. Unlike other insulins, U-500 covers both the basal and prandial insulin needs of patients. This unique PK/PD profile allows for its use as monotherapy, and patients can inject smaller volumes with fewer injections …

IN BRIEF “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a pilot project aimed at improving overall quality of care and reducing readmissions for patients discharged from a community hospital in Arizona.

Previous interventions to lower diabetes risks among pregnant women have been largely ineffective (1–3), and the identification of effective prevention tools is needed to protect both maternal and child health (4). The National Diabetes Prevention Program (NDPP) is a widely disseminated translation of the highly successful lifestyle change intervention from the Diabetes Prevention Program research study (5,6). The NDPP promotes weight loss of ≥5% through diet and physical activity, benefiting individuals who participate regularly (6). Eighty percent of participants are women (6), but most are beyond child-bearing years (7), and those who are pregnant at enrollment are excluded (8). Increasing enrollment in the NDPP among women of childbearing age has been identified as a priority (7), yet outcomes for those who become pregnant during the year-long program are unknown. To explore whether the NDPP may support beneficial outcomes during pregnancy, we examined case studies of women who became pregnant while participating in the NDPP. We delivered the year-long NDPP intervention in a Denver, Colo., health care system to eligible adults with diabetes risks (i.e., ≥24 kg/m2 and prediabetes, history of gestational diabetes mellitus [GDM], or positive score on a diabetes risk questionnaire [8]). Participants were largely referred by their primary care providers. Trained NDPP coaches led 22–25 group sessions over 1 year following guidelines developed by the Centers for Disease Control and Prevention (9). From March 2013 to March 2018, 924 women participated. Five women who subsequently reported having become pregnant were able to continue, but were no longer prescribed the NDPP’s weight loss goal. This article describes diabetes-related outcomes in pregnancy among three women using medical records available as of May 2018. An additional case was excluded because detailed records were unavailable, and another was excluded because of the early stage of the pregnancy. …

IN BRIEF “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an effort to improve attendance at scheduled appointments for group classes at a Pennsylvania diabetes education center.

Despite growing awareness of the problem, the diabetes epidemic shows no signs of abating and continues to pose a public health problem of grave concern (1). Nonpharmacologic interventions focused on lifestyle modifications, including diet and exercise, remain a major component of therapy. Individualized nutrition therapy has been shown to be effective for improvement of the metabolic profile and weight loss. However, most studies of popular diets are usually of short duration and have high attrition rates (15–50% within 1 year) (2). Adherence to any prescribed diet is a real challenge, especially when we are surrounded by easily accessible, processed food of high caloric and low nutritional value. It is therefore not surprising that lifestyle modification often fails, and as health care providers (HCPs), we find ourselves compelled to add more and more pharmacotherapies and often recommend metabolic surgery to achieve therapeutic goals. Indeed, despite significant advances in pharmacotherapy, there has been no significant change in the percentage of people who achieve therapeutic goals (3). A key question that needs to be addressed is how HCPs can help patients adhere to a treatment plan that will enable them to achieve and sustain improvements in metabolic control. One of the most essential components of diabetes care is access to an HCP. There is a significant shortage of primary care providers and endocrinologists in the United States, with the rising number of patients with diabetes outstripping the number of HCPs (4). Endocrinologists are asked to see more patients in less time, and new patients may have to wait for months to be seen. The problem is even worse for patients in remote areas, who must travel long distances to be seen. It is also commonly observed that patients …

Despite the availability of 12 different classes of medications, many people with type 2 diabetes struggle to maintain glycemic control (1). Among the many new antidiabetic medications to have emerged in recent years, sodium–glucose cotransporter 2 (SGLT2) inhibitors have proved to be a particularly effective oral treatment for these patients (2). Since the approval of the first drug in this class, canagliflozin, by the U.S. Food and Drug Administration (FDA) in March 2013, a total of four SGLT2 agents have become available (both as single and fixed-dose combination formulas) (1). In 2017, an estimated 1.7 million patients received a dispensed prescription for an SGLT2 inhibitor from U.S. outpatient retail pharmacies (2). Ertugliflozin is the newest agent among these, having received FDA approval in December 2017 (3). Ertugliflozin is indicated as an adjunct to diet and exercise for control of hyperglycemia in adults (≥18 years of age) with type 2 diabetes (4). It can be used as monotherapy in patients for whom metformin is contraindicated or not well tolerated. It can also be used in combination with other antidiabetic agents (most commonly metformin or a dipeptidyl peptidase 4 [DPP-4] inhibitor) to help reduce A1C. Currently, ertugliflozin is available as an oral tablet sold under the brand name Steglatro or in oral tablet combinations with the DPP-4 sitagliptin (brand name …

EDITOR’S NOTE: This article is adapted from the address Dr. Harris delivered as the recipient of the American Diabetes Association’s Richard R. Rubin Award for 2017. This award recognizes a behavioral researcher who has made outstanding, innovative contributions to the study and understanding of the behavioral aspects of diabetes in diverse populations. Dr. Harris delivered the address in June 2017 at the Association’s 77th Scientific Sessions in San Diego, Calif.

Diabetes affects 29.1 million Americans, or 9.3% of the U.S. population, and is associated with significant costs to the health care system (1). The estimated total cost of diabetes increased from $132 billion in 2002 to $245 billion in 2012. Average medical expenditures are 2.3 times higher in patients with diabetes compared to those without diabetes (1). Diabetes self-management education (DSME) is the ongoing process of facilitating the knowledge, skills, and ability necessary for diabetes self-care (2). Patients with diabetes make multiple decisions every day about their health management. The literature supports the effectiveness of diabetes education to improve clinical outcomes and quality of life in this complicated patient population (3). General practice providers have limited time to spend with patients for diabetes education (4). To overcome this barrier, an interprofessional approach to care has been used to give patients the tools they need to achieve glycemic targets. Because of their medication expertise in a variety of chronic disease states, pharmacists are well positioned to provide comprehensive diabetes services, including basic education and counseling on diabetes topics such as blood glucose management, diet, and exercise. Pharmacists also have the ability to monitor patients’ laboratory testing values and to recommend therapies for hypertension, dyslipidemia, cardiovascular disease, and microvascular complications, which are often seen with advanced diabetes (5). Diabetes regimens have become more involved as multiple new therapies have become available within the past several years (6). Patient counseling is imperative regarding new medications such as glucagon-like peptide-1 (GLP-1) receptor agonists, sodium–glucose cotransporter 2 inhibitors, and concentrated insulins. With multidrug regimens that include new agents, the risk of adverse effects and hypoglycemia increases. Pharmacists can draw on their training and expertise to improve both clinical and economic outcomes related to diabetes medications (5). Because of the versatility of …

Malnutrition Worsens Mortality Risk in Older Adults With Diabetes Malnutrition in older adults can be a problem, but when it’s combined with diabetes, it can dramatically increase mortality risk and health care costs, according to Ahmed et al. ( BMJ Open Diabetes Research and Care , doi.org/gc2jqw). As a result, the authors suggest that identifying and treating patients with malnutrition should be a priority in diabetes care for older adults. The conclusion comes from a retrospective observational study of >15 million diabetes patients that looked at the impact of malnutrition in diabetes with or without a range of significant comorbidities. The authors identified just over 800,000 diabetes patients who had an additional diagnosis of malnutrition and found that the patients had a 69% higher risk of death compared to diabetes patients without malnutrition. Patients who had diabetes, malnutrition, and another significant comorbidity also had significantly higher risks of death compared to those without malnutrition, ranging from a 47% higher risk with acute myocardial infarction to a 63% higher risk with ischemic heart disease. Higher risks of death were also associated with chronic kidney disease, heart failure, stroke/transient ischemic attack, or chronic obstructive pulmonary disease. Median survival time from diabetes diagnosis to time of death was reportedly just under 2.5 years when malnutrition was present compared to just over 5 years in patients without malnutrition. On the secondary outcome of health care costs, the authors found an average annual cost of just over $36,000 for patients with diabetes and malnutrition compared to just over $20,000 for those with diabetes but no malnutrition. Bottom line? They conclude that concerted efforts are needed to identify and treat malnutrition in patients with diabetes. ### Study Confirms Success of a Consultation Model for Diabetes Care A study by Rutten and van Vugt et al. ( Diabetes Care , doi.org/ck5w) on the implementation of the Dutch Diabetes Federation’s consultation model of diabetes care suggests that the approach can …

Gestational diabetes mellitus (GDM) is diabetes that is diagnosed during the second or third trimester of pregnancy and is not clearly overt diabetes (1). Diagnosis is defined by severity of carbohydrate intolerance. The upper end of the GDM diagnostic glucose range is the same as would be indicative of diabetes outside of pregnancy, whereas the lower end of the GDM range is only slightly above normal and asymptomatic but still associated with increased risk of fetal morbidity (1,2). Diabetes during pregnancy is diagnosed by either a one-step approach involving a 75-g oral glucose tolerance test (OGTT) or a two-step approach starting with a 50-g (nonfasting) screen followed by a 100-g OGTT for those who initially screen positive (1). Glycemic goals for patients with a GDM diagnosis are as follows: preprandial ≤95 mg/dL and either 1-hour postprandial ≤140 mg/dL or 2-hour postprandial ≤120 mg/dL. Hyperglycemia throughout pregnancy carries increased risk for adverse fetal and maternal outcomes (3–8). Treatment of diabetes during pregnancy is aimed at decreasing the risk of perinatal outcomes such as macrosomia, birth trauma, neonatal metabolic abnormalities, and cesarean section (4,9–12). Lifestyle modification is first-line treatment and includes medical nutrition therapy (MNT), exercise, and glucose monitoring (13). Pharmacological therapy generally consists of insulin, glyburide, or metformin, and agents may be used adjunctly to MNT depending on presence and severity of hyperglycemia (13). Insulin is the preferred pharmacological treatment for management of diabetes in pregnancy if lifestyle modification is insufficient in achieving euglycemia (13). The setting of this review is the diabetes clinic located within the Hall County Health Department (HCHD) prenatal clinic in Gainesville, Ga. The population of Gainesville is ∼187,000 and includes a large percentage of Latino immigrants (14). The proportion of Latinos in the diabetes clinic has grown …

Diabetes is a major worldwide epidemic with >415 million individuals living with the disease. This number is expected to grow to a staggering 642 million by 2040 (1). According to the American Diabetes Association, diabetes affects 29.1 million Americans, or 9.3% of the population. Diabetes management in the United States presents several challenges: 20% of individuals with diabetes remain undiagnosed, 1.4 million new cases are diagnosed annually, and one-third of adults with diabetes are not at the general recommended A1C goal of

A 13-year-old girl with type 1 diabetes presented to the emergency department (ED) after being found unresponsive at home by her mother with a capillary blood glucose (CBG) of 1.488 mmol/L (26.8 mg/dL) (Figure 1). She was given intramuscular (IM) glucagon and intravenous (IV) dextrose by emergency medical services, and her CBG increased to 4.628 mmol/L (83.4 mg/dL) by the time of her ED arrival. FIGURE 1. Timeline of glucose and insulin levels during admission. The line is glucose levels, squares are insulin levels, and arrows indicate times of glucagon doses given, 1 mg each. At presentation, she was diaphoretic and somnolent, with an otherwise unremarkable exam, body temperature 37°C (98.6°F), heart rate 93 beats/min, respiratory rate 22 breaths/min, blood pressure 103/62 mmHg, and oxygen saturation 99%. Other significant admission laboratory values were sodium 139 mmol/L, potassium 3.6 mmol/L, carbon dioxide 23 mmol/L, creatinine 32 μmol/L, magnesium 0.86 mmol/L, phosphorus 1.35 mmol/L, alanine aminotransferase 95 units/L, and aspartate aminotransferase 75 units/L. While in the ED, her CBG value repeatedly fell to 10 mg/kg/min to maintain euglycemia. She was admitted to the intensive care unit (ICU) for further management and careful monitoring. In the ICU, she received intermittent doses of IM glucagon (1 mg each) because of continued hypoglycemia even on continuous dextrose infusion with a GIR of 10 mg/kg/min (Figure 1). With her first glucagon dose, her glucose level rose from 2.09 mmol/L (37.7 mg/dL) to 9.97 mmol/L (179.6 mg/dL) after 20 minutes. On hospital day 2, her dextrose infusion was slowly weaned. At 55 hours from admission, her dextrose infusion was discontinued, and she maintained euglycemia with frequent …

IN BRIEF “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a successful effort to improve glycemic control in presurgical patients with an A1C >8%.

IN BRIEF “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a referral-based program for managing high-risk patients with type 2 diabetes in California.

IN BRIEF “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a project aimed at reducing inpatient critical hypoglycemia episodes in a community hospital setting.

The gold-standard goal of diabetes management has been to achieve meaningful and sustained glycemic control to reduce the risk of long-term complications. Unfortunately, results from the National Health and Nutrition Examination Survey indicate that only ∼50% of adults with diabetes in the United States, mostly with type 2 diabetes, are achieving an A1C 9%, has actually increased (2,3). The Healthcare Effectiveness Data and Information Set results, with data from >1,000 health plans covering >171 million lives, are even more striking, demonstrating that, in 2014, ∼40% of commercially insured health maintenance organization patients and 30% of government insured patients achieved an A1C 40 new treatment options for people with type 2 diabetes. This fact is quite shocking and difficult to understand, especially given that our armamentarium of effective and safe type 2 medications has expanded over the same time period to include dipeptidyl peptidase 4 (DPP-4) inhibitors, sodium glucose cotransporter 2 inhibitors, designer insulins, inhaled insulin, and glucagon-like peptide 1 (GLP-1) receptor agonists. Although there may be many reasons why these new treatment options haven’t made a dent in the glycemic control of our patients with type 2 diabetes during these past 10 years, I feel strongly that the basic and primary issue is a lack of patient education, motivation, and activation. Type 2 diabetes is a silent condition with few or no symptoms caused by poor …

About a year ago, I had one of those moments that stops you in your tracks. I still haven’t forgotten it. I was on a ride to the airport when the driver, a man I’ll call Sam, asked me what I did for a living. “I write about diabetes,” I said. There was a long pause, and then Sam admitted he had diabetes. I immediately began asking questions to learn more about his story. It was heartbreaking to hear, and even though I live with diabetes myself, Sam reminded me why managing it can be so hard. I have not been able to get his story out of my head, which is why I’m sharing it now. Sam’s journey highlights six diabetes challenges, all of which are frustratingly common: lack of blood sugar data, low motivation, judgment/failure, lack of support from loved ones, a challenging food environment, and uncoordinated care. Using some of the tips proposed below, I hope we can start to address these challenges as a community. Sam was diagnosed with diabetes 16 years ago. He took pills for years and resisted going on insulin for a long time. When we spoke, he was taking NPH and fast-acting insulin twice daily, using a sliding scale to determine the dose; it didn’t matter what he had eaten. Sam only checked his blood glucose twice daily. He said his A1C “once got down to 8%,” but he recently had several weeks of blood sugars “way off the range.” He later clarified that he meant “over 300 mg/dL” for weeks straight (roughly equating to an A1C of ∼12%). Sam had already developed some kidney problems and, more recently, issues with his feet. He’s only in his 40s. “I love fried chicken and eat it every single day,” Sam told me. He …

IN BRIEF Rates of obesity and diabetes are growing, as are their costs. Because the two diseases share many key determinants, the paradigms for their treatment overlap. For both, optimal treatment involves a multidisciplinary team following the Chronic Care Model of health care delivery. Combined treatment programs that include 1) a low-calorie diet individualized to patients’ preferences, 2) structured exercise that is also tailored to each patient, and 3) psychotherapy induce the largest weight changes in patients with diabetes. Although diet alone can achieve weight loss, exercise and cognitive behavioral therapy components can enhance the effects of dietary modification. A multidisciplinary team that includes a physician with expertise in pharmacotherapy, a nurse and/or nurse practitioner, a dietitian, an exercise physiologist, and a psychologist can provide a comprehensive weight loss program combining the most effective interventions from each discipline.

Combination treatment with basal insulin and a glucagon-like peptide-1 (GLP-1) receptor agonist targets different aspects of the pathophysiology of type 2 diabetes to achieve glycemic control. In November 2016, the U.S. Food and Drug Administration approved two titratable fixed-ratio combinations (FRCs) of basal insulin and a GLP-1 receptor agonist: insulin glargine/lixisenatide 3:1 ratio (iGlarLixi [Soliqua]) and insulin degludec/liraglutide 1:0.036 ratio (IDegLira [Xultophy]) (1,2). Both agents are indicated to improve glycemic control in adults with type 2 diabetes inadequately controlled on basal insulin or the respective GLP-1 receptor agonist along with diet and exercise (1,2). Use of these agents is not recommended for patients with type 1 diabetes, diabetic ketoacidosis, gastroparesis, or a history of pancreatitis. Additionally, these agents should be avoided in patients using another GLP-1 receptor agonist or prandial insulin (1,2). Insulin glargine and insulin degludec improve glycemic control through stimulation of glucose uptake in the body and inhibition of glucose production in the liver (1,2). Lixisenatide and liraglutide mimic the action of GLP-1 through stimulation of glucose-dependent insulin release, suppression of glucagon production, and slowing of gastric emptying (1,2). A main advantage of FRCs, as single daily injections of two glycemic control medications, is regimen simplification to promote treatment adherence with less potential for clinical inertia. Greater efficacy in glycemic control is …

A 77-year-old Latina woman was referred to our center for a second opinion regarding poorly controlled type 2 diabetes, with the specific question of an underlying neuroendocrine neoplasm as a possible secondary cause. Diabetes had been diagnosed >30 years earlier, and the patient was initially treated with oral agents alone for several years but had been using insulin injections for as long as she could remember. There was no history of diabetic ketoacidosis or other hyperglycemic emergency and no known history of definitive diabetes microvascular or macrovascular complications. Most recently, her regimen consisted of the combination of saxagliptin and metformin 2.5/1,000 mg twice daily, glargine 50 units at bedtime, and lispro 28 units three times daily before meals. The patient usually self-administered her insulin, although, at times, her son administered it when she visited his home to share a meal. For many years, her A1C had hovered in the low 7% range. Approximately 2 years before our evaluation, the patient noted a relatively abrupt increase in her blood glucose levels, as determined by fingerstick glucose monitoring and as corroborated by an increasing A1C into the 9–10% range. The patient had recently been under the care of an endocrinologist in another city who had added the oral agents to her insulin regimen and aggressively increased her insulin doses, seemingly to no avail. In the 1–2 months before her visit with us, her capillary blood glucose levels, checked four times daily, had been consistently >200 mg/dL, with frequent excursions to >300 mg/dL. The patient had had no recent hypoglycemia, although occasionally she noted improved glucose control for 1–2 days that was unexplained. The patient and her family were becoming increasingly frustrated by her seeming inability to achieve the quality of glycemic control to which she had become accustomed earlier in the course …

Diabetes is an increasingly common medical condition affecting ∼29 million people (8 million of whom are undiagnosed), or 9% of the U.S. population. The estimated health expenditures to prevent and treat diabetes and associated direct and indirect complications totaled $245 billion in 2012, and this cost is on a trajectory to double by 2030 (1,2). An estimated 25% of patients with diabetes will require surgery (3). Twenty-eight percent of patients with diabetes are unaware that they have the disease (2). Furthermore, 5–10% of patients presenting for surgery are found to have previously unrecognized diabetes (4,5). This is particularly important because patients who are unaware of their diabetes have higher preoperative blood glucose levels (4) and a higher risk of perioperative mortality compared to patients who are aware of their diabetes (5). Diabetes is a well-known risk factor for postoperative infection, acute renal failure, ileus, and prolonged hospital stay (6–9). Poor preoperative glycemic control portends poor intraoperative glycemic control, which is an established risk factor for perioperative morbidity (10,11). Surgical patients with perioperative hyperglycemia (with and without underlying diabetes) have a greater risk for infection and related adverse outcomes after surgery compared to patients without hyperglycemia. Patients with diabetes are more prone to these surgical complications due to the microangiopathy (e.g., nephropathy and neuropathy) and macroangiopathy (e.g., atherosclerosis) intrinsic to the disease and also have mortality rates significantly greater than those of patients without diabetes (12–16). When patients with poorly controlled diabetes present for surgery, they impose a significant financial health resource burden, including prolonged ventilator dependence, longer hospital stay, and greater postoperative loss of productivity. As the prevalence of diabetes increases, optimal screening, management, and timing of elective surgery for patients with diabetes has become a matter of increasing …

The gluten-free diet, touted by celebrities for weight loss (1) and athletes for improved performance (2), is virtually impossible to avoid hearing about. Between 2004 and 2011, the market for gluten-free products grew at an annual rate of 28% (3), with an estimated $2.6 billion in sales in 2012 (4) that is expected to reach $6.6 billion by 2017 (5). A 2013 survey from NPD (formerly National Purchase Diary, a market research group) found that 30% of Americans showed interest in avoiding gluten (6). Also in 2013, the U.S. Food and Drug Administration (FDA) issued the final rule on gluten-free food labeling, effective in August 2014 (7), making the gluten-free label a more common sight in the grocery store. Although the gluten-free diet is an absolute necessity for people with celiac disease or nonceliac gluten sensitivity (NCGS), people without diagnosed gluten issues are trying the diet to assist in the management of other medical issues. A 2013 study found that 65% of American adults think gluten-free foods are healthier, and 27% choose gluten-free products to aid in weight loss (8). There is a well-established relationship between type 1 diabetes and celiac disease. But for those with diabetes who have not been diagnosed with either celiac disease or NCGS, is there a benefit to going gluten-free? Are there risks to eating gluten-free without a diagnosis of celiac disease or NCGS? What special challenges exist for those with concurrent diabetes and celiac disease or NCGS? And finally, how can patients improve the nutritional profile of the gluten-free diet in terms of fiber, iron, calcium, and vitamin D to address deficiencies created by celiac disease or by the gluten-free diet? Celiac disease is an inherited autoimmune condition that affects ∼1% of the population, although for every case diagnosed, it is thought that …

The burden of diabetes is complex and growing in epidemic proportions. According to the American Diabetes Association (ADA), ∼29.1 million Americans (9.3% of the population) were diagnosed with diabetes as of 2015, and >1 million new cases of diabetes are diagnosed in people ≥20 years of age in the United States each year (1). Diabetes is also on the rise globally. The International Diabetes Federation has predicted that the number of people with diabetes worldwide will rise from the present 415 million to 642 million in 2040 (2). Diabetes is the seventh leading cause of death in the United States and kills more people every year than AIDS and breast cancer combined (1). Patients with diabetes often have comorbid conditions of hypertension, dyslipidemia, retinopathy, neuropathy, kidney failure, lower limb amputations, and cardiovascular disease (3). Alarmingly, in the past decade, research has shown an increased risk for pancreatic, liver, colorectal, endometrial, and breast cancer among people living with diabetes (4). Although additional studies are needed to determine the causes of this risk, cancer screening is a necessary standard of diabetes care. Increased diabetes incidence in the United States is attributed to an aging population, increased diabetes risk among expanding minority groups (i.e., non-Hispanic blacks, Asians, Hawaiians/Pacific Islanders, and Native Americans/Alaska Natives), sedentary lifestyle, and high rates of obesity (5). In 2012, the ADA reported that diabetes accounted for $245 billion in public costs, including $176 billion in direct costs and $69 billion in indirect costs (i.e., disability, work loss, and premature mortality). In the absence of an improved diabetes management strategy, escalating costs will create an enormous economic burden for the already strained U.S. health care system. The prevalence of diabetes is 17% higher in adults living in rural areas than in the population as a whole (6). Rural populations …

In January, the American Diabetes Association (ADA) published the Standards of Medical Care in Diabetes—2017 (1), its comprehensive evidence-based clinical practice recommendations for the care of people with or at risk for diabetes. The Standards are updated annually by the ADA’s Professional Practice Committee (available at http://care.diabetesjournals.org/content/40/Supplement_1) based on the latest clinical research and are funded from the ADA’s general fund without industry support. In addition, the ADA publishes occasional position statements on a range of diabetes-related topics, most recently neuropathy (2), hypoglycemia (3), and physical activity (4). Following are some highlights from the ADA’s 2017 Standards and from recent position statements, tailor-made for busy point-of-care providers. ### Tap Into Community Resources The latest Standards include new recommendations aimed at reducing health disparities stemming from discrimination, racism, socioeconomic status, lack of health care access, and language barriers, among other factors, by encouraging providers to refer patients to community resources. Furthermore, ADA makes the assertion, based on high-quality evidence for benefit, that patients should be provided self-management support from lay health coaches, navigators, or community health workers. ### More Candidates for Metabolic Surgery Obesity management is a treatment for type 2 diabetes, and the specific approach—lifestyle, pharmacologic, or metabolic surgery—should be individualized according to a patient’s characteristics and preferences. A big change for 2017 was the expansion of the pool of patients for which metabolic surgery is an appropriate treatment. Based on the findings of an international workgroup report, ADA now suggests metabolic surgery for

Diabetes is the most common comorbidity in individuals with cystic fibrosis (CF). Among people with CF, the prevalence of CF-related diabetes (CFRD) is estimated to be 2% in children, 19% in adolescents, 40% in individuals in their 20s, and 45–50% in those ≥30 years of age (1). CFRD shares some aspects with type 1 diabetes in that it is primarily due to insulin deficiency, but it is distinguished from type 1 diabetes because of its insidious onset over years and the persistence of some insulin production long after diagnosis, which makes diabetic ketoacidosis (DKA) very rare in CFRD (2). Routine screening for type 1 diabetes autoantibodies is not recommended for patients with CF and hyperglycemia (3). However, the following three cases illustrate certain instances that may warrant checking for type 1 diabetes autoantibodies (i.e., hyperglycemia before age 10, symptomatic presentation, and DKA; increasing insulin requirement; or presence of other autoimmune diseases or family history of autoimmune diseases in a CF patient). ### Patient 1 Patient 1 is a non-Hispanic white male with CF (genotype delta F508 homozygous), pancreatic insufficiency, and CF-related liver disease who presented at 16 years of age with polyuria, polydipsia, dry mouth, and weight loss of 5 kg over 3 months. His family history was positive for hypothyroidism in his father and CF in his sister and negative for diabetes. His height was 152 cm (

IN BRIEF “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a successful effort to ensure that patients who are at risk for severe hypoglycemic events have a viable glucagon emergency plan in place.

Barbara Morrison’s Quality Improvement Success Story titled “Increasing Attendance at Scheduled Appointments for Group Classes at a Diabetes Education Center” (1), which is published in this issue of Clinical Diabetes , raises several important issues. First, although other investigators have studied no-show rates for primary care visits (and have investigated various tactics to lower those rates), Morison’s article reminds us that not all literature-based solutions are generalizable to every care setting. The staff of the diabetes center at which this quality improvement (QI) project took place recognized that 1 ) they had a no-show rate, 2 ) they care for an ethnically diverse community, and 3 ) the development of tactics to address their no-show rate should be locally …

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’ …

Diabetes is a complex, chronic medical condition affecting 29.1 million people in the United States (9.3% of the population) and is projected to affect one in three Americans by 2050 if the current trend continues (1). Diabetes management can be challenging, often requiring multiple therapeutic agents as the disease progresses. Current guidelines recommend metformin as first-line pharmacological therapy for the treatment of type 2 diabetes. Multiple second-line options are available for patients whose A1C goal is not achieved with monotherapy, and selection should be based on patient- and drug-specific factors. Sodium–glucose cotransporter 2 (SGLT2) inhibitors, the newest U.S. Food and Drug Administration (FDA)–approved oral antidiabetic agents, are among these options for patients with type 2 diabetes. Canagliflozin, dapagliflozin, and empagliflozin are the currently available SGLT2 inhibitors in the United States (2,3). Sodium–glucose cotransporter 1 (SGLT1) is predominantly located in the small intestine, but is also expressed in the kidneys, trachea, heart, and colon (4,5). In the kidneys, SGLT1 is primarily located in the S3 segment of the proximal convoluted tubule (PCT) (4). SGLT2 is expressed in the kidneys and primarily located in the S1 and S2 segments of the PCT (4,5). In normoglycemic adults, about 180 g of glucose (Figure 1) is filtered per day in the glomerulus, and most is reabsorbed (4,6). In people with diabetes, reabsorption of glucose is increased compared to people without diabetes (7,8). SGLT1 and SGLT2 are located in the apical membrane and facilitate the transport of glucose with sodium from the renal tubular lumen into the cells (Figure 2) (4). FIGURE 1. Structures of glucose, phlorizin, canagliflozin, dapagliflozin, and empagliflozin. FIGURE 2. Cotransport of glucose and sodium by SGLT1 and SGLT2 in the PCT. Phlorizin (Figure 1), an O -glucose derivative/ O -glycoside, was discovered in …

Diabetes in children and youth poses a unique diagnostic and therapeutic challenge. Although type 1 and type 2 diabetes are undoubtedly the most frequently encountered forms of diabetes, other forms are not uncommon in this age-group. Many young patients with so-called “specific types of diabetes due to other causes” may be misdiagnosed as having type 1 or type 2 diabetes because of a lack of awareness of the various diagnostic possibilities (1). The group of patients with other forms of diabetes constitutes

Diabetes, the most common metabolic disorder in primary care, is the leading cause of cardiovascular disease, renal failure, retinopathy, and lower-extremity amputations (1). Diabetic foot abnormalities, including ulcers and lower-extremity amputations, are associated with substantial morbidity, loss of quality of life, and disability and are very costly for the individuals affected, their families, and society as a whole (2). Approximately 84% of nontraumatic major amputations in individuals with diabetes are preceded by foot abnormalities such as an ulceration (3). According to the Centers for Disease Control and Prevention, the total cost of diagnosed diabetes in the United States was $245 billion in 2012, with the majority of costs attributed to a high occurrence of hospital admissions, including $9 billion associated with foot ulcers alone (2). Diabetes is a treatable condition, yet it is the seventh leading cause of death in South Carolina. South Carolina ranks tenth highest in the nation in the percentage of population with diabetes (4). In 2013, South Carolina had the fourth highest prevalence of diabetes in the United States, with ∼25,000 diabetes-related hospitalizations and emergency visits, costing $367 million. The cost of diabetes care in South Carolina is expected to exceed $3 billion in 2016 and to hit $4 billion by 2020 (5). Many of the costs associated with diabetes could be reduced with preventive intervention in the primary care setting, where diabetes is the most common metabolic disorder encountered. However, gaps occur in the care and management of diabetes, especially in the area of foot care. In 2012, an Institute for Preventive Foot Health/National Purchase Diary survey revealed that only 46% of patients with diabetes reported ever having foot screenings with their primary care provider (6). Foot complications, specifically ulcers and amputations, are the number one reason for hospitalization in patients with diabetes …

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 …

The transition from urinary glucose measurement to more sophisticated self-monitoring of blood glucose (SMBG) systems in the 1970s and 1980s dramatically changed the approach to and understanding of diabetes management (1). Innovations in the design and technology of portable blood glucose meters have become integral to the success of intensive treatment of both type 1 and type 2 diabetes, and the outcome of this treatment has led to a tremendous decrease in the development of long-term micro- and macrovascular complications (2–4). However, intensive insulin therapy has its limitations, including increased frequency of hypoglycemia and the need for frequent SMBG testing. In the past decade, continuous glucose monitoring (CGM) technology has evolved into a novel tool to support diabetes management. Unlike conventional glucose meters, which provide a snapshot of the blood glucose value at the time of testing, CGM provides semi-continuous information about glucose levels. It does this indirectly, by extrapolating blood glucose levels from interstitial fluid glucose via an algorithm. Importantly, CGM allows users to make decisions regarding their day-to-day diabetes management using real-time glucose trends. Along with this information, CGM systems provide customizable hypo- and hyperglycemia alarms and display trends of the rate of change of glucose levels. Most recently, CGM systems have been integrated with insulin pumps and are being used in artificial pancreas clinical trials. In this article, we discuss the clinical benefits of CGM; its challenges, including accuracy and user experience; and its present and future role in the management of diabetes. Numerous studies have explored whether sustained use of CGM offers clinical benefits in individuals with diabetes. Randomized, multicenter clinical trials have shown improved glycemic control in adults with type 1 diabetes using CGM compared to those using SMBG and a reduction in the time spent in hypoglycemia with concomitant improvement in A1C …