Continuous Glucose Monitoring Using the Dexcom G6 in Cardiac Surgery During the Postoperative Period.

OBJECTIVE: Cardiac surgery is associated with hyperglycemia, which in turn is associated with adverse postsurgical outcomes such as wound infections, acute renal failure, and mortality. This pilot study seeks to determine if Dexcom G6Pro continuous glucose monitor (Dexcom G6Pro CGM) is accurate during the postoperative cardiac surgery period when fluid shifts, systemic inflammatory response syndrome, and vasoactive medications are frequently encountered, compared to standard glucose monitoring techniques. METHODS: This study received institutional review board approval. In this prospective study, correlation between clinical and Dexcom glucose readings was evaluated. Clinical glucose (blood gas, metabolic panel, and point of care) data set included 1428 readings from 29 patients, while the Dexcom G6Pro CGM data included 45 645 data points following placement to upper arm. Additionally, average clinical measurements of day and overnight temperatures and hemodynamics were evaluated. Clinical and Dexcom data were restricted to being at least 1 hour after prior clinical reading Matching Dexcom G6Pro CGM data were required within 5 minutes of clinical measure. Data included only if taken at least 2 hours after Dexcom G6Pro CGM insertion (warm-up time) and analyzed only following intensive care unit (ICU) admission. Finally, a data set excluding the first 24 hours after ICU admission was created to explore stability of the device. Patients remained on Dexcom G6Pro CGM until discharge or 10 days postoperatively. RESULTS: The population was 71% male, 14% with known diabetes; 66% required intravenous insulin infusion. The Clarke error grid plot of all measures post-ICU admission showed 53.5% in zone A, 45.9% in zone B, and 0.6% (n = 5) in zones D or E. The restricted dataset that excluded the first 24 hours post-ICU admission showed 55.9% in zone A, 43.9% in zone B, and 0.2% in zone D. Mean absolute relative difference between clinical and Dexcom G6Pro CGM measures was 20.6% and 21.6% in the entire post-ICU admission data set, and the data set excluding the first 24 hours after ICU admission, respectively. In the subanalysis of the 12 patients who did not have more than a 5-minute tap in the operating room, a consensus error grid, demonstrated that after ICU admission, percentage in zone A was 53.9%, zone B 45.4%, and zone C 0.7%. Similar percentages were obtained removing the first 24 hours post-ICU admission. These numbers are very similar to the entire cohort. A consensus error grid created post-ICU admission demonstrated: (zone A) 54%, (zone B) 45%, (zone C) 0.9%, and the following for the dataset created excluding the first 24 hours: (zone A) 56%, (zone B) 44%, (zone C) 0.4%, which demonstrated very close agreement with the original Clarke error grid. No adverse events were reported. CONCLUSIONS: Almost 100% of Dexcom G6Pro CGM and clinical data matching points fell within areas considered as giving clinically correct decisions (zone A) and clinically uncritical decisions (zone B). However, the relatively high mean absolute relative difference precludes its use for both monitoring and treatment in the clinical context. As technology evolves, interstitial glucose monitoring may become an important tool to limit iatrogenic anemia and mitigate glycemic fluctuations.

A Review of Incretin Therapies Approved and in Late-Stage Development for Overweight and Obesity Management.

OBJECTIVE: To review clinical trial data for incretin therapies that are approved or in late-stage development for overweight or obesity management, along with clinical implications of these therapies and future directions. METHODS: We searched for clinical trials involving incretin therapies studied specifically for overweight or obesity management in ClinicalTrials.gov and PubMed from registry inception through December 2023. RESULTS: Glucagon-like peptide-1 (GLP-1) receptor agonism, alone and in combination with glucose-dependent insulinotropic polypeptide (GIP) receptor agonism or glucagon agonism, leads to significant weight reduction in people with overweight or obesity. Newer incretin therapies have demonstrated weight reduction between 15% to 25%, far outpacing non-incretin therapies for weight management and achieving levels of weight loss that may prevent weight-related complications. However, the discontinuation of incretin therapies is associated with weight regain. The main side effects of incretin therapies are transient, mild-to-moderate gastrointestinal side effects - nausea, diarrhea, constipation, and vomiting - that commonly occur in the first 4 to 8 weeks of treatment. There is a rich late-stage pipeline of incretin therapies for weight management, consisting of oral GLP-1 receptor agonists, dual GLP-1/GIP receptor agonists, dual GLP-1/glucagon receptor agonists, triple GLP-1/GIP/glucagon receptor agonists, and combination therapies with nonincretin drugs. CONCLUSION: Newer incretin therapies for weight management have the potential to improve the treatment for overweight and obesity, the treatment and prevention of weight-related complications, and the individualization of weight management. Ensuring that these therapies are accessible - and that treatment with them is consistent and sustainable - is necessary to translate findings from trials into the real world.

Prevalence of Sodium Glucose Cotransporter 2 (SGLT-2) Inhibitor Prescribing in Patients with Type 2 Diabetes Mellitus and Reduced Estimated Glomerular Filtration Rate.

Sodium glucose cotransporter 2 (SGLT-2) inhibitors have demonstrated benefit in people with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD), including slowing the progression of CKD and lowering the risk of kidney failure and death. Despite this evidence, literature suggests SGLT-2 inhibitors are underutilized in this population. To assess prescribing practices and identify potential variables predictive of SGLT-2 inhibitor prescribing, a non-interventional, retrospective, cross-sectional study was conducted in patients with T2DM and reduced estimated glomerular filtration rate (eGFR). The primary outcome compared prevalence of SGLT-2 inhibitor prescribing in patients with T2DM and eGFR of 30-44 mL/min/1.73m2 to patients with T2DM and eGFR 45-59 mL/min/1.73m2. The secondary outcome described possible predictors of prescribing SGLT-2 inhibitors in this population. Of the 9,387 patients identified with T2DM and reduced eGFR, an SGLT-2 inhibitor was prescribed to 324 (12.2%) patients with eGFR of 30-44 mL/min/1.73m2 versus 799 (11.9%) patients with eGFR of 45-59 mL/min/1.73m2. Patients more likely to be prescribed SGLT-2 inhibitors were younger, male, had a higher body mass index (BMI), a higher hemoglobin A1c (HbA1c), were on other antihyperglycemic medications, had concomitant cardiovascular disease, or had concomitant heart failure. This study found no significant difference in prevalence of SGLT-2 inhibitor prescribing between patients with T2DM and eGFR 30-44 mL/min/1.73m2 versus eGFR 45-59 mL/min/1.73m2 (p=0.70). Further exploration into the causes of low SGLT-2 inhibitor prescribing prevalence is warranted given the growing evidence supporting the use of these agents in patients with T2DM and reduced renal function.

Pharmacokinetics and Clinical Implications of Oral Semaglutide for Type 2 Diabetes Mellitus.

Since the approval of subcutaneous glucagon-like peptide-1 receptor agonists, this therapeutic class has become a preferred choice for the management of type 2 diabetes due to A1C reduction, minimal risk of hypoglycemia, weight loss, and cardiovascular benefit. An oral option, with gastrointestinal absorption, would overcome any potential fear of injection among patients. Oral semaglutide has been studied in randomized controlled trials within the PIONEER program. From a robust pool of literature with a global patient population, oral semaglutide has been an effective option as monotherapy and combination therapy to improve clinical outcomes, such as A1C and body weight from baseline to week 78, depending on the randomized controlled trial. In addition, a noninferiority result was observed with oral semaglutide versus placebo in a cardiovascular outcomes trial in patients with type 2 diabetes with established cardiovascular disease or risk factors. Similar to injectable glucagon-like peptide 1 receptor agonists, transient nausea and vomiting was seen with oral semaglutide. Overall, this new oral option may be a choice for patients with barriers to injectable therapy. This review evaluates and summarizes the pharmacokinetics, pharmacodynamics, and clinical application of oral semaglutide in patients with type 2 diabetes.

Pharmacokinetics and Clinical Implications of Semaglutide: A New Glucagon-Like Peptide (GLP)-1 Receptor Agonist.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) came to market in the year 2005, as a new therapeutic classification, for clinical use in the management of type 2 diabetes mellitus (T2DM). Since 2005, there have been six approved products on the market, with the newest product being semaglutide (Novo Nordisk). Several studies have been conducted and completed evaluating its pharmacokinetics as a once-weekly subcutaneous injection. As a dose of 0.5 or 1 mg, semaglutide has a half-life of 7 days; therefore, it would reach steady state in 4-5 weeks. There are few drug interactions and dose adjustments are not necessary. However, similar to other GLP-1 RAs, semaglutide can delay gastric emptying and may impact the absorption of oral medications. Based on clinical trials, semaglutide has been compared with placebo, sitagliptin, exenatide extended release, and insulin glargine as monotherapy or add-on therapy. Semaglutide has resulted in a 1.5-1.9% glycosylated hemoglobin A1c reduction after 30-56 weeks. It also produced 5-10% weight reduction from baseline in clinical efficacy studies. Semaglutide can be another acceptable option for patients with T2DM, and it has a potential role among patients who require weight loss with a low risk of hypoglycemia. This article evaluates the pharmacokinetics of semaglutide and summarizes its application to clinical practice based on efficacy and safety data.

Partners in Public Health: Public Health Collaborations With Schools of Pharmacy, 2015.

To collect data on public health collaborations with schools of pharmacy, we sent a short electronic survey to accredited and preaccredited pharmacy programs in 2015. We categorized public health collaborations as working or partnering with local and/or state public health departments, local and/or state public health organizations, academic schools or programs of public health, and other public health collaborations. Of 134 schools, 65 responded (49% response rate). Forty-six (71%) responding institutions indicated collaborations with local and/or state public health departments, 34 (52%) with schools or programs of public health, and 24 (37%) with local and/or state public health organizations. Common themes of collaborations included educational programs, community outreach, research, and teaching in areas such as tobacco control, emergency preparedness, chronic disease, drug abuse, immunizations, and medication therapy management. Interdisciplinary public health collaborations with schools of pharmacy provide additional resources for ensuring the health of communities and expose student pharmacists to opportunities to use their training and abilities to affect public health. Examples of these partnerships may stimulate additional ideas for possible collaborations between public health organizations and schools of pharmacy.

Jazzin' Healthy: Interdisciplinary Health Outreach Events Focused on Disease Prevention and Health Promotion.

OBJECTIVES: Health-related disparities are a significant public health concern. In conjunction with a university concert series, healthcare professionals and students provided education, clinical services, and preventive care using an interdisciplinary approach to a primarily African American cohort. The objective was to assess cardiovascular risk factors and readiness to change health-related behaviors. METHODS: Six outreach events were conducted over 3 years by an interdisciplinary team including pharmacy, medicine, nursing, nutrition, occupational therapy, public health, optometry, and health information technology. Clinical services, such as health screenings for glucose, blood pressure, cholesterol, and body fat along with counseling on the results and smoking cessation behavioral counseling, were provided. Education initiatives addressed bone health, heart disease, HIV risk, nutrition, and access to physician care. Preventative care included vaccinations and eye exams. RESULTS: There were 285 participants that were predominantly African American (95.8 %), female (71.5 %), and age within 55-64 years (45.1 %). Hypertension (50.8 %) and obesity (65.1 %) were the most common cardiovascular risk factors. Of those advised to make health behavior changes, 76.4 % reported they planned to make changes within 1 month. CONCLUSION: These interdisciplinary outreach events provided health information and access to care in a novel setting and led to a high rate of planned health behavior changes.

Role of glucagon-like peptide 1 receptor agonists in management of obesity.

PURPOSE: Published data on the weight loss effects of glucagon-like peptide 1 (GLP-1) receptor agonists are reviewed, with a focus on data from clinical trials. SUMMARY: Obesity is a significant health problem in the United States (an estimated 69% of U.S. adults are overweight and nearly 35% are obese), and few drugs have proven safety and efficacy as adjuncts to lifestyle modification for weight management. GLP-1 receptor agonists are used for glycemic control in patients with type 2 diabetes and have been studied for their weight loss effects in patients with and without diabetes; these agents produce weight loss benefits through their effects on satiety and gastric emptying. In December 2014, the liraglutide product Saxenda (Novo Nordisk) became the first GLP-1 receptor agonist approved by the Food and Drug Administration (FDA) for use in long-term weight management. Results of clinical trials that evaluated the effects of GLP-1 receptor agonist therapy on weight and body mass index indicated outcomes comparable or superior to those achieved with the use of other antiobesity agents. As a class, GLP-1 receptor agonists have a generally more favorable safety profile than several other antiobesity agents; transient, mild-to-moderate gastrointestinal symptoms were the most frequently reported adverse effects in clinical trials. CONCLUSION: Originally marketed for glycemic control in type 2 diabetes, GLP-1 receptor agonists have been found effective for weight reduction in patients with and without type 2 diabetes. Liraglutide is currently the only GLP-1 receptor agonist approved by FDA for obesity treatment.

A clinical review of GLP-1 receptor agonists: efficacy and safety in diabetes and beyond.

The prevalence of type 2 diabetes is increasing at an astounding rate. Many of the agents used to treat type 2 diabetes have undesirable adverse effects of hypoglycemia and weight gain. Glucagon-like peptide-1 (GLP-1) receptor agonists represent a unique approach to the treatment of diabetes, with benefits extending outside glucose control, including positive effects on weight, blood pressure, cholesterol levels, and beta-cell function. They mimic the effects of the incretin hormone GLP-1, which is released from the intestine in response to food intake. Their effects include increasing insulin secretion, decreasing glucagon release, increasing satiety, and slowing gastric emptying. There are currently four approved GLP-1 receptor agonists in the United States: exenatide, liraglutide, albiglutide, and dulaglutide. A fifth agent, lixisenatide, is available in Europe. There are important pharmacodynamic, pharmacokinetic, and clinical differences of each agent. The most common adverse effects seen with GLP-1 therapy include nausea, vomiting, and injection-site reactions. Other warnings and precautions include pancreatitis and thyroid cell carcinomas. GLP-1 receptor agonists are an innovative and effective option to improve blood glucose control, with other potential benefits of preserving beta-cell function, weight loss, and increasing insulin sensitivity. Once-weekly formulations may also improve patient adherence. Overall, these are effective agents for patients with type 2 diabetes, who are either uncontrolled on metformin or intolerant to metformin.