#567 - Medications for T2D, Light Tx for Depression, Powered by Apology
Take 3 – Practical Practice Pointers©
From the Guidelines, AACE, ADA, and a Request from a Colleague
1) Some Useful Resources for the Med Management of T2D
Request: Could you please provide some of your favorite resources for guiding the medical management of Type 2 Diabetes (T2D)?
Answer: Two organizations have historically provided the most practical and accessible summaries for T2D management for those practicing primary care medicine – the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE). Below is one from each of the two organizations on their approach to initial medical management. Links to additional algorithms (including insulin initiation and dosing) are below as well. These would be worth keeping close by as a link. Unfortunately, unless you have a color printer, they are harder to read when printed out.
It should be noted that both algorithms emphasize comorbidities when choosing medications for patients with T2D. One difference is that the ADA guideline (1st below) doesn’t account well for medication expenses, which are a significant issue for many of our patients. Also, the AACE better emphasizes that metformin is still the first agent we should consider for most patients (think of it as “basal metformin”!).
Link: ADA Medications for T2D
Link: AACE Medications for T2D
Additional Links:
- AACE Algorithm for adding/intensifying insulin: Link
- AACE Profiles of antihyperglycemic medications: Link
Mark’s Comments:
I love these “one pagers” that provide a helpful overview/review of a common and often changing aspect of our practice.
References:
- Comprehensive Type 2 Diabetes Management Algorithm – 2023 Update. Endocrine Practice 29(5) Volume 29, Issue 5p305-340May 202329(5)29 (2023) 305e340. Link
- American Diabetes Association Primary Care Advisory Group. Introduction: Standards of Care in Diabetes—2024 Abridged for Primary Care Professionals. Clin Diabetes 2024;42(2):181-222. Link
From the Literature
2) Bright Light Therapy for Any Depression
Light therapy is a well-recognized treatment for seasonal affective disorders; and, certainly, as we slide into the winter months and prepare to fall back into standard time, we all start craving the light a little more. Bright light therapy (BLT) is defined as using a fluorescent light box that produces white light for at least 30 minutes, the commonly used range is 10,000 lux. But does BLT have the same benefits for non-seasonal depression that it does for seasonal mood disorder?
Researchers published in JAMA Psychiatry set out to review the literature on this question. They used the Cochrane Handbook and PRISMA guidelines to conduct and report their review and, thereby, covered all the major quality criteria.
They found 11 studies (with 858 patients) that compared “BLT alone or BLT plus antidepressant with placebo, antidepressant monotherapy, or dim red light.” They only included studies after the year 2000.
The studies all used common depression scales to measure effect. BLT improved depression remission rates in the BLT group (40.7% vs 23.5%; odds ratio (OR), 2.42; 95% confidence interval (CI), 1.50-3.91; P <.001; I2 (heterogeneity) = 21%, NNT ~ 5.8). Response rates ("response” was, unfortunately, left undefined) after 4 weeks were higher in the BLT group (63.0% vs 44.9%; OR, 1.79; 95% CI, 1.01-3.17; P = .04; I2 = 32%, NNT ~ 5.5; they were higher in the less than 4-week time frame also). The researchers note a low risk of bias in the studies, and a low risk of publication bias across the studies. The authors note that this is the first review that could offer a consistent recommendation for BLT, but they suggest that it is probably best used as an adjunct to pharmacologic treatment of depression.
John’s Comments:
Lamps that deliver 10,000 lux BLT run from $19 to ~$150 on Amazon.com, making them reasonably accessible to a large segment of the population. Sunlight delivers 10,000 to 20,000 lux in 20-30 minutes on a partly cloudy day. BLT lamps frequently block the UV light, and do not depend on latitude or weather, making their dose delivery that much more reliable.
Reference:
- Menegaz De Almeida A, Aquino De Moraes FC, Cavalcanti Souza ME, et al. Bright Light Therapy for Nonseasonal Depressive Disorders: A Systematic Review and Meta-Analysis. JAMA Psychiatry. Published online October 2, 2024. Link
From PeerRxMed ( www.PeerRxMed.org )
3) Can We Start Over? Re-connection Powered by Apology
“Apologizing … means you value your relationship more than your ego.” Mark Matthews, author
It was one of those mornings when, for whatever reason, the universe seemed to be conspiring against me and I was primed for frustration. I had forgotten about a deadline and had an overflowing patient schedule. When I arrived at work, logging onto the network seemed to take forever. As I started clinic, the N95 mask I decided to wear that morning (due to a recent COVID “mini-surge”) was once again making communication with some of my hard-of-hearing patients particularly challenging. Then, of course, everyone I had seen so far that morning, in addition to their lengthy “list,” had saved the significant “by the way” until my hand was on the door to leave the room. Likely you can relate.
Now running behind, I had taken on a bit of an “attitude” as I prepared to enter the room of a patient I had never seen before who in reviewing his chart had terminal cancer and was experiencing a sore throat and intractable vomiting. “Why didn’t the front desk direct him to the ED?!” I asked my nurse. “The family insisted on bringing him here,” was her reply. I sighed and may have rolled my eyes ….
So I put on my mask, knocked, and opened the door. There in the small exam room were 4 people, including the patient, who was already lying on the exam table and obviously not well. The tension in the air was palpable. After brief introductions, I asked, “How can I help you today?”, my mask hiding my scowl, but perhaps not my scowling eyes and tone. “Dad can’t stop vomiting,” was the reply from one of the daughters. “I see you were in contact with your oncologist yesterday and they recommended going to the emergency department. What prevented you from doing that?” My impatience and frustration were already showing.
And then two very unexpected things happened. The patient started to cry and said, “I thought you’d be able to help me. I’m just so scared …” and I also became tearful, could feel my demeanor softening, and these words came out of my mouth from somewhere deep inside me: “I’m sorry. I came into this room carrying much of the emotion from my morning, which has been challenging for me. That’s not fair to you. Can we start over?”
We did. And in that transition, my presence, rather than being toxic, became salve for 4 hurting and scared souls. Somehow miraculously my “pity party for Mark” turned into a celebration of a life that, unbeknownst to us at the time, was to end 5 days later. Tension was replaced by Holy tears as the family shared important and incredibly loving sentiments that had been withheld due to a fear of giving the impression that they had “lost hope.” And it all happened because a lost connection was found again, powered by an apology …
Where are those reconnections waiting to happen in your life …?
______________
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