News & Alerts

Diabetes Medication Update

Diabetes Medication Update

by Diana Podlecki

 

In the past 2 years there have been many new medications that have come out to help us treat type 2 diabetes more effectively.  For those of you in primary care, but also for those of you who do not specially treat diabetes, but have patients who are diabetic, here is a quick overview of some of the new medications to come on the market.

 

SGLT2 Inhibitors

Canagliflozin (Invokana) was the first sodium glucose co-transporter 2 (SGLT2) inhibitor to be approved in March 2013.  Dapagliflozin (Farxiga) and empagliflozin (Jardiance) were approved in early 2014.

These SGLT 2 inhibitors work by blocking the kidney’s reabsorption of glucose, so that more glucose is excreted in the urine, thus lowering the patient’s blood sugar.  This is the first medication on the market that utilizes the kidney to lower blood sugar and works completely independently of insulin.  These medications pose a low risk of hypoglycemia. 

Unlike a lot of other medications for diabetes that cause weight gain, these medications are associated with modest weight loss caused by the increase in sugar excreted in the urine.  They also have a mild diuretic effect and can also help to lower blood pressure which is often a co-morbidity in many patients with type 2 diabetes.  Side effects to watch for include lightheadedness or dizziness (from drops in blood pressure) and genital yeast and urinary tract infections.  These medications were also found to modestly increase levels of LDL (“bad”) cholesterol, but the potential for increased rates of heart attack, stroke and other cardiac events are still being studied.  There is also a concern for dapagliflozin specifically for increase in bladder cancer and liver toxicity. These medications can be used alone, or in combination with any of the other diabetes medications on the market.  The patient who would benefit from these medications the most is an obese type 2 diabetic who also has hypertension but normal kidney function (eGFR >45).

In addition, there are combinations of these new SGLT 2 inhibitors with other oral meds: Invokamet (canagliflozin and metformin) and Glyxambi (empagliflozin and linagliptin [Tradjenta, a DPP-4 inhibitor])

 

Incretin mimetics (GLP-1 receptor agonists)

GLP-1 receptor agonists work to reduce meal-related hyperglycemia by increasing insulin secretion (only) when required by increasing glucose levels, delaying gastric emptying, and suppressing prandial glucagon secretion.  These medications have a fairly low risk of hypoglycemia, have the potential  for stimulating regeneration of beta cells, reduce triglyceride levels, decrease appetite and inhibit body weight gain.  

Eventide (Byetta) and Liraglutide (Victoza) are GLP-1 receptor analogs that have been around for a few years now.  They are injections given once or twice a day to help lower blood sugars in type 2 diabetics.  Bydureon is the once weekly form of Byetta, that was approved in 2012.  

Albiglutide (Tanzeum) and dulaglutide (Trulicity) were recently approved as once weekly injections that are given any time of the day, without regard to meals, on the same day each week.  

Similar to Byetta and Victoza, these two new medications have been associated with increased rise of thyroid cancer and pancreatitis. Common side effects include nausea, diarrhea and indiegestion.  These medications are not indicated for first line treatment. These medication are often added on to oral meds to help get better control of blood sugars, before starting long acting or mealtime insulin.

Also, important to know, liraglutide has recently been approved and marketed under the brand name Saxenda as treatment for weight loss in adults with at least one weight-related comorbidity.

 

Insulin

Toujeo is the new U-300 long acting, or basal insulin pen that was just approved a few weeks ago.  Toujeo contains the same active ingredient, insulin glargine, as Lantus. The concentration, however, is 300 units per mL instead of 100 units per mL. 

The conversion from Lantus to Toujeo is 1:1.  So if a patient takes 10 units of Lantus daily, they will use 10 units of Toujeo, but since it is more concentrated they will only get 1/3 of the volume, and the convenient thing is, the pen does the math for you!  It is approved for once a day dosing.  Also note that you get 1.5mL in each pen, which gives you 450 units per pen as opposed to 300 units in the Lantus solostar pens, so the pns last longer. This is ideal for patients using more than 30 units of a long acting insulin a day, or patients taking long acting insulin twice a day.

Afrezza is probably the most exciting new product to come out this year.  Afrezza is a rapid acting INHALED insulin that comes in 4 unit and 8 unit doses.  The conversion is 1:1, so if a patient uses 8 units of injectable short acting insulin with breakfast, they would use 8 units of Afrezza (one 8 unit cartridge).

There is a requirement for patient to have spirometry (FEV1) done before starting this medication, after 6 months of therapy, and annually there after.  It is contraindicated in patients with asthma and COPD as it may cause acute bronchospasm in these patients.Side effects, besides hypoglycemia as with injected short acting insulin, include cough, and throat pain or irritation.

 

Stomach Flu or Something More Sinister?

Stomach Flu or Something More Sinister?

Kathy Tonkin, PA-C, NAPA Treasurer 

It’s your fifth day in a row at work.  Cold and flu season is here full force.  You’ve seen so many patients with coughs, fevers, runny nose, vomiting, headache and sore throat that you think you’ve seen it all.  You walk into the exam room to see another sick patient and there is a Mom with not one, but three sick little ones.  You quickly start gathering histories on all three, even though you’ve only been given enough time on the schedule to see one.  Tommy has a sore throat, headache and fever.  You order a Strep screen for him and it’s positive.  Second child’s story is the same as the first.  But little Sally’s symptoms are a little different.  She has a headache and isn’t acting herself.  She did have a fever last week, but nothing in the last few days.  She tells you her stomach hurts and Mom states she has vomited twice at home.  Despite that she is still eating and drinking well and is going to the bathroom quite a bit.  Does she have just another case of viral gastroenteritis that is going around town?  Does she have Strep throat like the others?

No, little Sally has Type 1 Diabetes (T1) and is in Diabetic Ketoacidosis (DKA).

Was that diagnosis on your radar?  Tragically, “there is an under-awareness of T1D among the public and in the healthcare system”, says Dr. Richard Insel, Chief Scientific Officer for the Juvenile Diabetes Research Foundation (JDRF).  “Missed diagnosis even occurs in emergency rooms, people don’t always think of it”.  Every day about 80 Americans are diagnosed with T1D and this diagnosis is on the rise with a 23% increase in incidence between 2000 and 2009.  Those under the age of 5 are seeing the fastest rate of new diagnosis in their age group compared to other age groups.

T1D hits close to home for me as my daughter was diagnosed with this illness when she was 2 ½ years old.  Being a PA myself and my husband growing up with a brother with T1D, we knew the signs and we diagnosed her ourselves.  Unfortunately though, I read stories all too often of children whose T1D isn’t diagnosed when they presented to health care providers and the results are often catastrophic, even deadly.  As providers we’ve all had those moments where we realized we missed a diagnosis.  After the fact it seems so obvious – why didn’t I think of that?!  None of us want to miss something that harms our patients, just thinking about it causes us to lose sleep at night (at least it does for me).

So when I read stories of little ones who’s T1D was missed, I’m reminded as a provider to make sure I have an open mind with each patient and keep those blinders off.  I need to really listen to my patients.  Are their symptoms the same as the last 8 patients I’ve just seen, or is there something else going on?

So as you’re taking care of your younger patients this cold and flu season, keep in mind the symptoms of T1D can often overlap those of common illnesses.  Often a new T1D patient will have a ‘trigger’ illness prior to their T1D diagnosis, so parents might report a recent fever or other illness and the child just doesn’t seem to be bouncing back the way they should.  Symptoms of new onset T1D include:

$1·         Extreme Fatigue

$1·         Irritability

$1·         Stomach Ache

$1·         Headache

$1·         Increased thirst

$1·         Vomiting

$1·         Weight loss, often extreme

$1·         Increased appetite

$1·         Frequent Urination (bedwetting or accidents in those potty trained or wetting completely through diapers)

$1·         Fruity breath, heavy or labored breathing (If they have this, they are sick!)

I’m not a T1D Mom that advocates screening every child for this disease or even every child with a stomach ache, but as a provider, keep it in the back of your mind. If something about the history doesn’t sound right, ask more questions and order a few tests.  A urine dip stick for glucose and ketones cost less than 50 cents.  Checking a blood sugar via finger stick is around $1.  Pretty cheap considering the cost of some of the tests we order on our patients every day, especially to catch a disease that can lead to quick deterioration of a patient’s condition or even death.

For more information about T1D visit the JDRF website at www.jdrf.org

Thank you for taking the time to read this and for pondering the ramblings of a fellow PA and T1D Mommy.

Kathleen Tonkin, PA-C

From Classroom to Clinic

Four months ago, I was sitting in class from 8-5pm Monday through Friday, then going home to study for two to four more hours depending on the number of examinations we had that week. I’m surprised I didn’t develop any pressure ulcers from all that sitting! Today, I’m in Broken Bow, Nebraska, one of the smallest towns I have ever been in, completing my three-month family practice clinical rotation. The transition from classroom to clinic has been more enjoyable than I ever could have imagined. One of our professors told our class before we went out on rotations that the worst day of rotation would be better than the best day in the classroom. She was right. Being on call all weekend and then working a full week of clinic is a thousand times better than sitting in class all day long.  
The clinical setting has helped so much with solidifying all the crazy mnemonics, common triads, buzz words, and dreaded pharmacology crammed in during many late night study sessions. It’s quickly becoming apparent that medicine is truly an art form and not always textbook medicine. I am learning about different aspects of medicine each day, from new brand name drugs to insurance plan coverages to billing and coding. Almost every day, I go home from clinic exhausted and drained because my mind has been racing, trying to capture everything from the day. 
Gone are the days of paper assignments on theoretical patients.  Now I am interviewing, performing physical exams, making diagnoses, and implementing treatment plans on real patients. The connection that a PA establishes with a patient leaves a much stronger imprint than simply memorizing a disease name and treatment option for an exam. Over the last four months, I have had so many “firsts”, from my first patient, first blood draw, first suture, first I&D of a thrombosed hemorrhoid (how satisfying), my first on-call shift, my first hospital rounds, to my first to delivery. Wow!
One thing that has been challenging for me, as a student, has been discussing treatment options with patients and providing patient education in an effective manner. My preceptors have helped me so much with this and have been wonderful teachers and role models. I am very appreciative of the time and energy they invest in their patients and in me. With every patient encounter, I learn something new, such as how to ask the same question in multiple ways or the correct verbiage to use when performing a pelvic exam. Even as I soak up so much new learning every day, as I’ve been out on clinicals, I have felt well prepared with the academic knowledge and clinical skills my PA education at UNMC provided me. And while I am thankful to be in the clinic and out of the classroom, I sure do miss seeing my wonderful classmates and trips to the coffee shop. Only one more year until I am a PA-C! 
By Jessica Taylor PA-S

Interviewing and Contracts

It's that time of year as many new graduates are preparing for their first job. Visit this site by AAPA for tips on interviewing and contracts http://www.aapa.org/twocolumn.aspx?id=341&fb_ref=Default&fb_source=message . This is also a great resource for PAs currently out in practice.

Don't forget the great resources the American Academy of Physician Assistants has! Visit aapa.org to learn more and become a member.

Be in the know... hydrocodone

Just a reminder, for those who do and don't prescribe hydrocodone, this medication has a new schedule.Just as tramadol got reclassified this Fall 2014, so did hydrocodone. What does this mean? Hydrocodone products are now treated just the same as oxycodone products. It is a schedule II medication...

  • Must be printed. Can not be called in to the pharmacy or sent by e-prescribing
  • Can not include refills. A patient needs a paper copy for each and every renewal

The Value of PAs

AAPA President John McGinnity, MS, PA-C, DFAAPA, appeared on C-SPAN's Washington Journal yesterday to talk about the valuable roles PAs play in today's healthcare system. Watch the video on AAPA.org.
http://ow.ly/E1ZUc

Influenza

INFLUENZA          by Diana Podlecki, PA-C

 

Flu season is almost here!  Here are some reminders about flu shots and some updates about the 2014-2015 flu season.

Last year, slightly more than 100 children died from  influenza, according to the U.S. Centers for Disease Control and Prevention. Of these, almost half had no underlying medical conditions, according to the American Academy of Pediatrics. More than 90 percent of children treated for influenza in intensive care units weren't vaccinated for flu last year, the AAP reported.

Who Should be Vaccinated?

Everyone 6 months and older should get an annual flu vaccine. It takes about two weeks after vaccination for your body to develop full protection against the flu, so the recommendation by the CDC is to be vaccinated by October.

The American Academy of Pediatrics updated their influenza vaccine recommendations to advise that the youngest kids, those aged 6 months through 8 years old, should have two initial doses of vaccine to build immunity. New to the recommendation this year is a stronger recommendation for the nasal spray form of the vaccine. That vaccine, called the live attenuated influenza vaccine (LAIV), should be considered for healthy children aged 2 to 8, the AAP said.  While the flu shot and the nasal spray both protect against the flu, there is evidence that the nasal spray may work better in younger children than the flu shot. These recommendations were published online Sept. 22 in the journal Pediatrics.

Pregnant women should get vaccinated to protect themselves as well as their newborns. During the first six months of life, it's the mother's immunity that protects the baby.  Anyone who has contact with newborns should also be vaccinated.

People who are at high risk of developing serious complications (like pneumonia) if they get sick with the flu for example people who have certain medical conditions including asthma, diabetes, and chronic lung disease.

People who live with or care for others who are at high risk of developing serious complications.  Household contacts and caregivers of people with certain medical conditions including asthma, diabetes, and chronic lung disease and caregivers of infants younger than 6 months old.

Health care personnel should be vaccinated.  Really, everyone should be vaccinated against flu unless there is a medical reason not to be vaccinated.

Get a Flu Vaccine Every Flu Season

You should get vaccinated every year for two reasons.

  1. Flu viruses are constantly changing and different flu viruses circulate and cause illness each season. The flu vaccine is often updated from one season to the next to protect against the influenza viruses that research indicates will be most common during the upcoming season.

  2. A person's immune protection from vaccination declines over time so annual vaccination is needed for optimal protection. Antibodies to flu drop 50 percent in the six to 12 months after vaccination.  Annual vaccination is recommended even for those who received the vaccine during the previous flu season.

Vaccine Options

This 2014-2015 season, there are multiple options available.  

Trivalent flu vaccines protect against two influenza A viruses and one influenza B virus. The following trivalent flu vaccines are available:

  • A high-dose trivalent shot, approved for people 65 and older.

  • A standard dose trivalent shot containing virus grown in cell culture, which is approved for people 18 and older.

  • A standard dose trivalent shot that is egg-free, approved for people 18 through 49 years of age who have an allergy to eggs.

  • Standard dose trivalent shots that are manufactured using virus grown in eggs. These are approved for people ages 6 months and older.

Quadrivalent flu vaccine protects against two influenza A viruses and two influenza B viruses.

There are 2 quadrivalent flu vaccines available: the standard dose quadrivalent flu shot and the standard dose quadrivalent nasal spray, approved for people 2 through 49 years of age (recommended preferentially for healthy children 2 to 8 years old when immediately available and there are no contraindications or precautions).

 

Vaccine Safety

The flu vaccine is safe. People have been receiving flu vaccines for more than 50 years. Vaccine safety is closely monitored by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Hundreds of millions of flu vaccines have been given safely to people across the country for decades.

A common misconception is that the flu vaccine can give you the flu. Remind patients that it cannot. The most common side effects from a flu shot are soreness where the shot was given, and maybe a low fever or achiness. The nasal spray flu vaccine might cause congestion, runny nose, sore throat, or cough. These side effects are NOT the flu. If you do experience them at all, these side effects are usually mild and short-lived.

 

Union College PA Students Serve in Peru

 

 

The sky was overcast and threatening to burst with rain as we sat down under our makeshift village clinic in Iquitos, Peru. Stray dogs sat beneath our feet and chickens pecked at the dirt floor as we attended to our first patient. "Hola, en que puedo ayudarle hoy?" That phrase translated “hello, how can I help you today,” would be said more than 500 times by the end of our week of serving in rural clinics. 

 

In June, a small group which included seven, first-year Union College PA students traveled to Iquitos, Peru--a city located in the Amazon Basin that can only be reached by plane or boat. Each year Union College's Chaplain, Rich Carlson, gives the PA students an opportunity to partner with the People of Peru Project--a non-profit organization providing aid to those in the region. The students have the opportunity to provide free medical and dental assistance to the inhabitant’s of this remote poverty stricken area.

 

For the majority of our clinic days we traveled by bus packed to the brim with medical and dental supplies to villages at the edge of the city. Our “clinical office” ranged from tents in the middle of the street to the humble homes of generous locals. Each day as we set up triage, consultation and our pharmacy, villagers congregated often waiting several hours to be seen. We were able to put our classroom knowledge to practice as we attended to over a hundred patients each day. We saw people of all ages from one week old to one hundred years old. We listened to heart sounds, looked in ears, bandaged wounds, and even pulled teeth.

 

It was such an amazing experience to be able to sit down and talk with each person. I was humbled by the confidence each one had in us, even though we were only students. We were limited in the care we were able to offer and there were many times I was saddened wishing I could do more for the people. But more often I was amazed at how grateful they were for even the little things. For some patients, all we could offer them were vitamins and yet they would take our hands in theirs with a smile on their face and an appreciative look in their eyes as they thanked us as though we had given them a miracle cure.

By: Jenessa King, PA-S

 

New DEA Guidelines on Tramadol

Tramadol will be classified as a controlled substance beginning August 18th, 2014. This includes all products containing tramadol: Ultram, Ultram ER, Ultracet, Ryzolt.

  • Tramadol will be classified as a Schedule 4 controlled substance (same as benzodiazepines)
  • Maximum of 5 refills are allowed at any time
  • It can be legally phoned in by a prescriber or their nurse

 

ICD-10 Delayed! *again*

ICD-10 DELAYED  (again)- the implementation of ICD-10 will not start till 10/01/2015.  The AAPA suggest that this maybe an opportunity to listen, and with a relaxed  frame of mind, re view this informative video regarding ICD-10 coding basics.  This can be found at http://www.youtube.com/watch?v=kCV6aFIA-Sc&feature=youtu.be.
  • This may be a great time to reorganize and re-prioritize her documentationIt may be beneficial to ask administrator or coder to run a list of the 50 most common ICD-9 codes that you use and then research and learn the ICD-10 equivalent.
  • And continue to watch and listen for coding updates for Medicare.

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