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Objective. Many patients with type 2 diabetes do not reach glycemic goals despite basal insulin treatment. This study assessed the achievement of a target A1C Methods. This was a retrospective analysis of pooled randomized controlled trial (RCT) data, from 11 24-week studies of patients initiating basal insulin performed between 2000 and 2005 and of outpatient electronic medical record (EMR) data from the General Electric Centricity database for insulin-naive patients initiating basal insulin between 2005 and 2012. Baseline characteristics stratified by target A1C and fasting plasma glucose (FPG) attainment were compared descriptively. Results. In the RCT dataset, 49.0% of patients failed to achieve the target A1C at 6 months versus 72.4% and 72.9% at 6 and 12 months in the EMR dataset, respectively. Despite this, in the RCT dataset, 79.4% of patients achieved the target A1C and/or an FPG 7.0% had a longer diabetes duration and were more likely to be female, nonwhite, and self-funding or covered by Medicaid. Among patients with an A1C >7.0%, more RCT patients (58.0%) had an FPG Conclusion. Unmet needs remain after basal insulin initiation, particularly in real-world settings, where many patients require further insulin titration. In both populations, patients failing to achieve the target A1C despite attaining an FPG

Oral semaglutide is the first US Food and Drug Administration-approved oral glucagon-like peptide-1 receptor agonist (GLP-1RA) for the treatment of type 2 diabetes (T2D). Prior articles within this supplement reviewed the PIONEER trial program, which demonstrated that oral semaglutide reduced glycated hemoglobin and body weight when given to patients with uncontrolled T2D on various background therapies, and had a safety profile consistent with subcutaneous GLP-1RAs. This article provides guidance on integrating oral semaglutide into clinical practice in primary care. Patient populations with T2D who may gain benefit from oral semaglutide include those with inadequate glycemic control taking one or more oral glucose-lowering medication (e.g. after metformin), patients for whom weight loss would be beneficial, patients at risk of hypoglycemia, those who would historically have been considered for treatment with a subcutaneous GLP-1RA, and those receiving basal insulin who require treatment intensification. Like other GLP-1RAs, oral semaglutide is contraindicated in those with personal/family history of medullary thyroid carcinoma, and in those with multiple endocrine neoplasia syndrome type 2, as noted in a boxed warning in the prescribing information. Oral semaglutide has not been studied in those with a history of pancreatitis, is not recommended in patients with suspected/confirmed pancreatitis, and is not indicated in type 1 diabetes. When initiating oral semaglutide, gradual dose escalation is recommended to minimize the risk of gastrointestinal adverse events. As food and excess liquid reduce oral semaglutide absorption, patients should swallow the tablet with up to 4 fl oz/120 mL of water on an empty stomach upon waking, and should wait at least 30 minutes before eating, drinking, or taking other oral medications. Those managing patients should be aware of the potential impact of these dosing conditions on concomitant medications. When counseling patients, it is important to discuss these administration instructions, realistic therapeutic expectations, and strategies for mitigation of gastrointestinal events. Oral semaglutide provides a new option for add-on to initial T2D therapy (or later in the treatment paradigm), with the potential to enable more patients to benefit from the improvements in glycemic control, reductions in body weight, and low risk of hypoglycemia afforded by GLP-1RAs.

Glucagon-like peptide-1 (GLP-1) is a hormone of the incretin system responsible for a variety of glucoregulatory effects, including glucose-dependent secretion of insulin and inhibition of glucagon release, the effects of which are impaired in people with type 2 diabetes (T2D). Targeting this deficiency using GLP-1 receptor agonists (GLP-1RAs) is a well-established approach in T2D, with over a decade of clinical experience now accrued. This article reviews the evidence for subcutaneous GLP-1RAs and their role in T2D treatment, and explores the rationale for an oral GLP-1RA from a primary care perspective. Clinical trials and real-world studies with subcutaneous GLP-1RAs indicate that these agents have good glycated hemoglobin (HbA

Long-acting inhaled bronchodilator medications are recommended as initial maintenance therapy for many patients with COPD. These medications include long-acting muscarinic antagonists (LAMA) and long-acting β

Type 2 diabetes (T2D) is a debilitating condition and more people are being diagnosed each year. T2D increases patients' risk of developing disabling micro- and macrovascular complications, significantly reduces patients' quality of life, and is a substantial global economic burden. The efficacy and safety of antihyperglycemic therapies have improved over the years and have increased the lifespan for these patients. Consequently, patients are living longer with the condition and the associated comorbidities, but with a lowered quality of life. Therefore, therapies should aim to provide both optimal glycemic control and improve quality of life. Glucagon-like peptide-1 receptor agonist (GLP-1 RA) therapy improves glycemic control, reduces body weight, and has a low risk for hypoglycemia. GLP-1 RAs are available as once-daily (OD), twice-daily (BD), or once-weekly (OW) injectable formulations; OW injections may increase patients' satisfaction and improve treatment adherence. In the last decade, concern has been raised about the cardiovascular (CV) safety of antihyperglycemic therapies. Clinical data have been limited on CV outcomes among OW GLP-1 RAs. However, a post hoc analysis of the SUSTAIN-6 trial suggested that semaglutide, the most recently US Food and Drug Administration (FDA)-approved OW GLP-1 RA therapy, may offer cardioprotection, addressing this previously unmet clinical need.

The importance of treatment adherence is well established, as poor adherence contributes to disease progression and increased morbidity and mortality. Analysis of 11,272 veterans with T2DM with a mean follow-up of 5 years showed that for each 10% increase in the medication possession ratio, the mean glycated hemoglobin (HbA1c) decreased by 0.24%. Poor adherence also leads to increased health care resource utilization and costs, including more frequent hospitalizations. Conversely, while improved adherence increases medication costs, it can decrease overall health care resource utilization and costs. Improved medication adherence also contributes to improvement in diabetes-related quality of life.

The kidney plays a key role in glucose homeostasis and the pathophysiology of type 2 diabetes mellitus (T2DM). Sodium glucose co-transporter 2 (SGLT2) inhibitors are a new class of antihyperglycemic agents for the treatment of T2DM with a novel insulin-independent mechanism of action that targets the kidney. The SGLT2 inhibitors decrease renal glucose reabsorption, thereby increasing urinary glucose excretion and lowering plasma glucose levels in patients with hyperglycemia. SGLT2 inhibitor canagliflozin has demonstrated efficacy in improving glycemic control and reducing body weight and blood pressure as monotherapy or as add-on to other antihyperglycemic agents across a broad range of patients with T2DM. Canagliflozin is generally well tolerated, with increased incidences of specific adverse events that are related to the mechanism of SGLT2 inhibition. Findings suggest that canagliflozin is a useful treatment option for patients with T2DM.

Dust mite proteins have been implicated as a predominant cause of the current increase in asthma prevalence. Recent advances in the understanding of these allergens have vastly increased the potential for more effective treatment and prophylaxis. In the absence of vaccines, environmental controls aimed at allergen avoidance are currently the best defense against the disease.

When I was in medical school, for the first 2 years, I lived at home. Home was behind my mother’s medical office. Both of my parents were physicians, and my entire life was spent surrounded by their patients. But it was not until the summer between my preclinical and clinical years, when I took a job as a salesman in a men’s clothing store, that I learned the most important lessons to prepare me for my role as a physician—the training of a consummate salesman. During that summer, I learned to

The dangers of elevated serum cholesterol levels--and in particular, of increased concentrations of small, dense lipoproteins--have been fully delineated. Although effective therapies are available, too many physicians fail to look for hypercholesterolemia, or fail to treat it effectively. Adhering to therapeutic guidelines and encouraging patient compliance can be lifesaving.

Despite an increased understanding of risk factors for cardiovascular disease and the development of new programs, procedures, and medications to reduce risk, effective large-scale primary and secondary prevention have remained difficult to achieve. Large-scale, primarily educational, community-based programs aimed at detecting and reducing risk can be effective, particularly when they are aimed at specific populations at increased risk. However, the long-term benefits of these programs have been modest. Recent studies have demonstrated that lipid-lowering therapy is a critical adjunct to dietary and lifestyle changes. The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors in particular are highly effective in reducing cardiovascular risk in both primary and secondary prevention programs that combine lifestyle modification and aggressive medical therapy. The ability of these drugs to produce rapid improvements in endothelial function and increase coronary perfusion also supports their use in the medical rather than surgical management of at least some patients with cardiovascular disease who are candidates for percutaneous transluminal coronary angioplasty.

Since angina and heartburn can feel the same, excluding cardiac disease may be the first order of business. That done, clinical findings and laboratory tests can help identify the esophageal disturbance. Gastric acid reflux, motility disorders, and visceral nerve hypersensitivity--alone or in combination--can cause chest pain, and each may call for a different pharmacologic regimen.

Steps for facilitating management include: 1) identification and referral of patients with a nonmechanical cause of pain, such as cancer or an aortic aneurysm; 2) matching the analgesic agent and the mobilization schedule to the patient's condition and pace of recovery; 3) referring patients whose condition may require surgery; 4) and caring for the remaining patients who have chronic pain.

Most physicians lack the training to deal effectively with battered spouses. Yet they are in an ideal position to intervene. With a few straightforward questions, they may be able to detect a volatile situation before it escalates to violence. When abuse does occur, they can take a key role in management by becoming patient advocates, making referrals, and coordinating team care.

The diagnosis may be as simple as sleep deprivation or a more complex, mixed disorder, such as obstructive sleep apnea complicated by a CNS abnormality. At least 65 primary sleep disorders have been identified. Polysomnographic and other sleep evaluations may be indicated to guide diagnosis and treatment.

LOMH is frequently observed in primary care, with an increasing prevalence in older men. The diagnosis is based on a combination of mostly nonspecific signs and symptoms and measurement of testosterone and other hormones. Various testosterone formulations are available to individualize therapy to restore the physiologic testosterone level and improve symptoms. Careful assessment must be undertaken prior to and during TRT to prevent harm, reduce adverse events, and foster adherence.

The prevalence of type 2 diabetes mellitus, which is directly associated with overweight/obesity and increased cardiovascular disease risk, is projected to continue to increase during the next few decades. Traditionally, treatment has focused primarily on glycemic control, but accumulating evidence suggests that the clinical management of patients with type 2 diabetes requires a more comprehensive approach to minimize associated morbidity and mortality. Because the majority (80%-90%) of patients with type 2 diabetes are overweight or obese, effective glucose control and weight loss are the cornerstones of initial management. Both effective glucose control and therapy to reduce cardiovascular risk factors, including overweight/obesity, are needed to prevent the complications of type 2 diabetes. Most conventional antidiabetes agents, including sulfonylureas, thiazolidinediones, and insulin, improve glycemic control but are associated with weight gain or, as with metformin, are weight-neutral or weight-sparing. The incretin-based therapies, such as the glucagon-like peptide-1 (GLP-1) receptor agonists and the dipeptidyl peptidase-4 inhibitors, have been shown to be safe and effective in lowering glucose while eliciting favorable effects on weight (ie, weight-reducing and weight-neutral, respectively). The effects of these agents on other parameters of cardiovascular risk are also being studied. Advances in GLP-1 receptor agonist therapy include development of agents with longer durations of activity allowing for more convenient dosing of therapies for patients with type 2 diabetes, which should lead to better patient compliance, adherence, and overall clinical outcomes.

The task of managing the ever-growing problem of type 2 diabetes falls mainly to primary care physicians. The currently available guidelines from the American Diabetes Association and the American College of Endocrinology/American Association of Clinical Endocrinologists aim to improve glycemic control, thus reducing morbidity and mortality associated with this chronic and progressive disease. However, the guidelines differ markedly in focus and depth. This review provides a clear summary of the guidelines and recommends how they can be implemented at the primary care level, explaining the different treatment options and providing practical advice on how commonly encountered situations should be approached in clinical practice. There is also a troubleshooting section on how to overcome obstacles to optimum therapy, and details on implementation strategies that will encourage the aggressive, stringent, and patient-centered, treat-to-target approach recommended in the guidelines.

Primary care physicians play central roles in the management of patients with diabetes, providing care for approximately 90% to 95% of adult patients with type 2 diabetes mellitus (DM). Treatment goals are well established, although treatment guidelines continue to evolve in response to new evidence and advances in therapy. Clinicians face significant challenges in managing this multifaceted and complex disease. Less than 12% of diagnosed patients reach treatment goals for blood glucose, cholesterol, and blood pressure. Treatment typically begins with the use of single-agent pharmacotherapy in conjunction with lifestyle modifications. As the disease progresses, other pharmacologic agents are added as treatment is intensified to achieve target goals. This CME activity examines the clinical uncertainties resulting from disease progression and provides recommendations for the long-term management of patients with type 2 DM.

Type 2 diabetes is primarily a disease that affects late-middle-aged and elderly individuals. Due to increasing affluence, lifestyle changes, and obesity, however, it is also affecting younger age groups. Therefore, treatment recommendations may need to be revised to reflect these changes. Fortunately, various new treatment options, including insulin analogs with more physiologic time-action profiles and drugs that target the incretin system, are now available.This review was based on a PubMed literature search done in August 2007, using relevant search terms.Improving diet and increasing physical activity are important therapeutic interventions in diabetes and associated conditions. However, many people find it difficult to maintain lifestyle changes, which is why the American Diabetes Association recommends lifestyle intervention plus metformin following initial diagnosis. Current guidelines recommend a stepwise approach, with additional oral antidiabetic drugs (OADs) being added as the disease progresses. Insulin therapy should be initiated once OADs fail to control hyperglycemia, as there is good evidence that intensive therapy, with strict glycemic targets, can reduce the long-term microvascular complications that are associated with poorly controlled diabetes. In addition, while the evidence is less conclusive, intensive therapy may also improve long-term macrovascular comorbidities.It is important that patients with diabetes receive the most effective therapy for maintaining glycemic control and that treatment is modified or augmented in those who are not achieving appropriate glycemic goals. Only by maintaining long-term, effective glycemic control can the microvascular and macrovascular comorbidities associated with diabetes be minimized.

Perennial allergic rhinitis (PAR) can have a significant impact on a patient's quality of life. While allergen avoidance is the first line of management for PAR, complete avoidance is difficult. Therapeutic options available for PAR include intranasal corticosteroids (INS), H 1 -antihistamines, decongestants and local chromones, as well as immunotherapy. For mild symptoms, INS and antihistamines are the standard of care, whereas for moderate-to-severe PAR, INS are the preferred therapy due to their proven efficacy. Patient quality of life and therapy preference play a role in maintaining adherence to treatment.

Allergic rhinitis is a highly prevalent disorder and oral antihistamines are often used to manage patient symptoms. Older-generation antihistamines, such as diphenhydramine and chlorpheniramine, are effective at relieving the symptoms of seasonal allergic rhinitis (SAR); however, they are associated with adverse events, including sedation and impairment, at, or above, the recommended dose. Newer-generation antihistamines, such as desloratadine, cetirizine and fexofenadine, were developed to minimize adverse events. In this article, studies examining newer-generation antihistamines in adults and children were reviewed. The clinical evidence confirms that desloratadine, cetirizine and fexofenadine are effective at managing the symptoms of SAR in adults and children; however, cetirizine is more likely to cause sedation. Physician intervention is paramount to SAR symptom management. It is essential that appropriate treatment relieves SAR symptoms with absent or minimal adverse events. This is particularly important for those patients involved in skilled and cognitive activities or safety-critical jobs.

Objective: Telithromycin, the first approved ketolide antibiotic, was developed to treat community-acquired respiratory tract infections, including acute bacterial maxillary sinusitis (ABMS). A previously published study showed that a 5-day course of 800 mg telithromycin once daily is as effective as a 10-day course in the treatment of ABMS. Materials and Methods: Data were pooled from two controlled, multinational, prospective, randomized, double-blinded ABMS trials comparing 5-day telithromycin (800 mg once daily) with 10-day amoxicillin-clavulanate (500/125 mg 3 times daily) and cefuroxime axetil (250 mg twice daily). Clinical cure and bacteriologic eradication rates were compared by means of descriptive statistics. Results: The clinical cure rate for telithromycin was 80.9% versus 77.4% for comparators; bacteriologic eradication rate for telithromycin was 84.9% versus 81.7% for comparators. Most adverse events were mild to moderate in intensity and, most commonly, gastrointestinal in nature. Conclusions: These results support the conclusion that 5 days of treatment with telithromycin is as safe and effective in patients with ABMS as a 10-day course of treatment with amoxicillin-clavulanate or cefuroxime axetil.