HealthTeamWorks has revised its clinical diabetes guideline to give providers a new screening algorithm, updated medication information and new tools for patients. Users familiar with the previous version, released in 2006, will first notice the new title: Guideline for Type 2 Diabetes. We make the distinction between Type 1 diabetes, which usually requires care by an endocrinologist, and Type 2, which usually falls under the purview of primary care.

The revised guideline features:

• A message noting that type 2 diabetes can be prevented or delayed by a healthy diet, an active lifestyle and a healthy body weight;

• A new algorithm to screen for type 2 diabetes;

• A recommendation to assess medication adherence, glucose control/hypoglycemia, and alcohol and drug use;

• A new glucose management algorithm;

• A flow sheet indicating what needs to be done for the patient at every visit, quarterly and annually;

• A patient handout and action plan; and

• A medication chart. 

“The new guideline allows the clinician to determine, ‘How much do I need to get the HgA1c* down, and what’s going to be the best [therapeutic] agent?’” says Stephanie Bacon, MS, RD, PA-C. She and Rocio Pereira, MD, chaired the guideline revision committee. Other members included two public health officials, seven physicians, two midlevel providers, a doctor of pharmacy, an optometrist and HealthTeamWorks Guidelines staff. The committee revised the guideline using evidence from the American Diabetes Association, the U.S. Preventive Services Taskforce and the American College of Endocrinology. Funding came from The Colorado Health Foundation.

Diabetes affects 8.3 percent of Americans — nearly 26 million people.¹ Almost 19 million new cases are diagnosed each year, but another 7 million go undiagnosed.² Diabetes is the leading reason for kidney failure, nontraumatic lower-limb amputations and new cases of blindness among adults, as well as a major cause of heart disease and stroke. It’s the seventh leading cause of death in this country.

In adults, type 2 diabetes accounts for about 90 percent to 95 percent of all diagnosed cases. It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce it. Type 2 diabetes is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity and ethnicity. African Americans, Hispanics, American Indians, and some Asian Americans and Pacific Islanders are at particularly high risk for type 2 diabetes and its complications.³

The incidence of type 2 diabetes mirrors the incidence of obesity among Americans. From 1980-2009, the number of Americans with diabetes has more than tripled, from 5.6 million to 19.7 million.⁴ If the trend is not reversed, one in three Americans will have diabetes by 2050.⁵

“Preventing a patient from becoming diabetic is much better than treating it after the fact,” Bacon says. “If you can decrease HgA1c by 1 percent, you reduce the risk of [diabetic] complications by 40 percent.”

HealthTeamWorks is mailing laminated copies of the revised diabetes guideline to 5,210 clinicians across Colorado. It’s also available for free download on our website. If you have questions about the guideline, please contact Emily Gingerich.

*Hemoglobin A1c is a lab test that shows the average amount of sugar in the blood over three months — an indicator of diabetes control.

Sources
1. National Diabetes Information Clearinghouse, a service of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health. 2011. www.diabetes.niddk.nih.gov/dm/pubs/statistics/#fast
2. Ibid.
3. Centers for Disease Control and Prevention. 2011 National Diabetes Fact Sheet. www.cdc.gov/diabetes/pubs/general11.htm
4. Centers for Disease Control and Prevention. Diabetes Data and Trends. www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm
5. American Diabetes Association. Diabetes basics. www.diabetes.org/diabetes-basics/

HealthTeamWorks has posted the 2012 immunization schedules for children and adolescents on our website. The schedules endorse those approved by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics and the American Academy of Family Physicians.

This year’s schedule contains numerous changes, including:

• Guidance on the administration of hepatitis B vaccine in infants with birth weights of less than 2,000 grams or equal to or more than 2,000 grams;

• Guidance on the use of measles, mumps and rubella vaccine in infants aged 6-11 months;

• Updated influenza vaccine footnotes that provide guidance on live, attenuated influenza vaccine contraindications;

• Dosage clarifications in the influenza vaccine footnotes for dosing children 6 months-8 years old for the 2011-12 and 2012-13 seasons;

• Updated Tdap vaccine recommendations for children aged 7-10 years; 

• Updated human papillomavirus vaccine footnotes that include routine recommendations for vaccination of males; and 

• Updated footnotes for inactivated poliovirus vaccine that include an upper age limit for routine vaccination.

In addition to the schedule, HealthTeamWorks has provided links to a wide range of related resources, including standing orders for vaccine administration; a screening questionnaire for parents/guardians; updates on vaccine shortages, handling and storage information; and helpline numbers.

One valuable resource for parents is www.immunizeforgood.com, a joint project of the Colorado Children’s Immunization Coalition, Colorado Department of Public Health and Environment, and Vaccine Advisory Committee of Colorado. The site gives parents “the truth about vaccinations” — describing the rationale, the vaccines, benefits vs. risks and more. The chart sums up the impact of vaccines in the United States:

Source: Immunize for Good. www.immunizeforgood.com/fact-or-fiction/benefits-vs.-risks

As Immunize for Good notes, “It may be hard to compare the worldwide benefits of immunization to your own child’s health, but following the recommended vaccine schedule can prevent your child from 14 diseases by the age of 2. The risks and complications of these diseases can cause serious, long-term disabilities, hospitalization, and in the worst cases, death.”

We hope you find the immunization schedule and the resources useful.

The HealthTeamWorks Guidelines staff

By Martha Johns, MD, MPH, FACPM, HealthTeamWorks Medical Director, Guidelines/Evaluation

Varenicline (Chantix) to aid in smoking cessation has been in the medical news twice recently. Should you think twice? Does it cause more problems than it cures? Let’s look at the evidence.

The FDA reviewed a randomized control trial of 700 smokers with cardiovascular disease treated with varenicline or placebo. While cardiovascular adverse events were infrequent overall, certain events were reported more often in patients treated with varenicline than in patients treated with placebo. The events included angina pectoris, nonfatal myocardial infarction, need for coronary revascularization, and new diagnosis of peripheral vascular disease or admission for the treatment of peripheral vascular disease.

The FDA has required that the manufacturer, Pfizer, conduct a large, combined analysis of randomized, placebo control trials to determine the risk of varenicline.

A large systematic review and meta-analysis of 14 randomized, clinical trials with 8,217 smokers without known cardiovascular disease was published early, online. The researchers found that use of varenicline was associated with a significantly increased risk of serious adverse cardiovascular events (ischemia, arrhythmia, congestive heart failure) compared with placebo. Again, the absolute numbers of events were small; however this analysis raises safety concerns about potential increased risk of serious adverse cardiovascular events associated with the use of varenicline among tobacco users, whether or not they have pre-existing cardiovascular disease.

The challenge is to balance these potential risks against the well-established, severe consequences of tobacco use on the heart and lungs. We don’t have all the answers yet. However, these two new studies and the FDA Alert make clear the necessity for healthcare providers to consider the issues and talk to patients who use tobacco products about the potential risks of using varenicline vs. the benefits of tobacco cessation. Smokers have many alternative methods to help with quitting; we healthcare providers can help our patients make informed decisions on how best to help them quit tobacco.

HealthTeamWorks can help you get your patients on the road to quitting tobacco products: Refer to our Tobacco Cessation/Second-Hand Smoke Guideline for more information.