Tirzepatide for type 2 diabetes.

One in ten adults worldwide is living with diabetes, with 95% having type 2 diabetes (T2D). Sustained glycaemic control in people with T2D is difficult to achieve despite recent advances in T2D management with the advent of glucagon-like peptide 1 receptor agonists (GLP1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i). Tirzepatide represents a first-in-class agent as a dual glucose-dependent insulinotropic polypeptide (GIP)/GLP1RA to be approved in the USA and Europe for the treatment of T2D. This narrative review intends to list and discuss the glycaemic efficacy, key safety and weight loss outcomes related to the treatment of T2D with tirzepatide. Tirzepatide has been evaluated in five published clinical trials (n=6278) within the SURPASS clinical trial programme, with a focus on glycaemic control and weight loss. These trials have demonstrated significant improvements in glycosylated haemoglobin (-1.24% to -2.11% versus placebo and -0.6% to -1.14% versus active comparator) and weight (up to 15.5 kg versus placebo or active comparator) in patients with T2D. Notably, tirzepatide exhibited superior glycaemic control and weight loss when compared directly with a GLP1RA. Adverse events with the use of tirzepatide are similar to other approved GLP1RA and are predominantly gastrointestinal (nausea, vomiting). The tirzepatide cardiovascular outcomes trial (SURPASS-CVOT) is in progress and is expected to be completed in the fall of 2024. Tirzepatide represents an attractive new option and first-in-class agent for the treatment of T2D in people unable to achieve their glycaemic or weight management goals.

Diabetes: how to manage cardiovascular risk in secondary prevention patients.

Atherosclerotic cardiovascular disease (ASCVD) commonly affects people with type 2 diabetes (T2D). Historically, traditional cardiovascular (CV) risk-lowering therapies in patients with T2D and ASCVD have included antiplatelet agents, blood pressure-lowering therapies, lipid-lowering therapies and healthy lifestyle modifications. In the past decade, multiple antihyperglycaemic agents have emerged as CV risk-lowering therapies in this population as well. This article provides a narrative review on the current non-glycaemic and glycaemic treatment options for CV risk reduction in patients with T2D and ASCVD. The FDA requirement that all new antihyperglycaemic agents undergo cardiovascular outcomes trials has demonstrated increasing evidence to support the role of glucagon-like peptide 1 (GLP1) receptor agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors as first-line agents for both glycaemic control and CV risk reduction in this population.

Examining the Directionality of the Relationship Between Maternal Warmth and Early School-Age Anxiety.

Maternal warmth has been identified as a contributing factor to the development of child anxiety; however, no studies to date have examined observed maternal warmth longitudinally in this relationship. The present study addressed this knowledge gap by examining the simultaneous development of maternal warmth and child anxiety over time (between-person effects using latent growth curve modeling) and the directionality of associations (within-person effects using autoregressive latent trajectory modeling). Participants included 753 mothers and children. Between-person effects indicated that lower initial levels of anxiety were related to greater levels of maternal warmth over time. Within-person effects showed that maternal warmth in grade 1 predicted subsequent decreases in child anxiety in grade 2 (i.e., a parent effect). Present findings demonstrate the importance of maternal warmth in the early school-age years for decreasing subsequent child anxiety.

Clinical Pharmacist Outreach to Increase Statin Use for Patients with Cardiovascular Disease in a Safety-Net Healthcare System.

BACKGROUND: Statin Therapy for Patients with Cardiovascular Disease (SPC) is a Centers for Medicare & Medicaid Services Star measure added to Medicare Part C (Medicare Advantage) plans in 2019 to incentivize statin use for secondary prevention of cardiovascular disease (CVD). The measure assesses statin dispensing and adherence in patients with atherosclerotic CVD (ASCVD). Clinical pharmacists are well-positioned to affect positively a health system's performance on the SPC measure. OBJECTIVE: To assess the effect of telephone outreach by clinical pharmacists on moderate- or high-intensity statin prescribing in patients with ASCVD. METHODS: Patients in managed care health plans who meet the SPC measure criteria and are not currently receiving a moderate- to high-intensity statin therapy were contacted by a clinical pharmacist through telephone outreach. If appropriate, they were prescribed a statin by a clinical pharmacist. The primary outcome measure was the proportion of patients who meet the SPC measure classification and had 1 confirmed prescription fill for a moderate- or high-intensity statin after intervention by a clinical pharmacist. RESULTS: A total of 84 patients were identified for review and outreach, of whom 35 (41.7%) met the SPC measure criteria. Of these 35 patients, 16 (45.7%) were female and the mean age was 66 years. A total of 22 (62.9%) patients agreed to a statin prescription, and 16 (72.7%) of these patients picked up the prescription within 10 days of prescribing. An additional 4 patients, for a total of 20 (57.1%) of the 35 eligible patients, were eventually dispensed a statin. Healthcare Effectiveness Data and Information Set (HEDIS) vendor data available after the intervention showed a larger SPC measure population than was captured with the health plan's internal report. HEDIS data showed an increase in statin prescribing for patients meeting the SPC measure classification from 24.7% to 56.6% during the study period (P <.001). The mean time spent per patient for chart review and/or outreach by the clinical pharmacist was 27.7 (standard deviation, 9) minutes. CONCLUSION: These results indicate that clinical pharmacists who conduct a telephonic population health intervention can achieve a high rate of success in initiating a moderate- to high-intensity statin therapy in patients with ASCVD.

Retrospective cohort study of statin prescribing for primary prevention among people living with HIV.

OBJECTIVE: To compare statin prescribing rates between intermediate-risk people living with human immunodeficiency virus (HIV; PLWH) and intermediate-risk patients without a diagnosis of HIV for primary prevention of atherosclerotic cardiovascular disease (ASCVD). METHODS: Retrospective cohort study . Electronic health record data were used to identify a cohort of PLWH aged 40-75 years with a calculated 10-year ASCVD risk between 7.5%-19.9% as determined by the Pooled Cohort Equation (PCE). A matched cohort of primary prevention non-HIV patients was identified. The primary outcome was the proportion of PLWH who were prescribed statin therapy compared to patients who were not living with HIV and were prescribed statin therapy. RESULTS: 81 patients meeting study criteria in the PLWH cohort were matched to 81 non-HIV patients. The proportion of patients prescribed statins was 33.0% and 30.9% in the PLWH and non-HIV cohorts, respectively (p = 0.74).Conclusion and relevance: This study evaluated statin prescribing in PLWH for primary prevention of ASCVD as described in the 2018 AHA/ACC/Multisociety guideline. Rates of statin prescribing were similar, yet overall low, among intermediate-risk primary prevention PLWH compared to those not diagnosed with HIV.

Antihypertensive prescribing patterns and hypertension control in females of childbearing age.

PURPOSE: The use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) to treat hypertension (HTN) during pregnancy presents well-established risks to a developing fetus. A cross-sectional study was conducted to evaluate the current state of antihypertensive prescribing and contraceptive use in females of childbearing age within a large safety-net health system. METHODS: The retrospective cross-sectional study focused on females aged 18-49 years with a documented diagnosis of HTN. The proportion of patients prescribed an ACE inhibitor or ARB and using a documented form of contraception was calculated. Documented forms of contraception included oral contraceptives, intrauterine devices, injections, implants, and surgical intervention. RESULTS: A total of 4,187 patients were identified from the HTN registry; after application of exclusion criteria 3,045 patients were included in the study population. The mean age was 39 years (range, 18-49 years). The most frequently prescribed classes of antihypertensive medications were ACE inhibitors and ARBs (one or the other was used by 1,146 patients [37.6%]), followed by thiazide diuretics (n = 710, 23.3%) and calcium channel blockers (n = 599, 19.7%). Of the 1,146 patients prescribed an ACE inhibitor or ARB, 553 (48%) were using a documented form of contraception. CONCLUSION: Rates of ACE inhibitor or ARB prescribing to females of childbearing age were high despite the teratogenic risks, and fewer than half of patients had documented protection from pregnancy. Provider and patient education and potential creation of best practice alerts in the electronic medical record regarding the risks of using ACE inhibitors and ARBs in females of childbearing age are warranted.

Drugs in Context Editorial: Review of 2020 and what lies ahead in therapeutic interventions.

The year 2020 was dominated by the COVID-19 pandemic, bringing with it unprecedented advancements in the fields of healthcare and therapeutic interventions as well as in vaccine and drug development. Nevertheless, several other advancements in various fields of medicine also deserve attention. Herein, the Senior Editors of Drugs in Context provide us with their expert opinion on the events of 2020 and what lies ahead in 2021.

Ertugliflozin in the treatment of type 2 diabetes mellitus.

More than 422 million people worldwide have diabetes, with 90-95% having type 2 diabetes (T2D). Glycemic control of T2D has demonstrated reductions in microvascular complications but recent data have demonstrated improvements in macrovascular outcomes with sodium-glucose cotransporter 2 (SGLT2) inhibitors. Ertugliflozin is the most recent SGLT2 inhibitor approved in the USA and Europe for the treatment of T2D. This narrative review aims to present and discuss the efficacy, safety, cardiovascular (CV), and renal outcomes related to the use of ertugliflozin in T2D. Ertugliflozin has been evaluated in eight clinical trials (n=5248) with a focus on glycemic control. These trials have demonstrated improvement in glycosylated hemoglobin (0.6-1%), fasting plasma glucose (30-50 mg/dL), 2-hour postprandial glucose (60-70 mg/dL), decreased body weight (2-3 kg), and lowering of blood pressure (3-5 mmHg) in patients with T2D when ertugliflozin is used as monotherapy or in addition to metformin, sitagliptin, insulin, and/or sulfonylureas. The findings from the VERTIS-CV trial (n=8246) were recently published and demonstrated that ertugliflozin use in patients with T2D and atherosclerotic CV disease is safe but did not demonstrate superiority in the lowering of major CV events compared to placebo. Other SGLT2 inhibitors, such as empagliflozin and canagliflozin, have demonstrated this benefit. The VERTIS-CV trial demonstrated that the use of ertugliflozin led to a decrease in the number of hospitalizations for heart failure and this lends further support that this benefit is a class effect of SGLT2 inhibitors.

Bempedoic acid for the treatment of dyslipidemia.

Cardiovascular disease (CVD) is the leading cause of death worldwide and one key factor associated with the increased CVD risk is dyslipidemia. Statin therapy remains the first-line treatment to manage dyslipidemia, yet many patients do not achieve optimal low-density lipoprotein-cholesterol (LDL-C) levels even after taking moderate- or high-intensity statins; therefore, additional, non-statin therapy is often needed. Bempedoic acid is a prodrug that, once activated, decreases LDL-C levels by the inhibition of adenosine triphosphate citrate lyase in the liver. Five clinical trials have demonstrated the safety and efficacy of bempedoic acid and the bempedoic acid/ezetimibe combination in lowering LDL-C in patients with atherosclerotic CVD and heterozygous familial hypercholesterolemia and also in high-risk primary prevention, and statin-intolerant patients. Bempedoic acid has been demonstrated to lower LDL-C levels by 15-25% in clinical trials and up to 38% when combined with ezetimibe. In 2020, the FDA approved bempedoic acid. Furthermore, the combination of bempedoic acid with ezetimibe is FDA approved for the treatment of adults with heterozygous familial hypercholesterolemia or established atherosclerotic CVD who require additional LDL-C lowering after maximally tolerated statin therapy. The ongoing CLEAR OUTCOMES trial aims to evaluate whether bempedoic acid can reduce cardiovascular events in patients with statin intolerance and results will be available in the next 3 years. This outcomes trial will be pivotal for determining the role of bempedoic acid in the non-statin lipid-lowering armamentarium.

Evaluation of a Pharmacist-Led Intervention to Improve Statin Use in Persons with Diabetes.

BACKGROUND: The Statin Use in Persons with Diabetes (SUPD) measure, developed and endorsed by the Pharmacy Quality Alliance and National Quality Forum, has been adopted by the Centers for Medicare & Medicaid Services as part of the star rating measure set. It was added as a display measure in 2015 and, as of 2019, has become a star measure. Clinical pharmacy specialists (CPS) embedded in the patient-centered medical home (PCMH) are well positioned to review and recommend statin therapy for patients with diabetes in order to improve patient care and health plan performance. OBJECTIVE: To improve rates of statin prescribing and performance on the SUPD measure in the Denver Health Medical Plan (DHMP) population with diabetes by creating a CPS-led intervention to initiate statin prescriptions in eligible patients. METHODS: Between February 1, 2018, and December 31, 2018, DHMP patients who met SUPD measure criteria (aged ≥ 40 and ≤ 75 years, dispensing events for at least 2 diabetes mellitus medication fills, and no statin prescribed) were identified by the health plan chart review and contacted by CPS as appropriate. For patients eligible and agreeable to statin therapy, the CPS initiated the statin prescription. Descriptive statistics were used to summarize outreach and statin prescribing data. Prescription drug event data were also collected from the health plan to verify SUPD measure performance. RESULTS: At the start of 2018, DHMP's performance on the SUPD measure was 65.7% (Medicare Advantage Part D national average was 68.5%). Of the 326 patients whose charts were reviewed and who were contacted, 275 (84.4%) were eligible for statin initiation, and of these, 115 (41.8%) were prescribed statin therapy. The increase in statin prescribing and dispensing increased DHMP's performance on the SUPD measure to 87.1% at the end of 2018, which correlates with a 5-star rating based on the 2019 cut points. CONCLUSIONS: CPS embedded in the PCMH setting are well positioned to participate in and positively affect population health initiatives such as the SUPD measure. Appropriate prescribing of statin therapy by CPS for patients included in the SUPD measure ensures that they are on key medication therapy for mitigating atherosclerotic cardiovascular disease and may improve a health plan's Medicare star rating. DISCLOSURES: This was an unfunded, investigator-initiated project. Anderson owns stock in Merck & Co. All other authors have no conflicts of interest to disclose.

Oral semaglutide in type 2 diabetes.

BACKGROUND: Previously, the only available glucagon-like peptide-1 receptor agonists (GLP-1 RA) were injectable. Approval of oral semaglutide (Rybelsus®) represents the first orally available GLP-1 RA. OBJECTIVE: To review the literature and describe pharmacologic, pharmacokinetic, and pharmacodynamics properties; clinical safety; and efficacy of oral semaglutide, a newly approved oral GLP-1 RA. METHODS: A MEDLINE (1995-October 2019) and ClinicalTrials.gov search was conducted using the terms oral semaglutide, semaglutide, PIONEER, and a combination of those terms. Reference citations from publications identified were also reviewed. All English-language studies, including abstracts, evaluating oral semaglutide use in humans were included in this review. CONCLUSIONS: The approval of oral semaglutide (Rybelsus®) represents a paradigm shift in the management of T2D as this is the first FDA-approved oral GLP-1 RA. Oral semaglutide may be an attractive option for patients with T2D who require improved glycemic control, would like to lose weight, and who are not interested in injectable therapy. However, the lack of positive cardiovascular (CV) and renal data are significant limitations to its use.

Can Direct Oral Anticoagulants Be Used for Stroke Prevention Among Patients with Valvular Atrial Fibrillation?

PURPOSE OF REVIEW: To review the clinical evidence underlying the efficacy and safety of the use of direct oral anticoagulants (DOACs) for the treatment of patients with valvular atrial fibrillation (AF). RECENT FINDINGS: The recent focused update to the 2014 AHA/ACC/HRS Atrial Fibrillation Guidelines defines valvular AF as AF in the setting of moderate-to-severe mitral stenosis (MS) and/or in the presence of a mechanical heart valve. Landmark clinical trials of DOACs in patients with AF systematically excluded these patient populations. However, there are trial data in both animals and humans regarding the use of DOACs in patients with MS and in those with mechanical heart valves. Based on sub-analyses and meta-analyses of clinical trial data in patients with AF, the use of DOACs in valvular AF is not recommended. Patients with moderate-to-severe MS or a mechanical heart valve and AF should be anticoagulated with dose-adjusted warfarin. DOACs are reasonable alternatives to warfarin in patients with AF and other types of valvular disease, including mild MS and bioprosthetic valves.

Implementation of a Pharmacist-Led Diabetes Management Protocol.

BACKGROUND: Little data exist regarding how pharmacist-led collaborative drug therapy management protocols are implemented in health systems. Barriers to collaborative drug therapy management protocol implementation exist, but they can be overcome by effective protocol education and communication, allowing pharmacists to manage more patients with chronic disease states, thereby enhancing quality health outcomes for patients and reducing health resource utilization. OBJECTIVE: To determine the preferred method of provider education regarding the implementation of a pharmacist-led type 2 diabetes collaborative drug therapy management protocol, and to assess pharmacist and provider satisfaction with the protocol implementation. METHODS: This single-center, prospective cohort study included pharmacists practicing within a pharmacist-led type 2 diabetes collaborative drug therapy management protocol, as well as providers practicing at 4 primary care clinics within a health system. All providers received an e-mail regarding education about the protocol. In addition, providers at 2 of the clinics received education about the protocol at a provider meeting, and providers at the other 2 clinics received a personalized provider report card. The personalized provider report card identified patients within the provider's panel who met criteria for referral to a pharmacist under the new protocol. The referred patients were tracked for 2 months, and provider and pharmacist satisfaction with the protocol were assessed. RESULTS: A total of 54 patients were referred for pharmacist management per the protocol. The majority (89%) of patients were referred by providers who received a personalized provider report card. Nearly all (96%) of the providers were satisfied with the protocol-driven services, and most (67%) pharmacists were satisfied with their role in managing patients with type 2 diabetes under the collaborative drug therapy management protocol. CONCLUSION: The majority of patients with type 2 diabetes who were referred for pharmacist management per the protocol were referred by providers who received personalized provider report cards. Provider and pharmacist satisfaction with the new pharmacist-led protocol was high.

The Influence of Social Support and Social Integration Factors on Return to Work Outcomes for Individuals with Work-Related Injuries: A Systematic Review.

Purpose In occupational rehabilitation, the biopsychosocial model endorses the role of social factors in worker recovery. We conducted a systematic review to explore three questions examining the role of social support for the return-to-work (RTW) of individuals with work-related injury: (1) What are the worker-identified social barriers and facilitators in RTW; (2) What is the relationship between social factors and RTW; and (3) What is the effectiveness of social interventions for RTW. Methods Systematic searches of six databases were conducted for each research question. These identified 11 studies meeting inclusion criteria for Research Question 1, and 12 studies for Research Question 2. No studies were identified that met inclusion criteria for Research Question 3. A narrative synthesis approach was used to analyse the included studies. Results Research Question 1 identified five themes in social barriers and facilitators to RTW, including contact/communication, person-centred approaches, mutual trust, reaction to injury, and social relationships. Research Question 2 identified moderate support for reaction to injury and social integration/functioning as predictors of RTW and weak evidence for co-worker support. Four studies reported significant associations between social factors and RTW, six reported mixed findings with at least one significant social predictor, and two found no significant relationships. However, conclusions were limited by the inconsistency in measurement of social factors. Conclusions Our findings indicate that social support and integration may influence RTW following work-related injury, and highlights the need for further systematic examination of social factors in the field of occupational rehabilitation.

Sacubitril/valsartan: evaluation of safety and efficacy as an antihypertensive treatment.

Hypertension (HTN) is a common disease state associated with extensive morbidity and mortality worldwide. It is often difficult for patients with HTN to achieve and maintain a goal blood pressure (BP), despite there being many effective treatment options available. Sacubitril/valsartan is a first-in-class angiotensin receptor neprilysin inhibitor (ARNI) that has garnered approval by the US Food and Drug Administration and the European Medicines Agency as a first-line treatment for heart failure with reduced ejection fraction. During clinical trials for heart failure as well as in independent trials for HTN, sacubitril/valsartan has demonstrated safety and efficacy when it comes to BP lowering, making it a promising antihypertensive agent. Most trials of sacubitril/valsartan were 8 to 12 weeks in length and demonstrated a clinically relevant BP lowering that was frequently more significant than its comparators. While more data are needed to confirm its role as an antihypertensive agent, the data available are promising and it is anticipated that sacubitril/valsartan will gain an indication of HTN.

A Review of the Role of the Pharmacist in Heart Failure Transition of Care.

This article reviews current literature on the role of pharmacists in the transition of care (TOC) for patients with heart failure (HF) and the impact of their contributions on therapeutic and economic outcomes. Optimizing the TOC for patients with HF from the hospital to the community/home is crucial for improving outcomes and decreasing high rates of hospital readmissions, which are associated with increased morbidity, mortality, and costs. A multidisciplinary team approach to the management of patients with HF facilitates the transition from the hospital to the ambulatory care setting, allowing for the consideration of medical, pharmacological, and lifestyle variables that impact the care of individual patients. Pharmacist participation on both inpatient and outpatient teams can provide a variety of services that have been shown to reduce hospital readmission rates and benefit patient management and treatment. These include medication reconciliation, patient education, medication dosage titration and adjustment, patient monitoring, development of disease management pathways, promotion of medication adherence, and postdischarge follow-up. In addition, as new pharmacologic treatments for HF become available, pharmacists can raise awareness of optimal drug use by maximizing education related to efficacy (e.g., adherence) and safety (e.g., potential side effects and drug interactions). Improving understanding of HF and its treatment will enable increased pharmacist involvement in the TOC that should lead to improved outcomes and reduced healthcare costs. FUNDING: Novartis.

Reliability and concurrent validity of the iPhone® Compass application to measure thoracic rotation range of motion (ROM) in healthy participants.

BACKGROUND: Several water-based sports (swimming, surfing and stand up paddle boarding) require adequate thoracic mobility (specifically rotation) in order to perform the appropriate activity requirements. The measurement of thoracic spine rotation is problematic for clinicians due to a lack of convenient and reliable measurement techniques. More recently, smartphones have been used to quantify movement in various joints in the body; however, there appears to be a paucity of research using smartphones to assess thoracic spine movement. Therefore, the aim of this study is to determine the reliability (intra and inter rater) and validity of the iPhone® app (Compass) when assessing thoracic spine rotation ROM in healthy individuals. METHODS: A total of thirty participants were recruited for this study. Thoracic spine rotation ROM was measured using both the current clinical gold standard, a universal goniometer (UG) and the Smart Phone Compass app. Intra-rater and inter-rater reliability was determined with a Intraclass Correlation Coefficient (ICC) and associated 95% confidence intervals (CI). Validation of the Compass app in comparison to the UG was measured using Pearson's correlation coefficient and levels of agreement were identified with Bland-Altman plots and 95% limits of agreement. RESULTS: Both the UG and Compass app measurements both had excellent reproducibility for intra-rater (ICC 0.94-0.98) and inter-rater reliability (ICC 0.72-0.89). However, the Compass app measurements had higher intra-rater reliability (ICC = 0.96 - 0.98; 95% CI [0.93-0.99]; vs. ICC = 0.94 - 0.98; 95% CI [0.88-0.99]) and inter-rater reliability (ICC = 0.87 - 0.89; 95% CI [0.74-0.95] vs. ICC = 0.72 - 0.82; 95% CI [0.21-0.94]). A strong and significant correlation was found between the UG and the Compass app, demonstrating good concurrent validity (r = 0.835, p < 0.001). Levels of agreement between the two devices were 24.8° (LoA -9.5°, +15.3°). The UG was found to consistently measure higher values than the compass app (mean difference 2.8°, P < 0.001). CONCLUSION: This study reveals that the iPhone® app (Compass) is a reliable tool for measuring thoracic spine rotation which produces greater reproducibility of measurements both within and between raters than a UG. As a significant positive correlation exists between the Compass app and UG, this supports the use of either device in clinical practice as a reliable and valid tool to measure thoracic rotation. Considering the levels of agreement are clinically unacceptable, the devices should not be used interchangeably for initial and follow up measurements.

Do Callous-Unemotional Traits and Conduct Disorder Symptoms Predict the Onset and Development of Adolescent Substance Use?

Despite strong evidence of the relationship between conduct disorder (CD) symptoms and substance use, it is unclear how callous-unemotional (CU) traits predict substance use over and above CD symptoms, and their potential interaction. This study used data from 753 participants followed from grade 7 to 2-years post-high school. Latent growth curve models showed that CU traits predicted the onset of cigarette use, alcohol misuse, and a substance use composite at grade 7 only when no CD symptoms were present. Among those without CD symptoms, boys showed greater change in the odds of using cigarettes, and were more likely to misuse alcohol or use any substance at grade 7 than girls. However, CD symptoms, CU traits, and their interaction did not predict the linear rates of growth of substance use over time. Thus, CU traits may uniquely predict adolescent substance use when CD symptoms are not present. This research has implications for predicting onset of adolescent substance use and for incorporating the assessment of CU traits into interventions targeting adolescent substance use.

Switching basal insulins in type 2 diabetes: practical recommendations for health care providers.

Basal insulin remains the mainstay of treatment of type 2 diabetes when diet changes and exercise in combination with oral drugs and other injectable agents are not sufficient to control hyperglycemia. Insulin therapy should be individualized, and several factors influence the choice of basal insulin; these include pharmacological properties, patient preferences, and lifestyle, as well as health insurance plan formularies. The recent availability of basal insulin formulations with longer durations of action has provided further dosing flexibility; however, patients may need to switch agents throughout therapy for a variety of personal, clinical, or economic reasons. Although a unit-to-unit switching approach is usually recommended, this conversion strategy may not be appropriate for all patients and types of insulin. Glycemic control and risk of hypoglycemia must be closely monitored by health care providers during the switching process. In addition, individual changes in care and formulary coverage need to be adequately addressed in order to enable a smooth transition with optimal outcomes.