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Philis-Tsimikas A.,Scripps Whittier Diabetes Institute
American Journal of Medicine | Year: 2013

Primary care practitioners are increasingly responsible for the management of the escalating numbers of patients with type 2 diabetes. The majority of these patients will require insulin replacement therapy as their disease progresses, because glycemic control is often unsustainable using oral antidiabetic drugs. This review explains the practicalities of initiating and optimizing basal insulin in clinical practice, emphasizing the need for regular glycated hemoglobin (A1c) monitoring to allow timely initiation of insulin when the A1c target is not met. The importance of patient education in overcoming barriers to insulin is discussed, as well as the choice of available basal insulins and the necessity to optimize basal insulin dosage by self-titration. The traditional view of insulin therapy as a last resort is challenged with the modern basal insulin analogues (insulin detemir and insulin glargine), which offer simple and effective glycemic control with a reduced risk of hypoglycemia compared with older insulin formulations such as neutral protamine Hagedorn. © 2013 Published by Elsevier Inc. Source

Philis-Tsimikas A.,Scripps Whittier Diabetes Institute
Current diabetes reports | Year: 2014

Diabetes affects a large and growing segment of the US population. Ethnic and racial minorities are at disproportionate risk for diabetes, with Hispanics and non-Hispanic Blacks showing a near doubling of risk relative to non-Hispanic Whites. There is an urgent need to identify low cost, effective, and easily implementable primary and secondary prevention approaches, as well as tertiary strategies that delay disease progression, complications, and associated deterioration in function in patients with diabetes. The Chronic Care Model provides a well-accepted framework for improving diabetes and chronic disease care in the community and primary care medical home. A number of community-based diabetes programs have incorporated this model into their infrastructure. Diabetes programs must offer accessible information and support throughout the community and must be delivered in a format that is understood, regardless of literacy and socioeconomic status. This article will discuss several successful, culturally competent community-based programs and the key elements needed to implement the programs at a community or health system level. Health systems together with local communities can integrate the elements of community-based programs that are effective across the continuum of the care to enhance patient-centered outcomes, enable patient acceptability and ultimately lead to improved patient engagement and satisfaction. Source

Cuddihy R.M.,International Diabetes Center | Philis-Tsimikas A.,Scripps Whittier Diabetes Institute | Nazeri A.,Novo Nordisk AS
Diabetes Educator | Year: 2011

Purpose The purpose of this study was to investigate the opinions of primary care physicians (PCPs) and diabetes specialists on their perceived role in tackling type 2 diabetes (T2D) and the challenges they face, particularly regarding insulin intensification. Methods Six hundred physicians from Germany, Japan, Spain, Turkey, the United Kingdom, and the United States were recruited to complete an online survey. Screening criteria included T2D patients seen per week (Europe/Japan: all ≥2; United States: PCPs ≥5; specialists ≥10) and years in practice (3-30 years). Results Most physicians had seen an increase in TD2 patients in the past 5 years, and almost all agreed that the burden of diabetes is increasing. Notable proportions of PCPs never initiate/modify insulin and never/rarely intensify insulin. Main barriers to insulin intensification cited were lack of experience and lack of time to educate patients. Better collaboration between primary and secondary care was considered one of the most important factors in improving insulin treatment of T2D. Conclusions PCPs are less involved in the initiation and intensification of insulin than specialists; however, all physicians appreciate the need for increased PCP involvement. A multidisciplinary approach that includes using the skills of diabetes educators will assist physicians in improving management of T2D. © 2011 The Author(s). Source

Philis-Tsimikas A.,Scripps Whittier Diabetes Institute | Brod M.,Julia Group, The | Niemeyer M.,Novo Nordisk AS | Ocampo Francisco A.M.,Novo Nordisk AS | Rothman J.,University Physicians Group Research Division
Advances in Therapy | Year: 2013

Introduction: Insulin degludec (IDeg) is a new basal insulin in development with a flat, ultra-long action profile that may permit dosing using a simplified titration algorithm with less frequent self-measured blood glucose (SMBG) measurements and more simplified titration steps than currently available basal insulins. Methods: This 26-week, multi-center, open-label, randomized, treat-to-target study compared the efficacy and safety of IDeg administered once-daily in combination with metformin in insulin-naïve subjects with type 2 diabetes using two different patient-driven titration algorithms: a "Simple" algorithm, with dose adjustments based on one pre-breakfast SMBG measurement (n = 111) versus a "Step-wise" algorithm, with adjustments based on three consecutive pre-breakfast SMBG values (n = 111). IDeg was administered using the FlexTouch® insulin pen (Novo Nordisk A/S, Bagsværd, Denmark), with once-weekly dose titration in both groups. Results: Glycosylated hemoglobin (HbA1c) decreased from baseline to week 26 in both groups (-1.09%, IDegSimple; -0.93%, IDeg Step-wise). IDegSimple was non-inferior to IDeg Step-wise in lowering HbA1c [estimated treatment difference (IDegSimple - IDegStep-wise): -0.16% points (-0.39; 0.07)95% CI]. Fasting plasma glucose was reduced (-3.27 mmol/L, IDegSimple; -2.68 mmol/L, IDegStep-wise) with no significant difference between groups. Rates of confirmed hypoglycemia [1.60, IDegSimple; 1.17, IDegStep-wise events/patient year of exposure (PYE)] and nocturnal confirmed hypoglycemia (0.21, IDeg Simple; 0.10, IDegStep-wise events/PYE) were low, with no significant differences between groups. Daily insulin dose after 26 weeks was 0.61 U/kg (IDegSimple) and 0.50 U/kg (IDegStep-wise). No significant difference in weight change was seen between groups by week 26 (+1.6 kg, IDegSimple; +1.1 kg, IDegStep-wise), and there were no clinically relevant differences in adverse event profiles. Conclusion: IDeg was effective and well tolerated using either the Simple or Step-wise titration algorithm. While selection of an algorithm must be based on individual patient characteristics and goals, the ability to attain good glycemic control using a simplified titration algorithm may enable patient empowerment through self-titration, improved convenience, and reduced costs. © 2013 Springer Healthcare. Source

Fortmann A.L.,San Diego State University | Gallo L.C.,San Diego State University | Philis-Tsimikas A.,Scripps Whittier Diabetes Institute
Health Psychology | Year: 2011

Objective: Although active diabetes self-management is required to achieve glycemic control, adherence is poor among ethnic minorities, especially Latinos. Research shows that individuals who report greater social-environmental support resources for disease management manage their diabetes more effectively than those with fewer support resources. Methods: Path analysis was conducted to investigate the value of a multiple-mediator model in explaining how support resources for disease management influence hemoglobin A1c (HbA1c) levels in a sample of 208 Latinos with Type 2 diabetes recruited from low-income serving community clinics in San Diego County. We hypothesized that the relationship between support resources for disease-management and HbA1c would be mediated by diabetes self-management and/or depression. Results: Participants who perceived greater support resources for disease-management reported better diabetes self-management (β = .40, p < .001) and less depression (β = -19, p < .01). In turn, better diabetes self-management and less depression were associated with tighter glycemic control (HbA1c; β = -17, p < .05 and β = .15, p < .05, respectively). Once the indirect effects via diabetes self-management (95% CI [-25; -03]) and depression (95% CI [-14; -01]) were statistically controlled, the direct pathway from support resources to HbA1c was markedly reduced (p = .57). Conclusions: These findings demonstrate the important connection that support resources for disease management can have with diabetes self-management, emotional well-being, and glycemic control among Latinos. Thus, programs targeting diabetes self-management and glycemic control in this population should consider culturally relevant, multilevel influences on health outcomes. © 2011 American Psychological Association. Source

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