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Elevating the role of basal insulin therapy in T2D management: From CGM use to fixed-ratio combinations and once-weekly regimens

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This activity is funded by an independent medical education grant from Novo Nordisk A/S.

This activity is jointly provided by USF Health, EBAC® and touchIME.

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    Faculty & Disclosures
    Dr Viswanathan Mohan

    Dr. Mohan’s Diabetes Specialities Centre, Chennai, India

    Dr Viswanathan Mohan is Chairman of Dr. Mohan’s Diabetes Specialities Centre in Chennai, South India, which is an International Diabetes Federation Centre of Excellence in Diabetes Care. read more

    Dr Mohan oversees a chain of 50 diabetes centres across eight states of India and has over 630,000 registered patients with diabetes. He is also Chairman of the Madras Diabetes Research Foundation, an Indian Council of Medical Research Centre for Advanced Research in Diabetes and Asia’s largest standalone diabetes research centre. His main research interests are the epidemiology of diabetes and its complications, the genomics of diabetes, precision diabetes and nutrition in diabetes.

    Dr Mohan has published more than 1,645 papers in peer-reviewed journals, including 1,057 original articles. His research has attracted over 196,000 citations and has a ‘h index’ of 154. He has received more than 200 awards, including the Dr Harold Rifkin Award by the American Diabetes Association and the Fellowship of the Royal Society of Edinburgh. For his extensive contribution in the field of diabetes, he was awarded Padma Shri in 2012, the fourth highest civilian award given by the government of India and, more recently, the Lakshmipat Singhania Award (Leader in Science and Technology) from Her Excellency, the President of India.

    Dr Mohan provides lifelong free treatment to thousands of poor patients through his free diabetic clinics and has adopted four slums and residential colonies in Chennai for free diabetes check-ups and treatment. In addition, he has provided free rural diabetes screening to 42 villages in Tamil Nadu, from which more than 50,000 people have benefitted.

    Dr Viswanathan Mohan discloses: Grants or research support from Abbott, Alembic Pharmaceuticals, Apex, Bayer, Biocon, Boehringer Ingelheim, Cipla, Dr. Reddy’s Laboratories, Eli Lilly, Emcure Pharmaceuticals, Fourrts, Franco-Indian Pharmaceuticals, Glenmark Pharmaceuticals, GSK, Intas Pharmaceuticals, Ipca Laboratories, LifeScan, Lupin, Mankind Pharma, Medtronic, MSD, Novartis, Primus Pharmaceuticals, Roche, Sanofi-Aventis, Servier, Sun Pharma, Torrent Pharmaceuticals, USV Private, Wockhardt and Zydus Lifesciences.
    Dr Alice Y Y Cheng

    Trillium Health Partners & Unity Health Toronto, Toronto, ON, Canada

    Dr Alice Y Y Cheng is an endocrinologist at Trillium Health Partners and Unity Health Toronto, and an associate professor at the University of Toronto, Canada. read more

    Since 2003, Dr Cheng has been involved with the development of the Diabetes Canada clinical practice guidelines and she served as Chair for the 2013 version. She is Chair of the Scientific Planning Committee for the 2023 and 2024 American Diabetes Association annual scientific meetings – the largest international diabetes conference. In addition, she is an Associate Editor for Diabetes Care, and co-host of the podcast series ‘Diabetes Care On Air’. 

    In recognition of her contribution to the diabetes community, Dr Cheng has received the national Charles H. Best Award and the Gerald S. Wong Service Award from Diabetes Canada. She is the creator of The Med Ed Pledge – an initiative to increase diversity and inclusion in continuing medical education (www.theMedEdPledge.com), along with CMEX (Continuing Medical Education Experts), a searchable database of healthcare professionals interested in contributing to medical education.

    Dr Alice Y Y Cheng discloses: Advisory board or panel fees from Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, Dexcom, Eisai, Eli Lilly, HLS Therapeutics, Insulet, Janssen, Novo Nordisk, Sanofi and Takeda. Consultancy fees from Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, Dexcom, Eisai, Eli Lilly, HLS Therapeutics, Insulet, Janssen, Novo Nordisk, Sanofi and Takeda. Grants or research support from Applied Therapeutics, Novo Nordisk and Sanofi. Speakers bureau fees from Abbott, Amgen, AstraZeneca, Bausch, Bayer, Boehringer Ingelheim, Dexcom, Eli Lilly, GSK, HLS Therapeutics, Insulet, Janssen, Novo Nordisk, Pfizer and Sanofi.
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    Poll

    What is the most common reason for you delaying initiation of basal insulin in T2D?

    Submit your answer to see the results

    Patient refusal/patient fears
       
    Lack of time and/or support (e.g. nursing staff, diabetes educators)
       
    Lack of knowledge, information and/or guidelines
       
    Suboptimal healthcare system infrastructure and/or planning
       

    Tutorial

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    What % of your T2D patients taking insulin also use continuous glucose monitoring?

    Submit your answer to see the results

    None
       
    <25%
       
    25–50%
       
    >50%
       

    Tutorial

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    Which of these potential approvals will make the biggest impact on T2D in future?

    Submit your answer to see the results

    A GLP-1 based triple agonist
       
    A GLP-1 based pancreatic gene therapy
       
    A once-weekly basal insulin
       
    A GLP-1 RA/once-weekly basal insulin fixed ratio combination
       
     
    Timely initiation of basal insulin therapy in T2D and overcoming barriers to insulin intensification
    The role of CGM and time-in-range in optimizing outcomes in T2D patients on basal insulin
    The evidence for once-weekly insulins in T2D and the practicalities of their use
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    Elevating the role of basal insulin therapy in T2D management: From CGM use to fixed-ratio combinations and once-weekly regimens

    Faculty Podcast Featured
    Useful tips
    • A practice aid is available for this activity in the Toolkit
    • Downloads including slides are available for this activity in the Toolkit
    Learning Objectives

    After watching this activity, participants should be better able to:

    • Appraise the importance of timely initiation of basal insulin treatment, and implement strategies to overcome the barriers to insulin intensification in T2D
    • Assess the role of continuous glucose monitoring and time-in-range measurement in supporting achievement of glycaemic control in patients with T2D on basal insulin
    • Recall the efficacy and safety data for once-weekly insulins currently under development for the treatment of T2D and plan for the practicalities of their use
    Overview

    In this activity, endocrinologists with expertise in type 2 diabetes (T2D) respond to questions from the endocrinology and primary care communities on practical considerations for the use of basal insulin therapy in patients with T2D, with a focus on the current and future use of continuous glucose monitoring, fixed-ratio combinations and once-weekly basal insulin regimens.

    This activity is jointly provided by USF Health, EBAC® and touchIME. read more

    Target Audience

    This activity has been designed to meet the educational needs of diabetologists, endocrinologists and primary care physicians who actively manage patients with type 2 diabetes.

    USF Accreditation
    Disclosures

    USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education. All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity. The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

    Faculty

    Dr Viswanathan Mohan discloses Grants or research support from Abbott, Alembic Pharmaceuticals, Apex, Bayer, Biocon, Boehringer Ingelheim, Cipla, Dr. Reddy’s Laboratories, Eli Lilly, Emcure Pharmaceuticals, Fourrts, Franco-Indian Pharmaceuticals, Glenmark Pharmaceuticals, GSK, Intas Pharmaceuticals, Ipca Laboratories, LifeScan, Lupin, Mankind Pharma, Medtronic, MSD, Novartis, Primus Pharmaceuticals, Roche, Sanofi-Aventis, Servier, Sun Pharma, Torrent Pharmaceuticals, USV Private, Wockhardt and Zydus Lifesciences.

    Dr Alice Y Y Cheng discloses Advisory board or panel fees from Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, Dexcom, Eisai, Eli Lilly, HLS Therapeutics, Insulet, Janssen, Novo Nordisk, Sanofi and Takeda. Consultancy fees from Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, Dexcom, Eisai, Eli Lilly, HLS Therapeutics, Insulet, Janssen, Novo Nordisk, Sanofi and Takeda. Grants or research support from Applied Therapeutics, Novo Nordisk and Sanofi. Speakers bureau fees from Abbott, Amgen, AstraZeneca, Bausch, Bayer, Boehringer Ingelheim, Dexcom, Eli Lilly, GSK, HLS Therapeutics, Insulet, Janssen, Novo Nordisk, Pfizer and Sanofi.

    Content reviewer

    Christy Thai, PharmD, BCPS has no financial interests/relationships or affiliations in relation to this activity.

    Touch Medical Contributors

    Sola Neunie has no financial interests/relationships or affiliations in relation to this activity.

    USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

    Requirements for Successful Completion

    In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

    If you have questions regarding credit please contact cpdsupport@usf.edu 

    Accreditations

    Physicians

    This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

    USF Health designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 CreditTM into European CME credit (ECMEC) should contact the UEMS (www.uems.eu).

    Advanced Practice Providers

    Physician Assistants may claim a maximum of 1 Category 1 credits for completing this activity. NCCPA accepts AMA PRA Category 1 CreditTM from organizations accredited by ACCME or a recognized state medical society.

    The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 CreditTM by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

    Date of original release: 28 March 2024. Date credits expire: 28 March 2025.

    If you have any questions regarding credit please contact cpdsupport@usf.edu

    EBAC® Accreditation

    touchIME is an EBAC® accredited provider since 2023.

    This programme is accredited by the European Board for Accreditation of Continuing Education for Health Professionals (EBAC®) for up to 1.0 hour(s) of CE credit(s). Each participant should claim only time that has been spent in the educational activity.

    The Accreditation Council for Continuing Medical Education (ACCME®), and the Royal College of Physicians and Surgeons of Canada hold an agreement on substantial equivalency of accreditation systems with EBAC®.

    Through an agreement between the European Board for Accreditation of Continuing Education for Health Professionals and the American Medical Association (AMA), physicians may convert EBAC® CE credits to AMA PRA Category 1 CreditsTM. Information on the process to convert EBAC® credit to AMA credit can be found on the AMA website. Other health care professionals may obtain from the AMA a certificate of having participated in an activity eligible for conversion of credit to AMA PRA Category 1 CreditTM.

    Faculty Disclosure Statement / Conflict of Interest Policy

    In compliance with EBAC® guidelines, all speakers/ chairpersons participating in this programme have disclosed or indicated potential conflicts of interest which might cause a bias in the presentations. The Organizing Committee/Course Director is responsible for ensuring that all potential conflicts of interest relevant to the event are declared to the audience prior to the CME activities.

    Faculty

    Dr Viswanathan Mohan discloses Grants or research support from Abbott, Alembic Pharmaceuticals, Apex, Bayer, Biocon, Boehringer Ingelheim, Cipla, Dr. Reddy’s Laboratories, Eli Lilly, Emcure Pharmaceuticals, Fourrts, Franco-Indian Pharmaceuticals, Glenmark Pharmaceuticals, GSK, Intas Pharmaceuticals, Ipca Laboratories, LifeScan, Lupin, Mankind Pharma, Medtronic, MSD, Novartis, Primus Pharmaceuticals, Roche, Sanofi-Aventis, Servier, Sun Pharma, Torrent Pharmaceuticals, USV Private, Wockhardt and Zydus Lifesciences.

    Dr Alice Y Y Cheng discloses Advisory board or panel fees from Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, Dexcom, Eisai, Eli Lilly, HLS Therapeutics, Insulet, Janssen, Novo Nordisk, Sanofi and Takeda. Consultancy fees from Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, Dexcom, Eisai, Eli Lilly, HLS Therapeutics, Insulet, Janssen, Novo Nordisk, Sanofi and Takeda. Grants or research support from Applied Therapeutics, Novo Nordisk and Sanofi. Speakers bureau fees from Abbott, Amgen, AstraZeneca, Bausch, Bayer, Boehringer Ingelheim, Dexcom, Eli Lilly, GSK, HLS Therapeutics, Insulet, Janssen, Novo Nordisk, Pfizer and Sanofi.

    Christy Thai, PharmD, BCPS has no financial interests/relationships or affiliations in relation to this activity.

    Touch Medical Contributors

    Sola Neunie has no financial interests/relationships or affiliations in relation to this activity.

    Requirements for Successful Completion

    Certificates of Completion may be awarded upon successful completion of the post-test and evaluation form. If you have completed one hour or more of effective education through EBAC® accredited CE activities, please contact us at accreditation@touchime.org to receive your EBAC® CE credit certificate. EBAC® grants 1 CE credit for every hour of education completed. 

    Date of original release: 28 March 2024. Date credits expire: 28 March 2025.

    Time to Complete: 1 hour

    If you have any questions regrading the EBAC® credits, please contact accreditation@touchime.org 

    This activity is CE/CME accredited

    To obtain the CE/CME credit(s) from this activity, please complete this post-activity test.

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    Diabetes
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    This Activity Is Funded By:

    An independent medical education grant from Novo Nordisk A/S.
    This activity is jointly provided by USF Health, EBAC® and touchIME.

    The information provided by this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical/clinical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

    USF is an Equal Opportunity / Affirmative Action / Equal Access Institution.

    USF
    USF Health is accredited by the Accreditation Council for Continuing Medical Education, the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education to provide continuing education to healthcare professionals. As an accredited provider, USF Health is required to disclose personal information to relevant accredited bodies that certify CME to process credits/contact hours, comply with reporting requirements, and for internal recordkeeping and regulatory purposes. USF Health does not share or sell any individual’s contact information or unique identifiers to any commercial supporter, advertiser, or third party without the specific permission of the individual.

    EBAC®
    touchIME is an EBAC® accredited provider since 2023.

    In compliance with EBAC® guidelines, all speakers/ chairpersons participating in this programme have disclosed or indicated potential conflicts of interest which might cause a bias in the presentations. The Organizing Committee/Course Director is responsible for ensuring that all potential conflicts of interest relevant to the event are declared to the audience prior to the CME activities.

    Unapproved products or unapproved uses of approved products may be discussed by the faculty; these situations may reflect the approval status in one or more jurisdictions. The presenting faculty have been advised by touchIME and USF Health to ensure that they disclose any such references made to unlabelled or unapproved use. No endorsement by touchIME or USF Health of any unapproved products or unapproved uses is either made or implied by mention of these products or uses in touchIME or USF Health activities. touchIME and USF Health accept no responsibility for errors or omissions.

    This content is intended for healthcare professionals outside the UK and USA.

    Date of original release: 28 March 2024. Date credits expire: 28 March 2025.

    This content is intended for healthcare professionals only outside of the UK and USA. Please confirm that you are a healthcare professional.

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    touchIN CONVERSATION
    Elevating the role of basal insulin therapy in T2D management: From CGM use to fixed-ratio combinations and once-weekly regimens
    1 CE/CME credit
    Question 1/4
    Which of these is a potential consequence of delayed initiation of basal insulin in patients with T2D?

    T2D, type 2 diabetes.

    Delayed initiation of basal insulin in patients with T2D is associated with chronic hyperglycaemia,1 micro- and macrovascular complications2,3 – the latter of which are not reversible with tighter glucose control4 – a diminished quality of life and a reduction in psychological wellbeing.2,5 Long-term delays to basal insulin initiation can ultimately lead to an increased risk of early mortality.5,6

    T2D, type 2 diabetes.

    References

    1. Zografou I, et al. Hippokratia. 2014;18:306–9.
    2. Martinez M, et al. BMJ Open Diab Res Care. 2021;9:e002032.
    3. Harding JL, et al. Diabetologica. 2019;62:3–16.
    4. Lovre D, Fonseca V. J Diabetes Complications. 2015;29:295–301.
    5. Kim SG, et al. J Diabetes Investig. 2017;8:346–53.
    6. Khunti K, et al. Diabetes Obes Metab. 2020;22:722–33.
    Question 2/4
    Your patient with T2D is asking you about the differences between continuous glucose monitoring (CGM) technology and their usual HbA1c test. How would you explain the difference between these two methods of measuring the patient’s glucose level?

    CGM, continuous glucose monitoring; HbA1c, glycated haemoglobin; T2D, type 2 diabetes.

    CGM uses a subcutaneous sensor to measure interstitial glucose concentrations every few minutes, enabling a comprehensive assessment of an individual patient’s glucose profile.1 Although HbA1c testing at HCP follow-ups provides an indication of glycaemic control, it does not evaluate short-term glycaemic variability or daily fluctuations in glucose, meaning low or high values that may occur can be missed.1–3 Retrospective review of CGM data provides clinicians with further insights into how to efficiently manage the patient’s treatment plan, allowing for timely analysis of a treatment’s effects rather than having to wait for the next HbA1c measurement.1 

    CGM, continuous glucose monitoring; HbA1c, glycated haemoglobin; HCP, healthcare professional.

    References

    1. Kushner PR, Kruger DF. Clin Diabetes. 2020;38:348–56.
    2. Martinez M, et al. BMJ Open Diab Res Care. 2021;9:e002032.
    3. Eyth E, Naik R. 2023. Mar 13. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–.
    Question 3/4
    You are examining the data from your patient’s continuous blood glucose monitor to assess their time-in-range. For what percentage of a 24-hour period should you aim for your patient’s blood glucose reading to be 3.9–10.0 mmol/L (70–180 mg/dL)?

    TIR is defined as the percentage of the time that CGM readings are between 3.9 and 10.0 mmol/L (70 and 180 mg/dL), with a TIR of >70% (i.e. >16 hours and 48 minutes in a day) roughly equating to a HbA1c value of <7%. The 2019 international consensus on time-in-range suggests aiming for <4% of the time (<1 hour) below 3.9 mmol/L (70 mg/dL) and <1% of the time (<15 minutes) with a blood glucose reading below 3.0 mmol/L (54 mg/dL).1,2

    CGM, continuous glucose monitoring; HbA1c, glycated haemoglobin; TIR, time-in-range.

    References

    1. Battelino T, et al. Diabetes Care. 2019;42:1593–603.
    2. Saboo B, et al. Heliyon. 2021;7:e05967.
    Question 4/4
    Which of these best describes the results for once-weekly insulin icodec compared with the comparator daily basal insulin in an insulin-naive population with T2D? “Compared with the daily basal insulin comparator, icodec demonstrated…”

    HbA1c, glycated haemoglobin; T2D, type 2 diabetes.

    ONWARDS 1 and ONWARDS 3 are phase IIIa clinical trials examining the effect of once-weekly insulin icodec versus a once-daily insulin comparator (glargine U100 and degludec, respectively) in insulin-naive patients with T2D.1,2

    The results demonstrated non-inferiority and superiority for icodec versus the comparator for the mean change in HbA1c from baseline (ONWARDS 1: non-inferiority, p<0.001 and superiority, p=0.02;1 ONWARDS 3: non-inferiority, p<0.001 and superiority, p=0.0022). The rate of level 2 or 3 hypoglycaemia (per patient years of exposure) was 0.3 for icodec and 0.2 for the comparator daily insulin in both trials.1,2

    HbA1c, glycated haemoglobin; T2D, type 2 diabetes.

    References

    1. Rosenstock J, et al. N Engl J Med. 2023;389:297–308.
    2. Lingvay I, et al. JAMA. 2023;330:228–37.
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    This Activity Is Funded By:

    An independent medical education grant from Novo Nordisk A/S.
    This activity is jointly provided by USF Health, EBAC® and touchIME.

    The information provided by this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical/clinical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

    USF is an Equal Opportunity / Affirmative Action / Equal Access Institution.

    USF
    USF Health is accredited by the Accreditation Council for Continuing Medical Education, the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education to provide continuing education to healthcare professionals. As an accredited provider, USF Health is required to disclose personal information to relevant accredited bodies that certify CME to process credits/contact hours, comply with reporting requirements, and for internal recordkeeping and regulatory purposes. USF Health does not share or sell any individual’s contact information or unique identifiers to any commercial supporter, advertiser, or third party without the specific permission of the individual.

    EBAC®
    touchIME is an EBAC® accredited provider since 2023.

    In compliance with EBAC® guidelines, all speakers/ chairpersons participating in this programme have disclosed or indicated potential conflicts of interest which might cause a bias in the presentations. The Organizing Committee/Course Director is responsible for ensuring that all potential conflicts of interest relevant to the event are declared to the audience prior to the CME activities.

    Unapproved products or unapproved uses of approved products may be discussed by the faculty; these situations may reflect the approval status in one or more jurisdictions. The presenting faculty have been advised by touchIME and USF Health to ensure that they disclose any such references made to unlabelled or unapproved use. No endorsement by touchIME or USF Health of any unapproved products or unapproved uses is either made or implied by mention of these products or uses in touchIME or USF Health activities. touchIME and USF Health accept no responsibility for errors or omissions.

    This content is intended for healthcare professionals outside the UK and USA.

    Date of original release: 28 March 2024. Date credits expire: 28 March 2025.

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