403 - Endorsing HPV Vaccine, Overbasalization, Automated BP Readings
Take 3 – Practical Practice Pointers©
From the Literature
1) The Importance of Provider Recommendation for HPV Vaccination
The HPV vaccination rate for teenagers still hovers in the mid 50 percent range. A strong recommendation from a healthcare provider is known to increase vaccination rates, but the authors of a systematic review wanted to understand the effect more fully.
They looked for studies in multiple databases, had specific inclusion/exclusion criteria and assessed heterogeneity. The included studies had to provide information about whether a recommendation was made, whether a discussion of the vaccine was conducted, and how strong the recommendation was, and examined the effect of those elements on vaccine uptake.
The authors found 59 studies of generally low-moderate quality. Most of them used self-report of vaccination as the outcome. A provider recommendation increased the odds of starting the HPV vaccination series (pooled odds ratio (OR) = 10.1, 95% confidence interval (CI): 7.6 to 13.4) and of completing it (pooled OR = 5.2, 95% CI 1.9 to 13.8). The true effect is probably a bit smaller – the authors demonstrated that separate analyses of the lower quality studies alone were associated with larger effect sizes (biased studies tend to overestimate effect size). Encouragingly, even just discussing vaccines with patients seemed to have a good effect on vaccination rates (pooled OR = 12.4, 95% CI: 6.3 to 24.3).
The authors scored the “quality” of the recommendation on a scale that accounted for strength of recommendation, inclusion of cancer prevention content, and the urgency of the recommendation (i.e., same-day vaccination). Both high- and low-quality recommendations were effective for initiation of the series (adjusted OR (aOR) = 9.3, 95% CI: 7.1 to 12.2 and aOR = 4.13, 95% CI: 3.0 to 5.7 respectively) but scant evidence showed that only high-quality recommendations seemed to lead to follow-through (completion of the series after at least one dose) and overall completion.
The authors noted a high degree of heterogeneity in the initiation analyses – citing as sources the different sampling strategies, the vaccination outcome data (self-report in most), and the use of federal survey data. They also note significant evidence of publication bias in the initiation analyses, though not in the follow-through or completion analyses.
To be most effective in getting adolescents vaccinated for HPV, this review of admittedly imperfect studies still makes a good case that we should provide a strong recommendation and be sure to discuss cancer prevention as a reason for the vaccine. Vaccination is too important a health topic to be relegated to others in the health care system to address. Our patients still count on us to recommend needed preventive health services.
Oh NL, Biddell CB, Rhodes BE, Brewer NT. Provider communication and HPV vaccine uptake: A meta-analysis and systematic review. Prev Med. 2021 Jul;148:106554. Link
From the American Diabetes Association (ADA) and Going Deeper
2) Overbasalization of Insulin Therapy in T2D
In the American Diabetes Association 2021 Standards of Medical Care for Diabetes, the following recommendation for patients with T2D was made:
- Clinicians should be aware of the potential for overbasalization with insulin therapy. Clinical signals that may prompt evaluation of overbasalization include basal dose more than ∼0.5 IU/kg, high bedtime-morning or post-preprandial glucose differential, hypoglycemia (aware or unaware), and high variability. Indication of overbasalization should prompt reevaluation to further individualize therapy. E
Overbasalization is defined as A1c > 8% despite use of more than 0.5 units/kg per day of basal insulin. For many clinicians practicing primary care, the concept of overbasalization is a new one. For that reason, we reached out to Jarrod Uhrig, DO, a Carilion FM colleague who has additional fellowship training in diabetology, for his thoughts on what this means for the care of patients with T2D. Below is a summary of his guidance:
- Using too high a basal insulin dose and/or not starting or titrating other medications for glycemic control is one of the most common issues with the treatment of both inpatient and outpatient T2D. Basal insulin is primarily meant to help meet basal metabolic needs for a patient and it does not help significantly with post-prandial hyperglycemia which is often the more prevalent issue for many patients with T2D – especially those with poor diet.
- Basal insulin has been shown to have diminishing effects as the dose is increased. The exact inflection point is generally thought to be around 0.5 units/kg/day at most for patients with T2D, which is reflected in the ADA guidelines. Even this dose seems high to me clinically. I tend to start basal insulin for T2D around 0.25 units/kg/day for most patients without other comorbidities and if I titrate basal insulin to 0.3-0.4 units/kg/day and blood sugars/A1c are still far from target I would typically intensify therapy by adding/substituting agents without continuing to titrate basal aggressively.
- High doses of basal insulin are associated with more weight gain which is a terrible long-term effect for patients with T2D. Since we know there are diminishing glycemic effects with higher doses but more weight gain and risk of hypoglycemia, this is all the more reason to avoid repeatedly increasing the dose.
- To avoid overtitrating basal insulin, it is important to not look at the fasting blood sugar in isolation. If a patient goes to sleep in the evening with a blood sugar of 300 after supper and wakes up with a blood sugar of 200, this is a failure of their post-prandial treatment(s) and/or lifestyle rather than basal insulin despite the fasting BG being elevated. In this situation, titrating basal insulin further (or maybe even keeping at that same dose) can put them at a dangerous risk of nocturnal hypoglycemia if they have a day with a better diet or more activity and go to bed with a more normal blood sugar and drop overnight. This is where having a patient test blood sugars at different times of day or use a continuous glucose meter can be helpful in identifying the patterns to know if the issue is with fasting or post-prandial blood sugars.
The prevalence of overbasalization in some studies approaches 40% for patients with an A1C > 8, so this is definitely a concern we should be aware of. And even though this is an ADA level “E” recommendation (expert opinion), it should still prompt us to at the least reexamine our present practice. It is also important to re-emphasize that basal insulin is not designed to address postprandial hyperglycemia, so many of these patients will need further medications, with either fixed dose or pre-meal insulin. Additional options in my reading include adding one premeal injection of rapid-acting insulin before the largest meal of the day if cost is a concern or adding a SGLT2i or GLP-1RA instead of premeal insulin if cost is not as much of a concern.
And don’t forget that intensive lifestyle changes really can work and are considered first line treatment for all patients with T2D by the ADA for a reason!
- ADA Standards for Medical Care in Diabetes – 2020: Abridged for Primary Care Providers. Clinical Diabetes 2021 Jan; 39(1): 14-43. Link
- ADA Standards of Care 2021: 1 January 2021; 44(S1). Link
- Umpierrez G et al. When basal insulin is not enough: A dose–response relationship between insulin glargine 100 units/mL and glycaemic control. Diabetes, Obesity, and Metabolism. June 2019; 2(6): 1305-1310. Link
A Question From a Colleague
3) Automated Blood Pressure Machines
I included a comment in last week’s Take 3 about the use of automated oscillometry devices to measure the blood pressure outcomes in the SPRINT trial, noting that if they were good enough for the research on which we base our hypertension treatment guidelines, it should be good enough for our practices. In response, a colleague and Take 3 reader wrote (paraphrased):
Question: “There has been much clinical conversation in our office about the accuracy of these “electronic devices”…We continue to have [staff] dispute the machine readings and their manual readings of blood pressures…They continue to use the manual blood pressure cuffs… How should I respond?”
Answer: This topic has been covered in Take 3 before, but as a reminder…A scientific statement from the AHA found multiple studies that showed, in controlled settings, the automated machines worked as well as auscultation to measure blood pressure. However, they also note: “Evidence suggests that high-quality, standardized office BP measurements, as typically obtained in research studies, with the auscultatory or the oscillometric method have better reproducibility than routine office BP obtained in real-world practice settings.”
They emphasize the importance of standardizing blood pressure measurements: appropriately selecting and applying the blood pressure cuff, positioning the patient correctly and managing the environment to allow a true resting blood pressure measurement.
Standardization is the key here. The machine oscillometry is not inferior to our auscultation. But we must perform our measurements in a standard way to get reliable readings. In the Carilion Clinic Department of Family & Community Medicine, we have a policy of universal use of the oscillometric machines to check BP, with repeated oscillometric measures indicated if the first reading is high.
- Muntner P, Shimbo D, Carey RM, Charleston JB, Gaillard T, Misra S, et al. Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association. Hypertension. 2019 May 1;73(5):e35–66. Link
Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.