Peer-to-Peer, Interactive GP Education can Reduce Barriers to Best Practice in Diabetes Management.

INTRODUCTION: Perceived difficulties in initiating insulin in patients with type 2 diabetes (T2D) may prevent many general practitioners (GPs) from using insulin even when recommended in guidelines. This paper describes a Royal Australian College of General Practitioners accredited education program on starting insulin in T2D, and its impact on GPs' attitudes and behavior. METHODS: A faculty comprising GPs with diabetes expertise, Credentialed Diabetes Nurse Educators, and endocrinologist developed and implemented the education program. The program content was highly procedure focussed, emphasizing simple, best-practice processes for starting insulin therapy and focussing on multidisciplinary models of care. The highly interactive format of the workshops included peer-to-peer learning, in which education was led by diabetes-experienced GP educators, as well as case study-based approaches and small group discussions. GP attendees were asked to rate their individual confidence and attitudes at the beginning and end of the meeting. In addition, participants (n = 220) from two workshops in 2013 were sent a survey 3 months after the meeting to gauge the longer-term impact on their clinical practice. RESULTS: Since 2008, more than 2500 GPs have attended the workshops, and report substantial improvements in confidence; after attending, more GPs were willing to start insulin within their practice. Evaluations at 3 months post-meeting indicate that the increased confidence was associated with behavioral changes in the subgroup evaluated at this time (n = 48). Success of this program was attributed to peer-to-peer education, multidisciplinary input, easily implemented best practice procedures and checklists for starting insulin, and constant adjustment of meeting process and content based on feedback and guideline changes. CONCLUSION: A peer-to-peer, interactive GP education program reduced GPs' perceptions of the difficulties of starting insulin in T2D and achieved changes in attendees' clinical practice. This education program offers an effective approach to overcome the therapeutic inertia that is too common in diabetes management.

HbA1c, blood glucose monitoring and insulin therapy.

BACKGROUND: Safe adjustment of insulin therapy requires review of both long-term and short-term glycaemic control, HbA1c and blood glucose monitoring (BGM), respectively. OBJECTIVE: To summarise the information that HbA1c and BGM provide about glycaemic control and to outline how to use these measures to guide insulin therapy. DISCUSSION: There are three components to the 24-hour blood glucose profile: 1. the flat baseline set by the fasting blood glucose 2. often a daytime increment in this baseline 3. the prandial blood glucose increase. Insulin therapy aims to sequentially control each component to achieve a desired level of glycaemic control (usually HbA1c <7%). Clinical use of the two glycaemic measures requires that BGM results are not highly variable (which complicates safe insulin adjustment) and that both BGM and HbA1c results are reliable. If these conditions are met and there is a discrepancy between the BGM profile and the average blood glucose expected from the measured HbA1c, there may be periods of undetected hyper- or hypoglycaemia over the 24-hour period, which require changes in insulin therapy.

SGLT2 inhibition with dapagliflozin -- a novel approach for the management of type 2 diabetes.

BACKGROUND: Because of the progressive nature of the disease, most patients with type 2 diabetes mellitus eventually require multiple treatments to achieve glycaemic targets. The majority of available therapies are insulin dependent, aiming to decrease insulin resistance and increase insulin secretion. Sodium glucose co-transporter 2 (SGLT2) inhibitors, a new class of antidiabetic agents, limit renal glucose reabsorption promoting urinary excretion of glucose, thereby reducing plasma glucose. OBJECTIVE: This article explores the mechanism of action and clinical data surrounding SGLT2 inhibitors, with a particular focus on dapagli-flozin. CONCLUSION: Clinical trials have shown dapagliflozin to be effective in reducing glycosylated haemoglobin, weight and fasting plasma glucose, either as monotherapy or as add-on therapy to metformin, sulphonylurea and insulin. Other SGLT2 inhibitors are currently under investigation.