The Effect of Proton Pump Inhibitors on Glycemic Control in Patients with Type 2 Diabetes.

Background: Type 2 diabetes patients have decreased pancreatic beta cell mass with a decline in beta cell function. Gastrin has increased beta cell proliferation in vitro and in animal studies. High gastric acid levels inhibit gastrin secretion. Proton pump inhibitors (PPIs) lower gastric acid, subsequently increasing gastrin levels. This may stimulate beta cell proliferation and function, and improve glycemic control. Studies with small numbers of type 2 diabetes patients have shown a slightly lower A1C in those taking PPI versus non-PPI users. Methods: This study was a retrospective multicenter electronic data analysis using data obtained from health care facilities within Veterans Integrated Service Network (VISN) 21. Patients were included if they had established care within VISN 21 and had type 2 diabetes with an A1C > 6.5%, were started on a PPI concurrently with stable doses of metformin or sulfonylurea (SFU) monotherapy, had at least two documented A1C values, and had a medication possession ratio >80% for metformin, SFU, or a PPI. Veterans were excluded if they were using insulin, combination antihyperglycemic therapy, or oral corticosteroids. A control group not using PPI was also identified. Results: There was a statistically significant decrease in A1C within each group. However, there was no statistically significant difference between the PPI and control group in the post-A1C. Conclusion: In patients with type 2 diabetes, A1C improved in both groups, but PPI addition did not affect glycemic control. Future randomized controlled trials are needed to determine the value of PPIs as a treatment option for patients with type 2 diabetes.

Long-term maintenance of glucose control in veterans with type 2 diabetes mellitus using oral agents.

PURPOSE OF STUDY: The aim of this study was to evaluate long-term glycemic control in individuals with type 2 diabetes mellitus on oral hypoglycemic agents. METHODS: We identified the cohort of veterans prescribed hypoglycemic agents every year from July, 1992, through June, 2007 (n=191). Glycosylated hemoglobin (HbA1c) was used to assess glycemic control. Data are expressed as mean±standard deviation (SD); statistics are expressed by t-test and chi-squared. P<0.05 was considered significant. RESULTS: In the first year, 96 of the select group of 191 veterans identified above received oral agents only (OAO), 74 insulin only, and 21 both insulin and oral agents. Fifteen years later, 59 were OAO, 78 insulin only, and 54 both. Six patients receiving insulin in 1992-1993 were OAO-treated in 2006-2007. In the subgroup on OAO both at baseline and at the end (n=53), HbA1c decreased from 7.89±1.21 to 7.09±1.13 (P<0.001). These veterans were older at baseline (62.4±6.2) and leaner at the 15-year follow-up [body mass index (BMI) 28.1±4.9] than those who received insulin in 2006-2007 (n=43; age=57.9±9.6; BMI=32.3±7.9; P<0.05 and 0.005, respectively). Patients in the stable OAO group (n=53) were 74.0% Caucasian, compared to 51.2% in former-OAO [n=43; P<0.05 (chi-squared)]. CONCLUSIONS: Over half (n=53; 55%) of patients originally in the OAO group remained so 15 years later. These stable patients were in better glycemic control, both at baseline and follow-up, less obese, older, and more likely to be Caucasian, than those who eventually received insulin. Currently used oral agents often maintain, or even improve, glucose control, over 2 decades after diagnosis of diabetes mellitus.

Comparative efficacy of ezetimibe/simvastatin, rosuvastatin, and atorvastatin in uncontrolled hyperlipidemia patients.

OBJECTIVE: Treatment of dyslipidemia in high-risk patients specifies a low-density lipoprotein (LDL) cholesterol <100 mg/dL. The efficacy of higher-potency regimens in clinical practice in patients who have not achieved their LDL goal on generic therapy is not well characterized. The primary objective of this study was to determine the LDL-lowering efficacy of higher-potency strategies (ezetimibe/simvastatin, rosuvastatin, and atorvastatin) in high-risk patients who were switched from simvastatin therapy. Secondary objectives were to evaluate patient adherence to these therapies, determine the efficacy of these interventions on other lipid parameters, and define the incidence of adverse effects. STUDY DESIGN: Retrospective data analysis derived from the Veterans Affairs Health Care System VISN 21 over a 3-year time period. METHODS: Lipid data were assessed prior to and within 2 to 6 months following the conversion from simvastatin. Adherence to therapy was determined by medication refill data. RESULTS: Treatment with ezetimibe/simvastatin resulted in significantly greater reductions in LDL compared with rosuvastatin or atorvastatin (37 vs 25 and 26 mg/dL, respectively; P <0.05). Adherence to therapy was 51% of all patients studied. All treatments significantly lowered total cholesterol, high-density lipoprotein, and triglycerides when compared with simvastatin. There was no difference between treatment groups in the number of adverse events. CONCLUSIONS: At the doses used in this population, ezetimibe/simvastatin resulted in greater LDL reductions than rosuvastatin or atorvastatin. The clinical impact of these differences is as yet undetermined.

Resistant hypertension and undiagnosed primary hyperaldosteronism detected by use of a computerized database.

A pharmacy database was used to identify patients with resistant hypertension who could then be tested for the presence of primary hyperaldosteronism. Inclusion criteria were: (1) resistant hypertension defined as uncontrolled hypertension and use of 3 antihypertensive medication classes or ≥ 4 antihypertensive classes regardless of blood pressure; (2) low or normal potassium levels (≤ 4.9 mEq/L); and (3) continuous health care from October 1, 2008, to February 28, 2009. Exclusion criteria were: (1) past or current use of an aldosterone antagonist, or (2) a medication possession ratio (adherence) <80% for any antihypertensive drug. Hyperaldosteronism was classified as an aldosterone/renin ratio (ARR) ≥ 30. Using the computer, 746 patients were identified who met criteria. After manual chart review to verify inclusion and exclusion criteria, 333 patients remained. Of 184 individuals in whom an ARR was obtained, 39 (21.2%) had a ratio of ≥ 30. A computer database is useful to identify patients with resistant hypertension and those who may have primary aldosteronism.

Computer-based screening of veterans for metabolic syndrome.

BACKGROUND: The worldwide obesity epidemic has focused attention on the prevalence of the metabolic syndrome, which is greater than previously believed. However, estimates of its overall prevalence vary widely. We wished to ascertain the prevalence of metabolic syndrome in the Veteran Affairs Northern California Health Care System (VANCHCS). METHODS: We used the VA computerized clinical database and modified Adult Treatment Panel III (ATP III) criteria of fasting blood glucose (FBG) >or=110 mg/dL, blood pressure >or=130/>or=85, triglyceride >or=150 mg/dL, high-density lipoprotein cholesterol (HDL-C) <40 mg/dL (men) or <50 mg/dL (women), but body mass index (BMI) >or=30 in lieu of waist circumference >102 cm (40 inches) for men and 88 cm (35 inches) for women. We also accepted current pharmacotherapy for diabetes as qualifying for elevated fasting blood sugar (FBS); current therapy with niacin, gemfibrozil, or fenofibrate for elevated triglyceride concentrations; and recent use of multiple International Classification of Diseases, 9(th) Revision (ICD-9) codes for hypertension for elevated blood pressure. RESULTS: We examined all clinical records for veterans registered in VANCHCS who filled any prescription between July 1, 2004, and June 30, 2005 (n = 51,026). Their average age was 63 years; 93% were male. In all 25% (n = 13,010) were diagnosed as having metabolic syndrome by meeting at least 3 of the above 5 criteria. Because only 60% (n = 30,727) of the population had data for 3 or more criteria, the actual percent with metabolic syndrome is probably substantially higher. CONCLUSIONS: Over one quarter of veterans in the VANCHCS may have metabolic syndrome based on our modified ATP III criteria. We urge screening more veterans with fasting laboratory testing. Computerized screening of a large clinical database can provide an effective strategy to aid clinicians in identifying more patients at risk for cardiovascular disease.

Capacity of hospitals to partner with academia to meet experiential education requirements for pharmacy students.

PURPOSE: Current hospital and health-system participation in and the future capacity for experiential education for pharmacy students was investigated. METHODS: An online survey of ASHP members identified as U.S. pharmacy directors was conducted to assess their current and future involvement in partnering with colleges and schools to meet the experiential education requirements for doctor of pharmacy students and the current status of the student learning experiences. Questionnaire items examined the factors on which expanded involvement in experiential education would depend, the nature of support provided by colleges and schools, the types of experiences available for students, respondents' perceptions of factors influencing the quality of experiential education, the value of experiential education to the sites, respondents' challenges and concerns about experiential education, and respondents' current capacity and projections for introductory and advanced experiences through 2012. RESULTS: Data from 549 respondents were analyzed. Most respondents indicated that they had conducted advanced experiences for their 2007 graduates and anticipated that they would continue to do so. Among the top challenges identified regarding advanced experiences were concerns about time to serve and be trained as preceptors and a lack of standardization and coordination among colleges and schools. Hospitals forecasting their future capacity to accommodate students indicated that their projections were highly dependent on the number of pharmacists at their hospitals. Many respondents noted that their capacity projections were tied to their ability to expand clinical services at their hospitals. CONCLUSION: A survey of pharmacy directors suggested an ability of U.S. hospitals to conduct advanced experiential education opportunities for pharmacy students through 2012 and to expand introductory experiences.

Clinical and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center.

Pharmacist recommendations and their clinical and economic outcomes in a Veterans Affairs (VA) medical center were studied. The first 600 pharmacist recommendations that met study criteria were evaluated for type and frequency, rate of acceptance by physicians, potential benefit or harm, and economic consequences. The study site included inpatient and outpatient settings and a skilled-nursing facility. The most frequent types of pharmacist recommendations involved adjusting the dosage or frequency of administration and discontinuing a drug that was not indicated for the patient's medical problem. The rate of acceptance of the recommendations was 92%. The recommendations led to improved clinical outcomes in over 30% of cases in each setting and no change in over 40% of cases in each setting. Evaluators determined that patient harm was avoided by the recommendations in 90% of cases; patient harm was caused in less than 1% of cases. The overall mean cost avoidance per recommendation was $700, and the mean total cost avoidance for all 600 recommendations was $420,155. Pharmacist recommendations improved clinical outcomes and saved money at a VA medical center.

Reduction in self-monitoring of blood glucose in persons with type 2 diabetes results in cost savings and no change in glycemic control.

OBJECTIVE: Recent Veterans Affairs (VA) guidelines recommend that persons with stable type 2 diabetes controlled on oral agents or diet therapy perform self-monitoring of blood glucose (SMBG) twice weekly. We assessed the impact of a modification of these guidelines on hemoglobin A1c (HbA1c) and monitoring cost. STUDY DESIGN: Retrospective, noncrossover clinical trial. PATIENTS AND METHODS: We instructed persons with type 2 diabetes to perform SMBG testing according to modified adapted VA guidelines. We compared patients' baseline average testing frequency and HbA1c with those obtained during a 6-month interval beginning 2 months after implementation of the modified guidelines. The impact on the cost of monitoring was calculated. RESULTS: At baseline, 913 of 1,213 SMBG users with diabetes on oral hypoglycemic agents had HbA1c tested (HbA1c = 7.83% +/- 1.34%); their frequency of SMBG was 1.36 +/- 0.95 strips per patient per day. Postimplementation, 974 of 1,278 persons with diabetes had HbA1c tested (HbA1c = 7.86% +/- 1.54%; P= .63 vs baseline); frequency of SMBG decreased by 46% to 0.74 +/- 0.50 strips per patient per day (P < .0001). At baseline, 154 of 254 SMBG users with diabetes on diet therapy had HbA1c tested (HbA1c = 6.85% +/- 0.97%); their frequency of SMBG was 1.07 +/- 0.90 strips per patient per day. Postimplementation, 177 of 282 diet-treated persons with diabetes had HbA1c tested (HbA1c = 6.78% +/- 1.20%; P = .56 vs baseline); frequency of SMBG decreased by 35% to 0.70 +/- 0.51 strips per patient per day (P < .0001). Similar findings were observed in a cohort of 421 drug-treated patients with paired HbA1c data before and after implementation, and a cohort of 50 diet-treated patients with paired HbA1c data. Linear regression analysis showed no significant impact on individuals' HbA1c with reduction in strip use. Average monthly cost savings were $8,800, or $6.37 per patient per month. CONCLUSIONS: This program decreased the frequency of SMBG in persons with type 2 diabetes, resulting in substantial cost savings without affecting glucose control.

Prevalence and Treatment of Hypertension Complicated by Comorbid Conditions.

Although the presence of a comorbid condition should be an important factor in etermining the choice of an antihypertensive agent, the prevalence of conditions complicating hypertension is unknown in most patient populations. It is also unknown whether the presence of comorbid conditions influences antihypertensive therapy. To address these questions, we determined the prevalence of comorbid conditions and antihypertensive prescribing patterns for 7526 patients receiving antihypertensive medication at four Department of Veterans Affairs clinics. Of these patients, 97% were male and 86% were over 50 years of age. In these hypertensives, 2507 had coronary artery disease (CAD), 2426 had diabetes mellitus (DM), 1553 had chronic obstructive pulmonary disease (COPD) or asthma, and 970 had congestive heart failure (CHF). The presence of comorbid conditions did not have a major impact on the choice of antihypertensive agents, with most hypertensives receiving calcium antagonists or ACE inhibitors. The use of à -blockers, for example, was not greatly influenced by the presence of CAD. (c)1999 by Le JacqCommunications, Inc.