Casandra A. Holveck, 2018 PharmD Candidate, the University of Connecticut

The number of patients who have from diabetes is expected to almost double from 285 million to 438 million people by 2030 due to obesity trends. Currently, 85-95% of cases are type 2 diabetes. 

Microvascular and macrovascular complications increase diabetes mortality and are especially common in poorly controlled patients. Antihyperglycemic therapy can restore glycemic control and prevent future complications.

Insulin has the highest efficacy among all glucose lowering agents. It is recommended as initial therapy for symptomatic diabetes, elevated blood glucose levels, and patients who fail to achieve/maintain their glycemic target with non-insulin monotherapy. 

 published a study in July 2017 evaluating experiences during and after basal insulin initiation among type 2 diabetes patients with different treatment persistence patterns. 

Researchers surveyed 942 patients who initiated basal insulin within the past 3-24 months and classified them as continuers (no therapy gaps of > 7 days), interrupters (first therapy gap > 7 days within 6 months of initiation and restarted therapy), or discontinuers (stopped therapy for > 7 days within 6 months of initiation without restarting). 

Insulin continuers report fewer concerns before and after therapy initiation, fewer challenges during the first week of use, and fewer adverse effects. Continuers reported insulin had a positive effect on glycemic control, physical well-being, and emotional well-being. 

Discontinuers were more likely to initiate insulin therapy after other antihyperglycemic therapies failed and thought providers did not considered their views when deciding to start insulin. The researchers concluded that the likelihood of continuing insulin is different for patients prescribed insulin as a necessary regimen versus patients who have treatment options.

Medication adherence is essential for managing 

and preventing complications. Providers must understand patient challenges, address concerns, and continually provide patient support to ensure therapy persistence. 

Perez-Nieves M, Ivanova JI, Hadjiyianni I, et al. Basal insulin initiation use and experience among people with type 2 diabetes mellitus with different patterns of persistence: results from a multi-national survey. 

 2017. doi; 10.1080/03007995.2017.1341403.

Articles

The number of patients who have from diabetes is expected to almost double from 285 million to 438 million people by 2030 due to obesity trends. 


Persistence Patterns Post Insulin Initiation in Diabetes

More than 60 million Americans experience heartburn at least once a month and 15 million suffer daily. Heartburn and acid regurgitation are hallmark 

Lifestyle interventions and anti-secretory medications like proton pump inhibitors (PPIs) are commonly used for GERD management. Seventeen to 32% of patients experience persistent symptoms despite medical therapy and are considered to have refractory GERD.

Physicians can manage refractory GERD surgically, but must consider its phenotype. Reflux hypersensitivity may only partially respond to surgery and functional heartburn should not be managed surgically. 

explores surgical advancements in management of GERD.

Laparoscopic Nissen fundoplication and concurrent hiatal hernia repair, if necessary, is the backbone in surgical GERD treatment. GERD and obesity are closely related and symptoms improve with weight loss. Laparoscopic Roux-en-Y gastric bypass surgery is recommended in obese patients who meet American Society for Metabolic and Bariatric Surgery. 

Researchers are currently studying other GERD treatment technologies. 

The Linx Reflux Management System uses a circular ring of magnetic beads to augment the lower esophageal sphincter (LES) and demonstrates symptomatic improvement in patients with small hiatal hernias. 

Lower Esophageal Sphincter Stimulation for GERD (LESS-GERD) is a randomized, controlled, trial studying EndoStim LES stimulation system in patients who respond partially to PPIs. Here, electrodes are placed anteriorly along the esophagus at the gastroesophageal junction. LESS-GERD results seems to result in esophageal acid exposure and less PPI use. 

Other novel technologies and minimally invasive endoscopic methods exist, but they lack long-term evidence and are not consistently used. 

Surgical and endoscopic GERD management methods have similar risks including: infection, post-operative dysphagia, and recurrent symptoms. Studies show surgical management is effective for refractory patients and outcomes depend on appropriate procedure selection.

Kethman W, Hawn M. New Approaches to GERD.  

More than 60 million Americans experience heartburn at least once a month and 15 million suffer daily. 