Part of the widespread interest in the care of individuals with diabetes surrounds the unprecedented changes that have occurred in the field. These changes have attracted the attention and efforts of investigators,businesses, and clinicians. Over the past dozen years, these changes have spanned the fields of pharmacotherapy, approaches to care, and supplies used to support care. This issue of Clinical Diabetes highlights some of those changes.
John R. White, Jr., PA, PharmD, summarizes a new class of medications aimed at raising endogenous levels of incretins—a class of hormones that is just being introduced in medical school curriculums(p. 53). Although we've known for decades about the differential insulin response to oral versus intravenous glucose, there was little appreciation that a class of gut hormones (incretins) was, in part, mediating the increased insulin response to oral glucose. During the past decade, the hormones, receptors, and enzymes responsible for regulating the hormone levels have been identified. Moreover,two products have come to market that leverage our understanding of this system.
First, exenatide1 was released as an exogenous mimic to our endogenous incretins. This injectable product augments the diminished glucose-induced insulin secretion seen in type 2 diabetes. In addition, given the pharmacological levels achieved with this product, there has also been a satiety effect that is poorly understood, as well as some gastric slowing and a diminished glucagon effect.
The second product, sitagliptin, was released as an inhibitor of the dipeptidyl peptidase-IV (DPP-IV) enzyme, which degrades our naturally occurring incretins (specifically glucagon-like peptide-1). This oral product increases endogenous incretins and their action, but not to levels equaling the action of the incretin mimetic exenatide. It still enhances glucose-induced insulin secretion and minimizes the glucagon effect. However,there is no significant effect on satiety, suggesting a differential effect of these products based on incretin concentration achieved.
Dr. White carefully and systematically summarizes the salutary effects of the DPP-IV inhibitors (only sitagliptin is currently available), which include a moderate antihyperglycemic effect, oral once-daily convenience, and limited side effects. Like most new products, cost is a significant consideration.
Also in this issue, Anne W. Brown, MSN, BC-ADM, BC-ANP, offers “A Clinician's Guide to Diabetes Gadgets and Gizmos,” which summarizes the latest devices enjoying widespread use in diabetes care(p. 66). The proliferation of pumps, meters, and pens has, in some ways, given clinicians an opportunity to offer patients greater flexibility and individualization of care. This has come at a cost: some physicians liken diabetes outpatients to Intensive Care Unit inpatients—so many connections and gadgets. Whether it's a pump or a continuous glucose sensor (both still relatively uncommon),physicians are struggling to keep up with the latest device.
Although the technology has in many ways outpaced the health care system's ability to fully incorporate it (assessing and modifying an insulin pump is rarely feasible in the context of an outpatient primary care practice), some technology is remarkably simple and provides tremendous convenience. Ms. Brown reviews the current pens used to deliver insulin, as well as the range of meters currently available, noting remarkably subtle differences but making clear the advances in ease of insulin delivery and blood glucose monitoring that have been achieved with these products.
The quantity of products available and the minor differences among them will likely cause caregivers to choose one because mastery of all is probably beyond the time commitment that a typical physician can give. Indeed, all these devices remind one of inpatient rounds with a beeping IV pole, where the physician calls for the nurse. It's no surprise the author of this section has a nursing background.
Finally, Andrew M. Davis, MD, MPH; Devin R. Sawyer, MD; and Lisa M. Vinci,MD, discuss in this issue the rationale for their experience with group visits(p. 58). Given the challenges of attaining and sustaining desired outcomes in diabetes, it is not surprising that a variety of approaches beyond the traditional one-on-one visit have been explored. The concept of group visits is potentially attractive for a condition that is so dependent on self-care behaviors. Groups, when properly facilitated, can provide complementary support to initiating and sustaining behavioral changes.
Davis et al. highlight the potential success of group visits for a subgroup of motivated patients, while clarifying some of the reimbursement challenges for the group education component. This approach has had mixed success in predominantly large health maintenance organization settings, and its integration into classic one- to four-person private practices is still unclear. Nonetheless, incorporating some level of group visits holds the promise of enhanced efficiency for clinicians and, perhaps, better outcomes for patients. What is missing from the discussion is the difficulty of delivering this intervention as optimally intended given the general lack of training that physicians and other caregivers have in facilitating group processes.
Whether it is how we interact with patients, what devices we find to support their care, or what new classes of medications become available,change in diabetes care during the past dozen years has been a constant. Although this may be a bit unsettling to some, it will represent an enormous opportunity to others.
