ADA guidelines for type 2 diabetes recommend metformin (MET) at all A1c levels, combination (COMBO) therapy at higher A1c levels and insulin (INS) for symptoms or A1c > 10. Current provider adherence to guidelines and the ability of educational session to alter that are unclear.

Methods: We assessed provider medication use before and after didactic diabetes medication and case management sessions designed to encourage multi-combination therapy and guideline adherence. Surveys asked 163 participants to report preferred drug regimens to be used for 6 patient cases: newly diagnosed (NEW) or established (EST) diabetes patients with A1c of 7.5 (LO), 9.5 (MID) or 10.5 (HI).

Results: MET use was remarkably low at higher A1c’s (69% HI, 85% MID, 98% LO) at baseline. After sessions, MET use improved significantly to 84%, 94%, 99%. COMBO (no-INS) was most frequently chosen for MID A1c levels: NEW 67%/EST 43%; compared to 13%/23% for LO 7%/5% HI. In the higher A1c cases, COMBO use increased dramatically with sessions to: 83%/72% MID, 30%/16% HI (all p< 0.005). Use of sulfonylureas decreased for 5 of the 6 cases. Changes in INS use were nuanced. Few providers (2%/4%) chose insulin for LO A1c; this decreased to near 0 after the sessions. INS was used in the majority of patients with HI A1c. INS use decreased significantly in favor of COMBO, not only for MID A1c (38%/51% to 13%/26%), but also for HI (93%/94% to 70%/84%).

Summary: Initially, guideline adherence was sub-optimal (underutilization of MET, COMBO and at HI A1c of INS). Short Provider Education sessions improved practices. Use of COMBO’s less likely to cause hypoglycemia increased substantially. However, appropriate INS at HI A1c also decreased.

Conclusion: There is a need for more training for better use of the antidiabetic armamentarium by primary care providers. Provider education emphasizing COMBO advantages improves planned prescribing patterns, but careful message tailoring is needed to avoid unintended consequences.


S. Sarkar: None. C.S. Barnes: None. J. Caudle: None. S.M. John: None. K.P. Clark: None. E. Heiman: None. J.C. Volcy: None. S. Schmidt: None. D.C. Ziemer: None.


Sanofi U.S.

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