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Overcoming Therapeutic Inertia

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Therapeutic inertia is a well-known problem in the management of diabetes.

From the Personal Continuous Glucose Monitoring Implementation Playbook from ADCES and AphA. Contributors include: Patricia L. Scalzo, MSN, NP, RN, CDCES, Kelly A. Brock, PharmD, RPh and Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, FADCES. This effort was supported by Dexcom & Abbott.

Overcoming Therapeutic Inertia Therapeutic inertia is a well-known problem in the management of diabetes. Treatment intensification may be delayed for a prolonged period due to several reasons.

Kamlesh Khunti, FMedSci, FRCGP, FRCP, MD, PhD, presented an overview of the scope and impact of therapeutic inertia as well as clinician barriers related to therapy intensification reported in the American Diabetes Association’s publication, Summary of the Proceedings of the American Diabetes Association Summit - Overcoming Therapeutic Inertia: Accelerating Diabetes Care For Life23.

These barriers include the following:

  • lack of time 
  • lack of resources
  • lack of training and education
  • suboptimal patient medication-taking behavior
  • perceptions about patients’ ability and willingness to follow treatment protocols
  • hypoglycemia concerns and management of comorbidities

In this same publication, session participants were asked to share their ideas of the causes and impact of therapeutic inertia and to summarize that in one word. Words identified to describe the top contributors to therapeutic inertia were “time,” “cost,” “fear,” “apathy” and “overwhelmed.” Words identified to describe the solutions to address therapeutic inertia were “education” and “time.”

Results of a nationally representative, serial cross-sectional study of adults with diabetes were reported in JAMA in 2019’s “Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016”24. The conclusion was that there was no significant improvement in diabetes care in the US between 2005 and 2016.

Certainly, therapeutic inertia comes into play here. A Personal CGM program can address therapeutic inertia by identifying glycemic patterns and changing the treatment plan to address problem areas that are uncovered. Changing the treatment plan does not only entail making medication related interventions, but also, very importantly, includes an analysis of lifestyle factors and behavioral issues and a plan to overcome these obstacles.

A diabetes care and education specialist is a great person to have on your team to address these topics with people with diabetes, as they are skilled at coaching persons with diabetes in all aspects of self-management of their condition using an evidence-based framework, the AADE7 Self-Care Behaviors®.

The pharmacist is another important person to have on your team to provide their expertise related to medication management and medication related interventions, and for helping adjust medications based on results from personal CGM.

References: 1 Chehregosha, H, Khamseh, ME, Malek, M, et al. A View Beyond HbA1c: Role of Continuous Glucose Monitoring. Diabetes Therapy. 2019;10, 853–863 2 Sagar R, Abbas A, Ajjan R. Glucose monitoring in diabetes: from clinical studies to real-world practice. Practical Diabetes. 2019;36. 57-62. 10.1002/pdi.2215. 3 Ajjan R, Slattery D, Wright E. Continuous Glucose Monitoring: A Brief Review for Primary Care Practitioners. Advances in Therapy. 2019;36:579-596 4 Aleppo G, Laffel LM, Ahmann AJ, et al. A Practical Approach to Using Trend Arrows on the Dexcom G5 CGM System for the Management of Adults With Diabetes, Journal of the Endocrine Society, Volume 1, Issue 12, 1 December 2017, Pages 1445–1460, https://doi.org/10.1210/js.2017-00388 5 Kudva YC, Ahmann AJ, Bergenstal RM, et al. Approach to Using Trend Arrows in the FreeStyle Libre Flash Glucose Monitoring Systems in Adults, Journal of the Endocrine Society, Volume 2, Issue 12, December 2018, Pages 1320–1337, https://doi. org/10.1210/js.2018-00294 6 Šoupal J, Petruželková L, Grunberger G, et al. Glycemic Outcomes in Adults With T1D Are Impacted More by Continuous Glucose Monitoring Than by Insulin Delivery Method: 3 Years of Follow-Up From the COMISAIR Study. Diabetes Care. 2020 Jan;43(1):37-43. doi: 10.2337/dc19-0888. Epub 2019 Sep 17. 7 Mulinacci G, Alonso T, Snell-Bergeon JK, Shah VN. Glycemic Outcomes with Early Initiation of Continuous Glucose Monitoring System in Recently Diagnosed Patients with Type 1 Diabetes. Diabetes Technology & Therapeutics. 2018;21. 10.1089/ dia.2018.0257. 8 Peters, AL. The Evidence Base for Continuous Glucose Monitoring. Role of Continuous Glucose Monitoring in Diabetes Treatment. American Diabetes Association. 2018 Aug: 3-7. doi: 10.2337/db20181-3 9 American Association of Diabetes Educators Practice Paper. The Diabetes Educator Role in Continuous Glucose Monitoring. 2018. Updated Dec2019; https://www.danatech.org/media/ntgjf2di/diabetescareeducationspecialistrolecgm_aug20.pdf 10 American Diabetes Association. Standards of Medical Care in Diabetes – 2020. Diabetes Care 2020;43(Suppl 1):S77-S88 11 Peters AL, Ahmann AJ, Battelino T, et al.: Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101:3922–3937 12 Garber AJ, Handelsman Y, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm - 2020 executive summary. Endocrine Practice 2020, 26 (1): 107-139 13 Danne T, Nimri R, Battelino T, et al. International Consensus on Use of Continuous Glucose Monitoring. Diabetes Care. 2017;40:1631–40 14 Aleppo G, Webb K. Continuous Glucose Monitoring Integration in Clinical Practice: A Stepped Guide to Data Review and Interpretation. Journal of Diabetes Science & Technology. 2018; https://doi.org/10.1177%2F1932296818813581 15 Petrie JR, Peters AL, Bergenstal RM, et al. Improving the clinical value and utility of CGM systems: Issues and Recommendations: A joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care. Oct 2017, dci170043; DOI: 10.2337/dci17-0043 16 American Diabetes Association. Standards of Medical Care in Diabetes – 2020. Diabetes Care 2020;43(Suppl 1):S77-S88 17 U.S. Centers for Medicare & Medicaid Services. Medicares Coverage of Diabetes Supplies, Services & Prevention Programs. Publication # 11022. Revised 12/01/2019 18 Kompala T, Neinstein A. A New Era: Increasing Continuous Glucose Monitoring Use in Type 2 Diabetes. American Journal Managed Care. 2019 Mar;25(4 Spec No.):SP123-SP126. 19 Welsh JB. Role of Continuous Glucose Monitoring in Insulin-Requiring Patients with Diabetes. Diabetes Technology & Therapeutics. Jun 2018.S2-42-S2-49.http://doi.org/10.1089/dia.2018.0100 20 Heinemann, L, Klonoff, D. C. An Opportunity to Increase the Benefit of CGM Usage: The Need to Train the Patients Adequately. Journal of Diabetes Science and Technology. 2019 https://doi.org/10.1177/1932296819895083 21 Longo, R, Sperling, S. Personal Versus Professional Continuous Glucose Monitoring: When to Use Which on Whom. Diabetes Spectrum. 2019;32. 183-193. 10.2337/ds18-0093 PART SIX: References Personal Continuous Glucose Monitoring Implementation Playbook 61 22 Tanenbaum ML, Adams RN, Lanning MS, et al. Using Cluster Analysis to Understand Clinician Readiness to Promote Continuous Glucose Monitoring Adoption. Journal of Diabetes Science & Technology. 2018;12(6):1108–1115 23 American Diabetes Association. Overcoming Therapeutic Inertia: Accelerating Diabetes Care for Life. American Diabetes Association Summit. Summary of Proceedings. 2019 24 Kazemian P, Shebl FM, McCann N, Walensky RP, Wexler DJ. Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016. JAMA Intern Med. 2019;179(10):1376–1385. doi:10.1001/jamainternmed.2019.2396 25 Rodbard D. Continuous Glucose Monitoring: A Review of Successes, Challenges, and Opportunities. Diabetes Technol Ther. 2016 Feb 1; 18(Suppl 2): S2-3–S2-13. doi: 10.1089/dia.2015.0417 26 Smith MB, Albanese-O’Neill A, Macieira TGR, Yao Y, et al. Human Factors Associated with Continuous Glucose Monitor Use in Patients with Diabetes: A Systematic Review. Diabetes Technology & Therapeutics. Oct 2019.589-601.http://doi.org/10.1089/ dia.2019.0136 27 Johnson ML, Martens TW, Criego AB, Carlson AL, et al. 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