Presuming that simple inconvenience is at least part of the reason for such limited use, UMass Memorial has implemented a new system (MyCareTeam™), which works with our EHR provider, Allscripts. This system, which has been shown to improve patient outcomes in other clinical settings, can be launched with a single mouse click from within our EHR. It works with most commercially available glucometers used by our patients, has a user-friendly interface, and provides access to educational resources designed to promote patient engagement. Our goal is to make it easy for patients to upload their own data from a desktop computer, or eventually from mobile devices. Like other systems that electronically capture glucose readings, it prevents patients from excluding any of the results.
At some facilities, physicians “prescribe” apps that patients can use to track chronic diseases on their smartphone or tablet and transmit data, such as glucose readings, to their clinician. Highly rated diabetes apps include Glooko Logbook, Glucose Buddy, and OnTrack Diabetes, to name a few.24
8. Learn more about b-cell function
As the medications available to manage glucose levels have increased in number, it has become more important for clinicians to understand T2D pathophysiology and how various pharmaceutical agents affect it. Central to this understanding are the individual’s sensitivity to insulin’s action and the status of his or her pancreatic b-cell function.
The b-cell dysfunction underlying T2D appears to respond, often dramatically, to even modest weight loss or increased physical activity. Thus, all patients with T2D should be encouraged to pursue daily physical activity and adhere to a diet designed to promote moderate weight loss; any discussion of pharmaceutical approaches should begin with mention of exercise and diet.
For patients whose diabetes is inadequately controlled by lifestyle interventions, medication should be chosen based on an understanding of the pathophysiology and disease state, and particularly, on the patient’s remaining b-cell function. Other considerations include comorbidities, anticipated efficacy, cost, mode of administration, and patient preferences.
Early in the T2D disease process, insulin resistance typically predominates, and b-cell dysfunction is mild. At our facility, we emphasize agents that help restore insulin sensitivity, especially metformin. Patients who are not achieving their glycemic target with lifestyle changes and metformin will benefit from the addition of a secretagogue, which provides a complementary mechanism of action.
Sulfonylureas are inexpensive and effective but potentially problematic because they may cause hypoglycemia and contribute to b-cell exhaustion. This is because they stimulate insulin secretion independent of circulating glucose levels. Glinides work in a similar manner, but have a more rapid onset and a shorter duration of action than sulfonylureas. Thus, they can be effective at mitigating prandial hyperglycemia, but require dosing with meals.
Newer secretagogues such as GLP-1 agonists and DPP-4 inhibitors stimulate secretion of insulin in response to hyperglycemia, reducing the risk of hypoglycemia and ultimately preserving some b-cell function. These newer agents, as well as glinides, are significantly more expensive than sulfony-lureas. GLP-1 agonists have the additional disadvantage of requiring injection. Patients who are Our Diabetes Scorecard, which is automatically populated by data from our EHR, provides an at-a-glance summary that is useful to clinicians and patients alike. far from their glycemic target will benefit from the addition of insulin.
CORRESPONDENCE
Ronald N. Adler, MD, UMass Memorial Medical Center, 279 Lincoln Street, Worcester, MA 01605; Ronald.adler@umassmemorial.org