Using a triggered endocrinology service consultation to improve the evaluation, management, and follow-up of osteoporosis in hip-fracture patients.

BACKGROUND: Nearly 2 million osteoporosis-related fractures occur yearly in the United States, with more than 400,000 requiring hospital admissions. Fewer than 30% receive proper evaluation and care for osteoporosis, representing a large opportunity to enhance secondary prevention of fractures. Methods to improve identification and triage of hospitalized fragility-fracture patients are desirable. METHODS: A multidisciplinary team was created, and definitions were established for an evidence-based best-practice protocol to assess, treat, and document an osteoporosis diagnosis and triage patients with hip-fragility fractures on the basis of the best-practice recommendations from The Joint Commission and the National Osteoporosis Foundation. The team initiated a preauthorized osteoporosis consultation from the endocrinology service for hip-fracture patients, "triggered" via a brief query in admission orders or by the orthopedic service nurse practitioner. Osteoporosis consultations used a consultation template reflecting the protocol. RESULTS: Data were analyzed for 71 baseline patients and 61 intervention patients. The groups possessed similar age, gender, race, and body mass index characteristics. The baseline (on-demand consultation) group suffered from poor performance, with only 3%-21% of patients receiving the desired evaluation, documentation, treatment, or outpatient follow-up. Intervention (triggered-consultation) patients improved markedly postintervention, With performance increasing by 52%-76% on all parameters except outpatient follow-up, which changed insignificantly (6%-15%). CONCLUSION: Although triggered consultation was effective, multimodal layered interventions may achieve even better results and address several identified barriers.

Longer acting GLP-1 receptor agonists and the potential for improved cardiovascular outcomes: a review of current literature.

With the rapidly rising incidence of Type 2 diabetes and an increasing variety of medications available for treatment, choosing the ideal regimen for patients can be challenging. Longer-acting glucagon-like peptide-1 (GLP-1) receptor agonists and devices have been recently developed and include once-weekly exenatide, dulaglutide, albiglutide, semaglutide and miniosmotic pump ITCA650. Some of the attractive qualities of the GLP-1 receptor agonist class include its association with weightloss and potential for cardiovascular benefits. The longer-acting forms have been shown in several studies to produce equal or greater reduction in A1c and weight compared with the standard twice-daily formulation of exenatide. They also result in lower reported incidence of nausea, in the setting of a less frequent injection schedule that would be desirable to many diabetic patients. There are emerging data to suggest patients treated with longer-acting GLP-1 receptor agonists have improved cardiac parameters, some of which are independent of weight and A1c reductions.

Proof of Concept: Matrix metalloproteinase inhibitor decreases inflammation and improves muscle insulin sensitivity in people with type 2 diabetes.

BACKGROUND: Obesity is a state of subclinical inflammation resulting in loss of function of insulin receptors and decreased insulin sensitivity. Inhibition of the inflammatory enzymes, matrix metalloproteinases (MMPs), for 6 months in rodent models restores insulin receptor function and insulin sensitivity. METHODS: This 12-week double-blind, randomized, placebo (PL)-controlled proof-of-concept study was performed to determine if the MMP inhibitor (MMPI), doxycycline, decreased global markers of inflammation and enhanced muscle insulin sensitivity in obese people with type 2 diabetes (DM2). The study included non-DM2 controls (n = 15), and DM2 subjects randomized to PL (n = 13) or doxycycline 100 mg twice daily (MMPI; n = 11). All participants were evaluated on Day 1; MMPI and PL groups were also evaluated after 84 days of treatment. RESULTS: There was a significant decrease in inflammatory markers C-reactive protein (P < 0.05) and myeloperoxidase (P = 0.01) in the MMPI but not PL group. The MMPI also significantly increased skeletal muscle activated/total insulin signaling mediators: 3'phosphoinositide kinase-1 (PDK1) (p < 0.03), protein kinase B (PKB/Akt) (p < 0.004), and glycogen synthase kinase 3ß (GSK3ß) (p < 0.03). CONCLUSIONS: This study demonstrated short term treatment of people with diabetes with an MMPI resulted in decreased inflammation and improved insulin sensitivity. Larger, longer studies are warranted to determine if doxycycline can improve glucose control in people with diabetes. TRIAL REGISTRATION: Clinicaltrials.gov NCT01375491.