Medication Optimization Among People With Type 2 Diabetes Participating in a Continuous Glucose Monitoring-Driven Virtual Care Program: Prospective Study.

BACKGROUND: The Onduo virtual care program for people with type 2 diabetes (T2D) includes a mobile app, remote lifestyle coaching, connected devices, and telemedicine consultations with endocrinologists for medication management and prescription of real-time continuous glucose monitoring (RT-CGM) devices. In a previously described 4-month prospective study of this program, adults with T2D and baseline glycated hemoglobin (HbA1c) ≥8.0% to ≤12.0% experienced a mean HbA1c decrease of 1.6% with no significant increase in hypoglycemia. OBJECTIVE: The objective of this analysis was to evaluate medication optimization and management in the 4-month prospective T2D study. METHODS: Study participants received at least 1 telemedicine consultation with an Onduo endocrinologist for diabetes medication management and used RT-CGM intermittently to guide therapy and dosing. Medication changes were analyzed. RESULTS: Of 55 participants, 48 (87%) had a medication change consisting of a dose change, addition, or discontinuation. Of these, 15 (31%) participants had a net increase in number of diabetes medication classes from baseline. Mean time to first medication change for these participants was 36 days. The percentage of participants taking a glucagon-like peptide-1 receptor agonist increased from 25% (12/48) to 56% (n=27), while the percentages of participants taking a sulfonylurea or dipeptidyl peptidase 4 inhibitor decreased from 56% (n=27) to 33% (n=16) and 17% (n=8) to 6% (n=3), respectively. Prescriptions of other antidiabetic medication classes including insulin did not change significantly. CONCLUSIONS: The Onduo virtual care program can play an important role in providing timely access to guideline-based diabetes management medications and technologies for people with T2D. TRIAL REGISTRATION: ClinicalTrials.gov NCT03865381; https://clinicaltrials.gov/ct2/show/NCT03865381.

Glycemic Outcomes in Adults With Type 2 Diabetes Participating in a Continuous Glucose Monitor-Driven Virtual Diabetes Clinic: Prospective Trial.

BACKGROUND: The Onduo virtual diabetes clinic (VDC) for people with type 2 diabetes (T2D) combines a mobile app, remote personalized lifestyle coaching, connected devices, and live video consultations with board-certified endocrinologists for medication management and prescription of real-time continuous glucose monitoring (RT-CGM) devices for intermittent use. OBJECTIVE: This prospective single-arm study evaluated glycemic outcomes associated with participation in the Onduo VDC for 4 months. METHODS: Adults aged ≥18 years with T2D and a baseline glycated hemoglobin (HbA1c) of ≥8% to ≤12% were enrolled from 2 primary care centers from February 2019 to October 2019. Participants were asked to engage at ≥1 time per week with their care team and to participate in a telemedicine consultation with a clinic endocrinologist for diabetes medication review. Participants were asked to use a RT-CGM device and wear six 10-day sensors (total 60 days of sensor wear) intermittently over the course of 4 months. The primary outcome was change in HbA1c at 4 months from baseline. Other endpoints included change in weight and in RT-CGM glycemic metrics, including percent time <70, 70-180, 181-250, and >250 mg/dL. Changes in blood pressure and serum lipids at 4 months were also evaluated. RESULTS: Participants (n=55) were 57.3 (SD 11.6) years of age, body mass index 33.7 (SD 7.2), and 40% (22/55) female. HbA1c decreased significantly by 1.6% (SD 1%; P<.001). When stratified by baseline HbA1c of 8.0% to 9.0% (n=36) and >9.0% (n=19), HbA1c decreased by 1.2% (SD 0.6%; P<.001) and 2.4% (SD 1.3%; P<.001), respectively. Continuous glucose monitoring-measured (n=43) percent time in range (TIR) 70-180 mg/dL increased by 10.2% (SD 20.5%; P=.002), from 65.4% (SD 23.2%) to 75.5% (SD 22.7%), which was equivalent to a mean increase of 2.4 hours TIR per day. Percent time 181-250 mg/dL and >250 mg/dL decreased by 7.2% (SD 15.4; P=.005) and 3.0% (SD 9.4; P=.01), respectively. There was no change in percent time <70 mg/dL. Mean weight decreased by 9.0 lb (SD 10.4; P<.001). Significant improvements were also observed in systolic blood pressure, total cholesterol, low-density lipoprotein cholesterol, and triglycerides (P=.04 to P=<.001). CONCLUSIONS: Participants in the Onduo VDC experienced significant improvement in HbA1c, increased TIR, decreased time in hyperglycemia, and no increase in hypoglycemia at 4 months. Improvements in other metabolic health parameters including weight and blood pressure were also observed. In conclusion, the Onduo VDC has potential to support people with T2D and their clinicians between office visits by increasing access to specialty care and advanced diabetes technology including RT-CGM. TRIAL REGISTRATION: ClinicalTrials.gov NCT03865381; https://clinicaltrials.gov/ct2/show/NCT03865381.

Active use of cocaine: an independent risk factor for recurrent diabetic ketoacidosis in a city hospital.

OBJECTIVE: To identify the risk factors for recurrent diabetic ketoacidosis (DKA) in a city hospital. METHODS: We performed a retrospective analysis of sequential adult admissions for DKA at Bronx Lebanon Hospital Center in New York between July 1, 2001, and June 30, 2004. The patients were divided into cohorts, which were compared with use of analysis of variance and X2 tests. Multivariate logistic regression analysis was performed where indicated. RESULTS: In 168 patients (96 men and 72 women), 219 episodes of DKA occurred. The mean age (+/- SD) of the overall study group was 38.6 +/- 14.8 years. Fifty-four patients (32%) had type 2 diabetes, and 44 patients (26%) had new-onset diabetes. The recurrence rate of DKA was 169% in cocaine users and 39% in nonusers (P<0.0001). Active use of cocaine, noncompliance, and Hispanic ethnicity emerged as independent risk factors for recurrent DKA-odds ratio (OR) = 4.38, P = 0.001; OR = 1.96, P = 0.05; and OR = 0.40, P = 0.005, respectively. The commonest precipitants of DKA were noncompliance (44%) and infection (26%). Noncompliance was associated with use of cocaine, use of cannabis, and cigarette smoking (P = 0.008, 0.04, and 0.01, respectively). In 91 of the hospital admissions for DKA (42%), the patients were active smokers. CONCLUSION: Active use of cocaine is an independent risk factor for recurrent DKA, as are noncompliance and Hispanic ethnicity. Of these 3 factors, cocaine showed the strongest association with DKA. Therefore, toxicology screening in patients with recurrent DKA may be prudent and worthwhile.

Admissions for diabetic ketoacidosis in ethnic minority groups in a city hospital.

Hospitalization for diabetic ketoacidosis (DKA) is increasing, perhaps due to the rising incidence of DKA in patients with type 2 diabetes mellitus (T2DM). Ethnic minority groups are at increased risk for T2DM. This study aimed at elucidating the characteristics of patients with ketosis-prone diabetes in a predominantly ethnic minority population. We performed a retrospective analysis of adults admitted with DKA at the Bronx Lebanon Hospital Center, Bronx, NY over 3 years. The patients were divided into cohorts based on type of diabetes and ethnicity. The cohorts were described and compared using statistical methods. We recorded 219 cases of DKA in 168 patients, 97% of whom were African American or Hispanic. Fifty-three (32%) patients had T2DM. New-onset diabetes, which was more common in T2DM (P < .0001), and African Americans (P = .008), occurred in 42 patients (25%). Readmission with DKA was more common in the Hispanic patients with type 1 diabetes mellitus (T1DM) (P = .0001). Type 2 diabetes mellitus was more prevalent in the African Americans (P = .04). Patients with T1DM had more severe acidosis than patients with T2DM (lower pH and bicarbonate and larger anion gap; P = .03, .02, and .005, respectively). Creatinine level was higher in patients with T2DM (P = .04) who were also less likely to have identifiable precipitating causes (P = .02). Hemoglobin A(1c) level was higher in patients with new-onset diabetes (P < .05), but did not differ between those with T1DM and T2DM. Mortality, which was 2%, occurred only in the African Americans with T2DM. We conclude that DKA is an important mode of initial presentation of T2DM, with new-onset T2DM accounting for about 60% of all new cases of DKA. African American patients with T2DM, in comparison with the Hispanic patients, are more susceptible to developing DKA. Diabetic ketoacidosis could occur in T2DM without any identifiable precipitant. The rising incidence of DKA may be attributable to its increasing occurrence in T2DM; therefore, measures aimed at primary prevention of T2DM are worthwhile.