#546 - Hepatitis Update, Type 2 Diabetes Rx 2024, Belongingness

From the USPSTF and the ACIP

1)  All the New Hepatitis Recommendations …

There have been a lot of recent changes to prevention (screening and vaccination) recommendations for viral hepatitis over the past few years. Our electronic health records, optimized for the most current Advisory Committee on Immunization Practices (ACIP) and US Preventive Services Task Force (USPSTF) recommendations, may show a lot more care gaps for these than we are prepared for. The table below summarizes the current recommendations.

Insurance coverage varies with these vaccinations also.

·         Hepatitis A vaccine:

o   Commercial insurers should cover routine childhood vaccination.

o   Insurers should cover vaccine for high-risk indications. Attach the relevant ICD-10 code (in addition to the Z23 vaccination code), and document indication in your progress note. Insurers usually do not cover adult vaccination solely for international travel.

·         Hepatitis B vaccine:

o   Medicare will cover in-office vaccination through part B for high-risk indications only (attach high-risk ICD-10 code and document indication in progress note.

o   Part D plans should cover all vaccines recommended by ACIP including routine adult vaccination (but not all eligible patients have Part D).

o   Commercial insurers should cover all vaccines recommended by ACIP.

Be careful with the combination Hepatitis A/Hepatitis B vaccine (Twinrix). This is a three-dose vaccination (it follows the Hepatitis B recombinant vaccine schedule) and will only be covered by insurance if both vaccines are indicated. It will not be covered by Medicare Part B.

John’s Comments: 

There’s a lot going on in hepatitis prevention these days, so the table above helped me organize things a bit. For full information about the indications for screening and vaccination, see the relevant recommendation documents from the USPSTF (links above) or ACIP recommendations (below).

I reached out to Mariana Gomez, MD, Assistant Professor of Medicine at Virginia Tech Carilion School of Medicine and an Infectious Disease Attending at Carilion Clinic. She emphasized: For high-risk patients getting hepatitis B vaccination, a post-vaccination series antibody test 1-2 months after the final dose is recommended. In hepatitis C, antibodies remain positive for life, and they do not confer immunity. Active HCV infection is diagnosed with a positive antibody that reflexes to an elevated RNA test.

References:

• Nelson NP. Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020. MMWR Recomm Rep. 2020;69. Link
• Schillie S. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67. Link
• Weng MK. Universal Hepatitis B Vaccination in Adults Aged 19–59 Years: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71. Link
• Billing & Reimbursement Archives. Immunize.org. Published October 26, 2022. Accessed May 28, 2024. Link

From the Literature and the Guidelines

2)  Newer Pharmacologic Treatments for Type 2 Diabetes (T2D) 

The age-adjusted prevalence of type 2 diabetes in adults is 14.8% in the United States and the age-adjusted incidence is 5.8 per 1000 persons; however, an estimated 23% of the U.S. adults with T2D are undiagnosed.  Despite multiple treatment options, 16% of adults with type 2 diabetes have inadequate glycemic control, with HbA_1c levels of 9% or higher. Inadequate glycemic control is more prevalent among Black (24%) and Hispanic (29%) adults than among White adults (9%) with T2D.

Since the American College of Physicians (ACP) published its last guideline in 2017 on the pharmacological treatment for T2D, newer pharmacologic treatments have been introduced, including glucagon-like peptide-1 (GLP-1) agonists (dulaglutide, exenatide, liraglutide, lixisenatide, and semaglutide), a GLP-1 agonist and glucose-dependent insulinotropic polypeptide agonist (tirzepatide), sodium–glucose cotransporter-2 (SGLT-2) inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, and bexagliflozin), dipeptidyl peptidase-4 (DPP-4) inhibitors (alogliptin, linagliptin, saxagliptin, and sitagliptin), and long-acting insulins (insulin glargine and insulin degludec).

In these updated guidelines, the ACP recommends for nonpregnant adults with T2D:

Recommendation 1:  Add a sodium–glucose cotransporter-2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control (strong recommendation; high-certainty evidence).

• Use an SGLT-2 inhibitor to reduce the risk for all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and hospitalization due to congestive heart failure.
• Use a GLP-1 agonist to reduce the risk for all-cause mortality, major adverse cardiovascular events, and stroke.

Recommendation 2:  Do not add a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control to reduce morbidity and all-cause mortality (strong recommendation; high-certainty evidence).

Interventions With No Recommendations

Evidence was inconclusive to develop recommendations for both add-on tirzepatide and add-on long-acting insulins to metformin and lifestyle modifications.

These recommendations are consistent with the more detailed and nuanced recommendations from the American Diabetes Association (ADA) 2024 Diabetes Standards of Care, which are summarized in this Figure:  Link

Mark’s Comments:    

Expense has been a substantial barrier for both the SGLT-2i and GLP-1 medications.  Fortunately, with the approval of bexagliflozin in late 2023 and retailing for approximately $50 - $60 for a 30-day supply, there is now an affordable SGLT-2i available.  Regrettably, this is not yet the case for any GLP-1 medication, the least expensive of which is exenatide, retailing for > $900/month. 

References: 

• Qaseem A, et al.  Newer Pharmacologic Treatments in Adults With Type 2 Diabetes: A Clinical Guideline From the American College of Physicians.  Ann Int Med Published Online 19 April 2024.  Volume 177, Number 5.   Link
• American Diabetes Association Professional Practice Committee.  Approaches to Glycemic Treatment: Standards of Care in Diabetes—2024.  Diabetes Care 2024;47(Supplement_1):S158–S178.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Recognizing Our Need to Belong 

"Belonging is being accepted for you. Fitting in is being accepted for being like everyone else." – Anonymous

Recently I’ve been thinking a lot about the power and importance of “belonging,” and when I have and have not experienced it.   This was catalyzed by the closing plenary at the recent  American Academy of Family Physicians (AAFP) Physician Well-being conference.  During her talk, former AAFP President Ada Stewart, MD, building on a quote by Verna Myers, made this memorable distinction:  “Diversity is being invited to the dance; Inclusion is being asked to dance; Belonging is being able to dance like no one is watching.” 

When Abraham Maslow, PhD, first published his "hierarchy of needs", he recognized that the human need for interpersonal connection and acceptance was so important that he placed “love and belonging” just after the needs for food, clothing, shelter, and physical safety and before those of self-esteem and self-actualization.  He understood that true belonging is not the same as inheriting (“I belong to my family”), joining (“I belong to my professional society”), being selected (“I belong to this honor society”) or fitting in, selling out, or pretending (“I belong to this social group”).  It is not about adaptation, but rather acceptance.     

Creating the conditions for belongingness requires an approach that fosters inclusivity, respect, and deeper understanding.  Encouraging open communication where every voice is sought and valued is crucial.  Raising awareness and educating about biases and stereotypes can be eye-opening.  Establishing mentorship or buddy systems (such as PeerRx) can facilitate connections and provide support.  Recognizing and celebrating individual and collective achievements regardless of background or identity reinforces a sense of belonging.  Additionally, creating opportunities for shared group experiences can strengthen bonds.  By prioritizing a culture where everyone feels respected, supported, valued, and needed, any group can cultivate belongingness.  

Indeed, what has been most impactful for me about the many times I have experienced belonging was both the level of acceptance I experienced from others and the space I felt to learn how to better accept myself.  During those times, we encouraged each other to share the hidden parts of ourselves, to take interpersonal risks, and while doing so, to show grace for and laugh with each other.  They were opportunities to "bring the best of me, and the rest of me."  In the process, “the rest of me” slowly began to transform, to heal, to soften, to grow. 

Given the amount of “life energy” we spend at work, I believe it is imperative that we are able to find a sense of belonging there and to create one for each other.  It shouldn’t surprise me that as I have allowed “the rest of me” to show up more in my present job by sharing more of the essential parts of myself, including my love of writing and passion for coaching, I’ve experienced a greater sense of belonging … and deeper meaning.  That is certainly something I’d wish for all of us.  No one should care alone. 

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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.

Email: mhgreenawald@carilionclinic.org