Initiating GLP-1 Therapy in Combination with FreeStyle Libre Provides Greater Benefit Compared to GLP-1 Therapy Alone.

BACKGROUND AND AIM: Glucagon-like peptide-1 receptor agonists (GLP-1 RA) therapy provides glycemic benefits to individuals with type 2 diabetes (T2D). However, the effects of GLP-1 RA therapy in combination with FreeStyle Libre systems (FSL) are unknown. This study aimed to compare changes in HbA1c between people acquiring GLP-1 with FSL (GLP-1+FSL) vs. GLP-1 without FSL (GLP-1). METHODS: This real-world study utilized Optum's de-identified Market Clarity Data, a linked electronic health records (EHR)-claims database and included adults with T2D and HbA1c ≥8% who acquired their first GLP-1 RA medication between 2018-2022. GLP-1+FSL subjects acquired their first FSL within ±30 days of their first GLP-1 acquisition. Cohorts were matched 1:5 on baseline insulin therapy, age, sex, baseline HbA1c and GLP-1 type. Paired changes in HbA1c were compared between unmatched and matched groups at six months. RESULTS: The study included 24,724 adults in the unmatched cohort (GLP-1+FSL, n=478; GLP-1, n=24,246). The matched cohort included 478 GLP-1+FSL users and 2,390 GLP-1 users: mean age 53.5±11.8 and 53.5 ±11.3 years, HbA1c 10.25±1.68% and 10.22±1.69%, respectively. HbA1c reduction was greater in the GLP-1+FSL group compared to the GLP-1 group in the unmatched cohort (-2.43% vs. -1.73%, difference 0.70%, p<0.001, respectively) and in the matched cohort (-2.43% vs. -2.06%, difference 0.37%, p<0.001). GLP-1+FSL vs. GLP-1 treatment was associated with greater HbA1c reduction in the intensive insulin (-2.32% vs. -1.50%), non-intensive insulin (-2.50% vs. 1.74%), and noninsulin group (-2.46% vs. -1.78%), as well as in patients using semaglutide (2.73% vs. 1.92%) and dulaglutide (2.45% vs. 1.71%) GLP-1 RA, all p<0.001. CONCLUSIONS: Adults with sub-optimally controlled T2D, initiating GLP-1 RA with FreeStyle Libre, had greater improvement in HbA1c compared to those treated with GLP-1 RA only. These results suggest an additional glycemic benefit of FSL when used with a GLP-1 RA in T2D treatment.

Opportunities to overcome underutilization of enhanced insulin delivery technologies in people with type 2 diabetes: a narrative review.

Use of innovative technologies such as continuous glucose monitoring (CGM) and insulin delivery systems have been shown to be safe and effective in helping patients with diabetes achieve significantly improved glycemic outcomes compared to their previous therapies. However, these technologies are underutilized in many primary care practices. This narrative review discusses some of the clinical and economic benefits of tubeless insulin delivery devices and discusses how this technology can overcome the main obstacles inherent to use of conventional insulin delivery devices.

Cardiorenal care coordination: holistic patient care opportunities in the primary care setting for patients with chronic kidney disease and atherosclerotic cardiovascular disease.

OBJECTIVES: Chronic kidney disease (CKD) and atherosclerotic cardiovascular disease (ASCVD) are closely linked conditions, and the presence of each condition promotes incidence and progression of the other. In this study, we sought to better understand the medical journey of patients with CKD and ASCVD and to uncover patients' and healthcare providers' (HCPs) perceptions and attitudes toward CKD and ASCVD diagnosis, treatment, and care coordination. METHODS: Cross-sectional, US-population-based online surveys were conducted between May 18, 2021, and June 17, 2021, among 239 HCPs (70 of whom were primary care physicians, or PCPs) and 195 patients with CKD and ASCVD. RESULTS: PCPs reported personally diagnosing CKD in 78% and ASVD in 64% of their patients, respectively. PCPs reported they are more likely to serve as the overall coordinator of their patient's care (89%), while slightly more than half of PCPs self-identified as a patient's coordinator of care specifically for CKD (54%) or ASCVD (59%). In contrast, patients viewed their PCP as their coordinator of care for CKD (25%) or ASCVD (9%). PCPs who personally treated patients with CKD and ASCVD most often recalled primarily prescribing or recommending pharmacologic treatments for CKD and ASCVD; however, patients reported that lifestyle modification was the most common treatment modality they had ever used to manage CKD and ASCVD. CONCLUSION: CKD and ASCVD are interrelated cardiometabolic conditions with underlying risk factors that can be managed in a primary care setting. However, few patients in our study considered their PCP to be the coordinator of their care for CKD or ASCVD. PCPs can and should take a more active role in educating patients and coordinating care for those with CKD and ASCVD.

Chronic kidney disease (CKD) is a medical condition where the kidneys are damaged, and their function is reduced. CKD is often linked to other health problems. Atherosclerotic cardiovascular disease (ASCVD) is a condition where cholesterol builds up in the arteries, leading to reduced blood flow and heart issues. This study wanted to understand what patients and healthcare providers (HCPs) know about these two conditions and how they are managed. We sent questionnaires to 195 patients with CKD and ASCVD as well as 239 HCPs who treat patients with CKD and ASCVD. The results showed primary care physicians (PCPs) are the main healthcare providers for most patients, but specialists are often involved in managing CKD and ASCVD. PCPs play a crucial role in helping patients understand how other health care conditions can impact their risk for CKD and ASCVD. PCPs can also guide patients on making lifestyle changes to lower their risk of these diseases and can refer patients to specialists, while still providing guidance on management of these conditions.

Continuous Glucose Monitoring in Practice.

LEARNING OBJECTIVES: After reading this review article, participants should be able to: Prepare the practice for continuous glucose monitoring (CGM). Understand options available to the practice for professional (practice-owned) and personal (patient-owned) CGM. Locate and interpret CGM data, using the ambulatory glucose profile (AGP), to determine if the patient is achieving targets established by the International Consensus on Time in Range. Modify a patient's treatment plan based on CGM data to improve patient outcomes.

What Role Might There Be for Continuous Glucose Monitoring in the Assessment of Diabetes Risk?

The term "prediabetes" has traditionally been used to describe the state of abnormal glucose homeostasis (dysglycemia) that could eventually lead to developing clinical type 2 diabetes. The HbA1c, oral glucose tolerance testing, and fasting glucose measurements represent the standard approaches for assessing risk. However, they do not predict with complete accuracy, nor do they provide individualized risk assessment to determine who will develop diabetes. Use of continuous glucose monitoring (CGM) provides a more complete picture of inter- and intraday glucose excursions that may help clinicians and patients quickly identify dysglycemia and make informed personalized intervention decisions. This article discusses the utility of CGM as a tool for both risk assessment and risk management.

Glucagon-Like Peptide 1 Receptor Agonists Have the Potential to Revolutionize the Attainment of Target A1C Levels in Type 2 Diabetes-So Why Is Their Uptake So Low?

A target A1C of <7% is the recommended goal for most people with type 2 diabetes. However, many are not achieving this target with their current treatment. Glucagon-like peptide 1 (GLP-1) receptor agonists are highly efficacious in achieving glycemic control and could aid primary care providers (PCPs) in getting patients to their A1C target. However, despite their potential, use of GLP-1 receptor agonists in the primary care setting is limited. This review provides guidance for PCPs on how to help patients achieve their glycemic target and overcome perceived barriers of GLP-1 receptor agonist use, with the overall goal of improving PCP confidence in prescribing these agents.

Common Questions on Continuous Glucose Monitoring in Primary Care.

LEARNING OBJECTIVES: Identify patients who are good candidates for a continuous glucose monitor (CGM) vs fingerstick self-monitoring of blood glucose (SMBG) Discuss the information provided by CGM systems Generate and interpret patient CGM data using the ambulatory glucose profile (AGP) to assess time targets established by the International Consensus on Time in Range Modify the treatment plan based on CGM data to improve patient outcomes.

Update on the Gut Microbiome for the Primary Care Clinician.

KEY TAKEAWAYS: The gut microbiome, sometimes referred to as the "organ" we do not know we have, is a dynamic ecosystem that plays an important role in human health and disease. Alterations in the gut microbiome (dysbiosis) are associated with wide-ranging disease states, including metabolic diseases like type 2 diabetes mellitus (T2D). Growing evidence suggests improved gut microbiome composition from targeted microbiome interventions leads to improvement in glycemic control in patients with T2D.

Remote Patient Monitoring in Diabetes: How to Acquire, Manage, and Use All of the Data.

The ability of patients and health care providers to use various forms of technology for general health has significantly increased in the past several years with the expansion of telehealth, digital applications, personal digital devices, smartphones, and other internet-connected platforms and devices. For individuals with diabetes, this also includes connected blood glucose meters, continuous glucose monitoring devices, and insulin delivery systems. In this article, the authors outline several steps to facilitate the acquisition, management, and meaningful use of digital diabetes data that can enable successful implementation of both diabetes technology and telehealth services in primary care clinics.

Flash glucose monitoring in type 2 diabetes managed with basal insulin in the USA: a retrospective real-world chart review study and meta-analysis.

INTRODUCTION: Evidence supporting use of continuous glucose monitoring in type 2 diabetes treated with basal insulin is unclear. This real-world study aimed to assess the impact on glycated hemoglobin (HbA1c) of flash glucose monitoring use in adults with type 2 diabetes managed with basal insulin. RESEARCH DESIGN AND METHODS: Medical records were reviewed for adult individuals with type 2 diabetes using basal insulin for ≥1 year with or without additional antihyperglycemic medication, HbA1c 8.0%-12.0% prior to FreeStyle Libre Flash Glucose Monitoring use for ≥90 days and an HbA1c measurement recorded between 90 and 194 days after device use. Exclusion criteria included utilization of bolus insulin. Meta-analysis data are from the current study (USA) and a similar Canadian cohort. RESULTS: Medical record analysis (n=100) from 8 USA study sites showed significant HbA1c decrease of 1.4%±1.3%, from 9.4%±1.0% at baseline to 8.0%±1.2% after device use, p<0.0001 (mean±SD).Meta-analysis of medical records from USA and Canada sites (n=191) showed HbA1c significantly decreased by 1.1%±0.14% (mean±SE), from baseline 9.2%±1.0% to 8.1%±1.1%, p≤0.0001, with moderate to high heterogeneity between sites (Q=43.9, I2=74.9, p<0.0001) explained by differences in baseline HbA1c between sites.The HbA1c improvement in both groups was observed by age group, body mass index, duration of insulin use and sex at birth. CONCLUSIONS: In a real-world retrospective USA study and a meta-analysis of a larger USA and Canada cohort, HbA1c significantly reduced in basal insulin-treated type 2 diabetes, without bolus insulin initiation and following the commencement of flash glucose monitoring technology.

Flash CGM associated with event reduction in nonintensive diabetes therapy.

OBJECTIVES: We evaluated the effects of acquiring a flash continuous glucose monitoring (CGM) system in the population with type 2 diabetes (T2D) treated with basal or noninsulin therapy. STUDY DESIGN: This was a retrospective database analysis of the IBM MarketScan Commercial Claims and Medicare Supplemental databases that assessed rates of acute diabetes-related events (ADEs) and all-cause inpatient hospitalizations (ACHs) in a large population with T2D treated with basal insulin therapy or noninsulin medications. ADE and ACH rates 6 months prior to and 6 months post CGM acquisition were compared. METHODS: Inclusion criteria for analysis were diagnosis of T2D; age 18 years or older; treatment with long-acting, neutral protamine Hagedorn, or premixed insulin or noninsulin therapy; naïve to CGM; and acquisition of their flash CGM system between October 2017 and March 2019. Patients served as their own controls. Event rates were compared using weighted Cox regression with Andersen-Gill extension for repeat events. RESULTS: A cohort of 10,282 adults with T2D (mean [SD] age, 53.1 [9.6] years; 51.9% male) who met inclusion criteria were assessed. ADE rates decreased from 0.076 to 0.052 events per patient-year (HR, 0.68; 95% CI, 0.58-0.80; P < .001). ACH rates decreased from 0.177 to 0.151 events per patient-year (HR, 0.85; 95% CI, 0.77-0.94; P = .002). CONCLUSIONS: Acquisition of the flash CGM system was associated with significant reductions in outpatient and inpatient ADEs and ACHs. These findings provide compelling evidence that use of flash CGM in patients with T2D treated with basal insulin therapy or noninsulin therapy improves clinical outcomes and potentially reduces costs.

Just Because You Can, Doesn't Mean You Should Now. A Practical Approach to Counseling Persons with Diabetes on Use of Optional CGM Alarms.

Advances in glucose monitoring technologies have led to the development of different types of continuous glucose monitoring (CGM) platforms: traditional CGM and flash CGM. Both platforms provide critical glucose data that enable persons with diabetes (PwDs) to make more informed decisions in their self-management. Until recently, a key advantage of traditional CGM over flash CGM was the availability of automatic alarms that warn users about current or impending hypoglycemia and hyperglycemia. However, with the introduction of the FreeStyle Libre 2 (FSL2) system (Abbott Diabetes Care, Alameda, CA), PwD can now utilize flash CGM with the option to set low and high glycemic thresholds and receive alarms when these thresholds are crossed. In addition, having the option to use or not use the alarms may attract previous traditional CGM users who grew fatigued by constant alarms. However, despite the additional layer of safety that alarms provide, many PwD are reluctant to switch from self-monitoring of blood glucose to CGM due to concerns about how alarms could impact the quality of their daily lives. This reluctance is heightened by their perceptions that use of alarms is mandatory. Because the functionality of the FSL2 alarms differs from current traditional CGM devices, it is important that clinicians become familiar with these differences. Moreover, clinicians will be challenged to help PwD overcome their concerns about the use of alarms. This article presents a comprehensive description of the FSL2 alarms function and provides guidance to clinicians when counseling PwDs about the strengths, limitations, and various ways that the FSL2 alarms can be used in daily diabetes self-management.

Integrating Continuous Glucose Monitoring Into Clinical Practices and Patients' Lives.

Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring (CGM) in individuals with diabetes. Within ongoing innovations in CGM technology, individuals now have an expanding array of options that allow them to select the device that meets their individual needs and preferences. Although demand for CGM in primary care continues to grow, many clinicians are reluctant to prescribe this technology due to their unfamiliarity with the various devices, uncertainty about which devices are best suited to each patient and the feasibility of using CGM. This article reviews the features and functionality of the most recent commercially available CGM devices and provides guidance for integrating CGM use into clinical practices.

Utilizing CGM Ambulatory Glucose Profiles to Optimize Diabetes Management.

LEARNING OBJECTIVES: At the end of the activity, participant will be able to: • Identify patients who could benefit from continuous glucose monitoring (CGM) vs fingerstick blood glucose monitoring. • List the types of information provided by CGM systems. • Interpret CGM data using the ambulatory glucose profile (AGP) to assess if the patient is achieving targets established by the International Consensus on Time in Range. • Modify the treatment plan based on CGM data to improve patient outcomes.

Use of Flash Continuous Glucose Monitoring Is Associated With A1C Reduction in People With Type 2 Diabetes Treated With Basal Insulin or Noninsulin Therapy.

BACKGROUND: Glycemic control is suboptimal in many individuals with type 2 diabetes. Although use of flash continuous glucose monitoring (CGM) has demonstrated A1C reductions in patients with type 2 diabetes treated with a multiple daily injection or insulin pump therapy regimen, the glycemic benefit of this technology in patients with type 2 diabetes using nonintensive treatment regimens has not been well studied. METHODS: This retrospective, observational study used the IBM Explorys database to assess changes in A1C after flash CGM prescription in a large population with suboptimally controlled type 2 diabetes treated with nonintensive therapy. Inclusion criteria were diagnosis of type 2 diabetes, age <65 years, treatment with basal insulin or noninsulin therapy, naive to any CGM, baseline A1C ≥8%, and a prescription for the FreeStyle Libre flash CGM system during the period between October 2017 and February 2020. Patients served as their own control subject. RESULTS: A total of 1,034 adults with type 2 diabetes (mean age 51.6 ± 9.2 years, 50.9% male, baseline A1C 10.1 ± 1.7%) were assessed. More patients received noninsulin treatments (n = 728) than basal insulin therapy (n = 306). We observed a significant reduction in A1C within the full cohort: from 10.1 ± 1.7 to 8.6 ± 1.8%; Δ -1.5 ± 2.2% (P <0.001). The largest reductions were seen in patients with a baseline A1C ≥12.0% (n = 181, A1C reduction -3.7%, P <0.001). Significant reductions were seen in both treatment groups (basal insulin -1.1%, noninsulin -1.6%, both P <0.001). CONCLUSION: Prescription of the flash CGM system was associated with significant reductions in A1C in patients with type 2 diabetes treated with basal insulin or noninsulin therapy. These findings provide evidence for expanding access to flash CGM within the broader population of people with type 2 diabetes.

Addressing Therapeutic Inertia in 2020 and Beyond: A 3-Year Initiative of the American Diabetes Association.

Research has shown that getting to glycemic targets early on leads to better outcomes in people with type 2 diabetes; yet, there has been no improvement in the attainment of A1C targets in the past decade. One reason is therapeutic inertia: the lack of timely adjustment to the treatment regimen when a person's therapeutic targets are not met. This article describes the scope and priorities of the American Diabetes Association's 3-year Overcoming Therapeutic Inertia Initiative. Its planned activities include publishing a systematic review and meta-analysis of approaches to reducing therapeutic inertia, developing a registry of effective strategies, launching clinician awareness and education campaigns, leveraging electronic health record and clinical decision-support tools, influencing payer policies, and potentially executing pragmatic research to test promising interventions.