Optimizing Therapeutic Outcomes With Oral Semaglutide: A Patient-Centered Approach.

In September 2019, the U.S. Food and Drug Administration approved oral semaglutide as the first orally administered glucagon-like peptide 1 (GLP-1) receptor agonist for treating people with type 2 diabetes. Although injectable GLP-1 receptor agonists are well-established treatment options for people with type 2 diabetes, clinical experience with an oral formulation in this class is limited. This article provides practical guidance for diabetes care and education specialists on how to effectively counsel patients initiating therapy with oral semaglutide on appropriate administration of the treatment and its possible effects on glycemic control, body weight, and quality of life. Strategies for mitigating potential side effects typical of the GLP-1 receptor agonist class, namely nausea, vomiting, and diarrhea, are also provided. Involving patients in treatment decisions and educating them about available and prescribed medications are key strategies for encouraging treatment adherence and ensuring optimal therapeutic outcomes.

Insulin initiation in type 2 diabetes: what are the treatment regimen options and how can we best help patients feel empowered?

PURPOSE: This article summarizes treatment regimens and issues involved in initiating insulin therapy in type 2 diabetes (T2D). Progressive deterioration of beta-cell mass and function characterizes the course of T2D. Following diet and exercise, oral antidiabetic drugs (OADs), and incretin therapies, many patients require insulin, but initiation is often delayed until complications develop. DATA SOURCES: Published guidelines for the management of T2D, primary and review articles, and Food and Drug Administration (FDA) prescribing information. CONCLUSIONS: The diabetes nurse practitioner should encourage patients to initiate insulin when appropriate; patients need to know that this represents a natural step in treatment, not a personal failing. Initiation often occurs when OADs no longer confer adequate glycemic control. Treatment regimens available include once-daily basal insulin, sometimes with addition of prandial insulin, or premix/biphasic insulin. Insulin analogs confer less risk of hypoglycemia and weight gain, and greater dosing flexibility compared with conventional insulins. Insulin efficacy may be enhanced by continuing metformin and/or incretin therapies, while discontinuing other drugs as appropriate. IMPLICATIONS FOR PRACTICE: The well-versed diabetes nurse practitioner assists the patient in selecting the most appropriate option for his/her specific needs. It is essential to help patients overcome barriers, including fears of injection pain, public embarrassment, and hypoglycemia risk.

Effects on post-prandial glucose and AGE precursors from two initial insulin strategies in patients with type 2 diabetes uncontrolled by oral agents.

OBJECTIVE: Progressive ß-cell dysfunction in Type 2 diabetes results in the need for insulin therapy in many patients. Yet the best regimen to prescribe to patients transitioning from oral anti-hyperglycemic drugs (OADs) is not clear. We sought to compare the effects of two standard initial insulin strategies (basal insulin alone versus premixed insulin) on post-prandial glucose metabolism and precursors of advanced glycation end-products in patients with type 2 diabetes suboptimally controlled on OADs. RESEARCH DESIGN AND METHODS: This was a 6-month, open-label, single-center study using a cross-over design. 14 subjects were randomized to one of two protocols: once daily insulin glargine or twice-daily 75%/25% neutral protamine lispro/lispro mix. At 12 weeks, the subjects were crossed-over to the opposite protocol. During each period, insulin doses were titrated to target fasting blood glucose of 90-110 mg/dL. At baseline and after the two 12-week treatment periods, subjects were studied in the Clinical Research Center; they consumed three liquid mixed isocaloric meals at 4-h intervals, and glucose, free fatty acids (FFA), lipids, and α-dicarbonyls (3-deoxyglucosone [3-DG] and methylglyoxal [MG]) were measured before and after each meal. Patient data were analyzed in the context of their assigned insulin strategy groups. RESULT: Both insulin regimens led to a significant improvement in glycemic profiles, including fasting glucose and HbA1c, compared to baseline. However, mean post-prandial glucose was lower with lispro mix than with glargine (153 ± 36 vs. 199 ± 49 mg/dL, respectively; P=0.001). Likewise, there was a reduction in both fasting (48 ± 13 vs. 57 ± 19, P=0.047) and post-prandial (53 ± 19 vs. 63 ± 23; P=0.007) 3DG levels with lispro mix as compared to glargine. No differences were noted in MG concentrations. CONCLUSION: In type 2 diabetes patients failing OAD therapy, an initial insulin regimen of twice daily premixed insulin results in significantly improved post-prandial glucose levels as well as a reduction in a precursor of AGEs. The effect of these two initial insulin regimens on long-term diabetic complications requires further study.

Understanding GLP-1 analogs and enhancing patients success.

Recent research into the mechanisms of type 2 diabetes reveals intricate interactions among many hormonal processes. Ultimately, these pathways lead to hyperglycemia, pancreatic beta-cell failure, and the emergence of type 2 diabetes. The incretin hormones, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), are now known to play major roles in endogenous glucose control, including regulation of insulin, glucagon, and hepatic glucose metabolism. Investigation of the incretin system has led to development of drugs that mimic or enhance the endogenous hormones, including GLP-1 receptor agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors. This supplement describes the role of incretin hormones in the pathophysiology of type 2 diabetes and their potential as therapeutic targets for disease management. In addition, safety and efficacy profiles of the GLP-1 receptor agonists are reviewed, and the advantages and limitations of these medications are discussed from the perspective of promoting their successful implementation in individualized treatment regimens. As understanding of the underlying pathophysiology and pathogenesis of type 2 diabetes advances, the number of new therapeutic approaches expands. GLP-1 receptor agonists address several aspects of the pathophysiology of type 2 diabetes. A large body of data reveals the efficacy, safety, and tolerability of these drugs. A clear understanding of the evidence base for these drugs will translate into improved education of patients regarding their options to improve glycemic control and, ultimately, to better patient care.

Diabetic neuropathies: diagnosis and treatment.

Diabetic neuropathy can affect every organ system of the body. Diagnosis of diabetic neuropathy is usually one of exclusion. Clinical guidelines and the introduction of new medications for pain relief in peripheral neuropathy are improving medical and nursing management. Simpler diagnostic tests for cardiac autonomic neuropathy, which can be performed in an office setting, may mean earlier recognition and treatment with less mortality. Oral medications for the treatment of erectile dysfunction make it easier for the patient to seek treatment for a condition that impact quality of life.