Specialists in the Diabetes Program at Brigham and Women’s Hospital (BWH) are delivering a wide range of specialized integrated services and tailored therapy designed to improve care for patients with diabetes, especially those with complex conditions.
“With the increasing prevalence of diabetes, we are dedicated to providing referring physicians and patients with expert specialty care and personalized approaches to treatment in order to better manage this disease across the lifespan,” said Marie E. McDonnell, MD, Director of the Diabetes Program.
Endocrinologists at BWH are working to determine the most precise medication for subgroups of patients with diabetes through funded research. Alexander Turchin, MD, and Donald Simonson, MD, are collaborating on a Patient-Centered Outcomes Research Institute (PCORI) grant to identify patient characteristics from a BWH database of 20 randomized trials with almost 7,000 patients to ascertain which treatment is likely to work best in a specific patient population (See Figure 1 and Figure 2). Dr. Turchin also has published a retrospective study of 107,000 patients with dyslipidemia that showed that even though 17 percent of patients reported adverse reactions to statins, many of them could ultimately tolerate statin therapy (Annals of Internal Medicine, 2013;158:526-534).
he diabetes research team is also conducting an investigator-initiated clinical trial (Safety and Efficacy of Saxagliptin for Glycemic Control in Non-Critically Ill Hospitalized Patient) studying the use of a low-risk diabetes drug in hospitalized patients with diabetes, who are typically only given insulin therapy. The ongoing study, led by principal investigator Rajesh Garg, MD, is evaluating the effect of saxagliptin, a DPP4 inhibitor, on glycemic control in non-critically ill hospitalized patients with type 2 diabetes.
Program specialists, including an endocrinologist and diabetes educators, are embedded in a variety of locations and practices throughout BWH. These include the Endocrinology Center at 221 Longwood Avenue in Boston, the Watkins Cardiovascular Center, the Fish Center for Women’s Health in Chestnut Hill, the Phyllis Jen Center for Primary Care, OB/GYN and Maternal Fetal Medicine (MFM) services at the Center for Women and Newborns at the main BWH campus, and Brigham and Women’s/Mass General Health Care Center in Foxborough, Massachusetts. Specialists in the Diabetes Program also work closely with bariatric surgeons and pancreas and renal transplantation experts at BWH for patients who require or may benefit from weight loss surgery or transplantation. For pregnant women with diabetes, care is provided through a close collaboration with MFM specialists (See Case Study).
BWH’s Diabetes Self Management Education Programs provide extensive education for patients. These programs, which have received American Diabetes Association Recognition, perform an annual review of data, including percentage of patients achieving goals. Later this year, the Diabetes Program will launch a new active disease management initiative for high-risk patients, including patients who frequently visit hospital emergency departments or have repeat hospitalizations due to poor diabetes control. Dr. McDonnell has shown that providing access to rapid follow up care from the emergency department to patients with diabetes can reduce hospitalizations in the next year by 50 percent (Diabetes.63:A1-A102,23-OR. June 2014).
As part of this initiative, a diabetes educator, physician, and other team members work with the patient to achieve a set target. Enrolled patients receive education and support via office visits, virtual visits, telephone calls, and other communication for three months to provide intensive education.
A 38-year-old woman (G4P0) with a history of recurrent miscarriage, obesity, and type 2 diabetes presented to BWH for preconception counseling. Thorough evaluation for etiology of recurrent miscarriage was unremarkable. Medications included statin therapy, metformin, insulin glargine, and an antidepressant. At her initial visit, she was found to be mildly hypertensive and with a BMI of 38. Exam was otherwise unremarkable. Hemoglobin A1C was 7.6 %; TSH was 5.1 with FT4 0.8.
The patient met monthly with a BWH team including an endocrinologist, nurse practitioner, and nutritionist with a goal of A1C <6.5% (<6.0% as possible without hypoglycemia). Metformin was continued and glargine transitioned to NPH in preparation for pregnancy. Lispro insulin was started with meals, and a detailed exercise and weight loss plan was initiated. Labetalol was started for blood pressure control, and levothyroxine initiated for a goal TSH of 1-2. Progress between visits was tracked with weekly team communication via the electronic patient portal. The patient’s husband also was engaged by the team in her care and dietary and exercise approach. The patient began using a lifestyle and glucose tracking phone app, and a meditation app for daily meditation for stress management.
The patient lost 20 pounds over the course of six months. Insulin was sequentially titrated upward and hemoglobin A1C decreased to 5.8% prior to conception without significant hypoglycemia. TSH and blood pressure were at goal. In addition to her endocrinologist and nutrition specialist, a MFM specialist was added to her team when she conceived. Throughout her pregnancy, she was seen on the same day by her joint endocrine and MFM team. Insulin requirements increased significantly over the course of her pregnancy, however, glycemia remained well controlled with her continued lifestyle efforts and glycemic tracking. The patient developed preeclampsia at 37 weeks. Via induction, she delivered a healthy baby boy at 6 lbs, 11 oz. The baby required a brief NICU stay for monitoring.
Post-partum, the patient has maintained her lifestyle. At her one year post-partum visit, her weight was 40 pounds less than her pre-pregnancy weight, and she required a regimen of metformin and low-dose glargine only to maintain A1C <6.5%.
"Our team delivered specialized care for this patient from pre-conception through the post-partum period, working closely with the patient and maternal fetal medicine specialists to set and meet goals to best manage her diabetes and other conditions,” said Dr. McDonnell. “This resulted in a successful pregnancy and improved long-term health of the patient in the post-partum setting.”
Diabetes Program specialists work with referring physicians and patients to determine which therapies best meet each patient’s needs, including:
Patients with type 2 diabetes who are not meeting their goals and all those with type 1 diabetes are encouraged to be evaluated. A single-access line is available to refer patients for diabetes care. Patients and referring physicians can call (800) 638-6294 to schedule an appointment at any of our locations.
Marie E. McDonnell, MD
Director, Diabetes Program
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