Doyle Cummings - Academia.edu (original) (raw)

Papers by Doyle Cummings

Research paper thumbnail of Cognitive Behavioral Intervention Produces Comparable Reductions in Regimen-Related Distress in Insulin Users and Nonusers—Twelve-Month Results from COMRADE

Diabetes, Jul 1, 2018

Complex treatment and monitoring behaviors that accompany insulin use can be associated with high... more Complex treatment and monitoring behaviors that accompany insulin use can be associated with higher levels of regimen-related distress (RRD), poor glycemic control, and lower medication adherence. Whether cognitive behavioral intervention can provide comparable impact on distress levels in insulin-using and non-insulin using patients is poorly described. COMRADE was a prospective randomized controlled trial that evaluated the effectiveness of a 16-session severity tailored cognitive behavioral intervention plus lifestyle change counseling (n = 67; IG=intervention group) delivered by trained staff compared to usual care (n = 72; CG=control group), in 139 rural adult patients (mean age = 52.6 ± 9.5 years.; 72% black; BMI = 37.0 ± 9.0) with uncontrolled (mean A1c = 9.6 ± 2.0) type 2 diabetes and co-morbid depressive (PHQ-2) or distress (DDS-2) symptoms at screening in an academic primary care clinic. At baseline and at 12-month follow-up: A1c, RRD (sub-score of DDS-17), self-care behaviors (SDSCA), and medication adherence (ModMAS) were measured using validated instruments. This analysis specifically examined changes in RRD in insulin users (n = 41, 61%) vs. oral medications and lifestyle change users (n = 26, 39%) in the intervention arm only. While A1c was higher in insulin users at baseline as expected, there were no other significant differences between insulin-users and non-users at baseline. Cognitive behavioral intervention produced comparable improvement in RRD (-1.1 ± 1.1 vs. -1.0 ± 0.9; p = 0.6), self-care behaviors (+1.0 ± 1.3 vs. +1.3 ± 1.3; p = 0.4) and medication adherence (+1.0 ± 1.9 vs. +1.0 ± 2.2; p = 0.9) in insulin users vs. non-users. Insulin users had a greater reduction in A1c (-1.1 ± 1.9 vs. -0.6 ± 1.5; p = 0.3). Tailored cognitive behavioral intervention produces comparable improvements in RRD, self-care behaviors, medication adherence and A1c in insulin users and non-users. Disclosure K. Littlewood: None. S. Patil: None. D.M. Cummings: None. L. Lutes: None. B. Hambidge: None. M. Carraway: None. A. Adams: None. C. Solar: None. S. Edwards: None. P. Gatlin: None.

Research paper thumbnail of Primary Care Fellowship in Diabetes: An Innovative Program in Postgraduate Diabetes Education

Teaching and Learning in Medicine, Oct 26, 2009

To address the need of caring for the growing number of patients with diabetes, East Carolina Uni... more To address the need of caring for the growing number of patients with diabetes, East Carolina University implemented a 1-year fellowship in diabetes. Most of the region has been designated as Health Professional Shortage Areas. The objective of the fellowship is to educate primary care physicians to serve as regional specialists in diabetes. The program is administered by physicians, educators, and representatives of the university's affiliated teaching hospital. The curriculum includes clinical, didactic, and experiential learning strategies in outpatient and inpatient settings. Adult and pediatric endocrinologists, obstetricians, and generalists mentor and evaluate the fellows. This innovative training program has improved the availability of high-quality diabetes care for underserved patients in the region. Mean glycemic control in fellows' patients improved and other clinical endpoints were also met. A 1-year diabetes fellowship is a replicable solution to address the need for diabetes care specialists.

Research paper thumbnail of Case 41: Effects of Glucagon-Like Peptide-1 Receptor Agonist (GLP-1RA) in an Individual With Type 2 Diabetes on High-Dose Insulin Therapy

American Diabetes Association eBooks, 2021

Research paper thumbnail of Comparing SGLT-2 inhibitors to DPP-4 inhibitors as an add-on therapy to metformin in patients with type 2 diabetes: A systematic review and meta-analysis

Diabetes & Metabolism, Mar 1, 2018

Type 2 diabetes is a chronic and progressive disease involving the liver, muscle, pancreatic b-ce... more Type 2 diabetes is a chronic and progressive disease involving the liver, muscle, pancreatic b-cells, pancreatic a-cells, gut, adipose tissue, kidney, and the brain, collectively referred to as the ''ominous octet'' [1]. Thus, multiple medications with different sites of action in these tissues can be used to achieve adequate glycaemic control. Most current guidelines recommend metformin

Research paper thumbnail of The efficacy and safety of DPP4 inhibitors compared to sulfonylureas as add-on therapy to metformin in patients with Type 2 diabetes: A systematic review and meta-analysis

Diabetes Research and Clinical Practice, Aug 1, 2015

The Efficacy and Safety of DPP4 Inhibitors compared to Sulfonylureas as add-on Therapy to Metform... more The Efficacy and Safety of DPP4 Inhibitors compared to Sulfonylureas as add-on Therapy to Metformin in Patients with Type 2 diabetes: a Systematic Review and Meta-analysis  Meta-analysis comparing DPP-4 inhibitors vs. Sulfonylureas added to metformin  Sulfonylureas lower HbA1c more early; this difference is lost at one year follow-up  Sulfonylureas are less expensive but have a greater risk of hypoglycemia  DPP-4 inhibitors cause little hypoglycemia and weight loss instead of weight gain

Research paper thumbnail of Comparing once-weekly semaglutide to incretin-based therapies in patients with type 2 diabetes: a systematic review and meta-analysis

Diabetes & Metabolism, Apr 1, 2019

Our aim was to compare once-weekly semaglutide to incretin-based therapies - defined as either di... more Our aim was to compare once-weekly semaglutide to incretin-based therapies - defined as either dipeptidyl peptidase-4 inhibitors (DPP-4i) or other glucagon-like peptide-1 receptor agonist (GLP-1RA) - in patients with type 2 diabetes. We searched for randomized trials comparing once-weekly semaglutide to other incretin-based therapies in patients with type 2 diabetes. We pooled trials that compared semaglutide to other GLP-1RA together while those comparing semaglutide to DPP-4i together. The primary outcome was the change in haemoglobin A over time. Five trials met our inclusion criteria. There was a significantly greater reduction in haemoglobin A favouring semaglutide when compared to other GLP-1RA or DPP-4i [MD (95% CI) = -0.38% (-0.62, -0.15) and -1.14% (-1.53, -0.75) respectively]. There was a significantly greater weight loss favouring semaglutide when compared to other GLP-1RA or DPP-4i [MD (95% CI) = -2.50 kg (-3.91, -1.09) and -3.19 kg (-3.66, -2.72) respectively]. The proportion of patients achieving glycaemic goals and goal weight loss was greater in semaglutide-treated patients when compared to either other GLP-1RA or DPP-4i. However, semaglutide-treated patients had a significantly higher incidence of gastrointestinal side effects. While both once-weekly semaglutide and other incretin-based therapies can reduce haemoglobin A, semaglutide causes a more potent haemoglobin A reduction and greater weight loss when compared to other incretin-based therapies. However, this potent effect of semaglutide was associated with a higher incidence of gastrointestinal side effects. Additional studies are needed to determine whether this marked reduction in both haemoglobin A and body weight may translate into improved cardiovascular outcomes.

Research paper thumbnail of Transitioning to non-insulin therapy in a patient receiving high dose insulin

Journal of the American Association of Nurse Practitioners, Jun 1, 2020

In people with type 2 diabetes with evidence of obesity-related insulin resistance, use of insuli... more In people with type 2 diabetes with evidence of obesity-related insulin resistance, use of insulin to treat hyperglycemia has not been shown to reduce macrovascular complications, despite widespread use for many years. However, newer classes of diabetes medications, designed to address the prevalent pathophysiologic defect of type 2 diabetes, have emerged. Consequently, in many patients, reduction of insulin doses or even total elimination is possible after the addition of these newer agents. The authors suggest a cautious approach in which people with type 2 diabetes and established cardiovascular disease who are on high insulin doses (>1.0 unit/kg/day) be treated with diabetes medications that showed evidence of cardiovascular benefit (such as glucagon-like peptide-1 receptor agonists [GLP-1RAs]), on whom close monitoring is crucial because they may be at particular risk for developing hypoglycemia. This approach can be labor intensive and may be challenging for busy primary care providers for who may have limited time to evaluate and follow the patient. The authors present a case report of adding a GLP-1RA to high insulin doses. If the hemoglobin A1c is <8.0% when GLP-1RA is added, insulin doses should be reduced by 20%. Patients should be monitored at least every 4 weeks initially until it is confirmed there is no hypoglycemia risk. If glycemic targets (defined as fasting or preprandial glucose level between 80 and 130 mg/dl) are consistently achieved, providers may consider proactively reducing insulin doses by 10-20% to avoid hypoglycemia. The authors recommend creating appropriate goals and expectation before initiating this process.

Research paper thumbnail of The Time Is Now: Diabetes Fellowships in the United States

Current Diabetes Reports, Sep 23, 2017

Purpose of Review Diabetes is a complex and costly chronic disease that is growing at an alarming... more Purpose of Review Diabetes is a complex and costly chronic disease that is growing at an alarming rate. In the USA, we have a shortage of physicians who are experts in the care of patients with diabetes, traditionally endocrinologists. Therefore, the majority of patients with diabetes are managed by primary care physicians. With the rapid evolution in new diabetes medications and technologies, primary care physicians would benefit from additional focused and intensive training to manage the many aspects of this disease. Diabetes fellowships designed specifically for primary care physicians is one solution to rapidly expand a well-trained workforce in the management of patients with diabetes. Recent Findings There are currently two successful diabetes fellowship programs that meet this need for creating more expert diabetes clinicians and researchers outside of traditional endocrinology fellowships. We review the structure of these programs including funding and curriculum as well as the outcomes of the graduates. Summary The growth of the diabetes epidemic has outpaced current resources for readily accessible expert diabetes clinical care. Diabetes fellowships aimed for primary care physicians are a successful strategy to train diabetes-focused physicians. Expansion of these programs should be encouraged and support to grow the cadre of clinicians with expertise in diabetes care and improve patient access and outcomes.

Research paper thumbnail of Endocrinologists’ Opinions of Diabetology as a Primary Care Subspecialty

Clinical Diabetes, Apr 1, 2018

Research paper thumbnail of Abstract MP01: Multiple Social Determinants of Health Disparities Increase the Risk of Diabetes and Mortality in the Reasons for Geographic and Racial Differences in Stroke Study

Circulation, 2020

Introduction: The Healthy People 2020 initiative proposed that social determinants contribute to ... more Introduction: The Healthy People 2020 initiative proposed that social determinants contribute to disparities in health outcomes. While studies have documented the influence of individual social determinants of health (SDOH) on health outcomes, few studies have examined how the aggregation of multiple SDOH within the same person affect health. Hypothesis: We hypothesized that as the number of individual-level and neighborhood-level SDOH increased, the relative risk of incident diabetes and mortality also increased. Methods: This study included 15,310 black and white adults aged > 45 years at baseline (2003-2007) who did not have prevalent diabetes and who completed the 10 year follow-up exam (2014-2016) or died prior to follow-up in the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study. Exposures included 6 SDOH which have been associated with increased health risks: annual household income 126 mg/dL, random blood glucose >200 mg/dL, or taking diabetes med...

Research paper thumbnail of Does the Association Between Hemoglobin A1c and Risk of Cardiovascular Events Vary by Residential Segregation? The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

Diabetes Care, 2021

OBJECTIVE To examine if the association between higher A1C and risk of cardiovascular disease (CV... more OBJECTIVE To examine if the association between higher A1C and risk of cardiovascular disease (CVD) among adults with and without diabetes is modified by racial residential segregation. RESEARCH DESIGN AND METHODS The study used a case-cohort design, which included a random sample of 2,136 participants at baseline and 1,248 participants with incident CVD (i.e., stroke, coronary heart disease [CHD], and fatal CHD during 7-year follow-up) selected from 30,239 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants originally assessed between 2003 and 2007. The relationship of A1C with incident CVD, stratified by baseline diabetes status, was assessed using Cox proportional hazards models adjusting for demographics, CVD risk factors, and socioeconomic status. Effect modification by census tract-level residential segregation indices (dissimilarity, interaction, and isolation) was assessed using interaction terms. RESULTS The mean age of participants in the r...

Research paper thumbnail of Elevated depressive symptoms and risk of all-cause and cardiovascular mortality among adults with and without diabetes: The REasons for Geographic And Racial Differences in Stroke (REGARDS) study

Journal of Diabetes and its Complications, 2020

Aims: To examine the association of elevated depressive symptoms with all-cause and cardiovascula... more Aims: To examine the association of elevated depressive symptoms with all-cause and cardiovascular disease (CVD) mortality and determine whether these associations differ for those with and without diabetes. Methods: We included 22,807 black and white men and women aged 45-98 years at baseline (2003-2007) from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study. Elevated depressive symptoms were defined as a score ≥4 on the 4-item Centers for

Research paper thumbnail of Risk factor control among Black and White adults with diabetes onset in older adulthood: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study

Preventive Medicine, 2020

The objective of this study was to determine whether attainment of clinical and lifestyle targets... more The objective of this study was to determine whether attainment of clinical and lifestyle targets varied by race and sex among adults with diabetes onset in older adulthood. This study included 1,420 black and white adults from the REGARDS study without diabetes at baseline (2003-07) but with diabetes onset at the follow-up exam (2013-16). Attainment of clinical targets (A1c <8%; blood pressure <140/90 mm Hg; and statin use) and lifestyle targets (not smoking; physical activity>=4 times/week; and moderate/no alcohol use) was assessed at the follow-up exam. Modified Poisson regression was used to obtain prevalence ratios (PR) for meeting clinical and lifestyle targets stratified by race and sex, separately. The mean age was 71.5 years, 53.6% were female, and 46.1% were black. The majority were aware of their diabetes status (85.7%) and used oral or injectable hypoglycemic medications (64.8%). Overall, 39.4% met all 3 clinical targets and 18.8% met all 3 lifestyle targets. Meeting A1c and blood pressure targets were similar by race and sex. Statin use was more prevalent for men than women among white adults (PR=1.13; 95% CI=0.99-1.29) and black adults (PR=1.23; 95% CI=1.06-1.43). For lifestyle factors, the non-smoking prevalence was similar by race and sex, while white men were more likely than white women to be physically active. Although the attainment of each clinical and lifestyle target separately was generally high among adults with diabetes onset in older adulthood, race and sex differences were apparent. Comprehensive management of clinical and lifestyle factors in people with diabetes remains suboptimal.

Research paper thumbnail of Cognitive Behavioral Intervention Produces Comparable Reductions in Regimen-Related Distress in Insulin Users and Nonusers—Twelve-Month Results from COMRADE

Diabetes, 2018

Complex treatment and monitoring behaviors that accompany insulin use can be associated with high... more Complex treatment and monitoring behaviors that accompany insulin use can be associated with higher levels of regimen-related distress (RRD), poor glycemic control, and lower medication adherence. Whether cognitive behavioral intervention can provide comparable impact on distress levels in insulin-using and non-insulin using patients is poorly described. COMRADE was a prospective randomized controlled trial that evaluated the effectiveness of a 16-session severity tailored cognitive behavioral intervention plus lifestyle change counseling (n = 67; IG=intervention group) delivered by trained staff compared to usual care (n = 72; CG=control group), in 139 rural adult patients (mean age = 52.6 ± 9.5 years.; 72% black; BMI = 37.0 ± 9.0) with uncontrolled (mean A1c = 9.6 ± 2.0) type 2 diabetes and co-morbid depressive (PHQ-2) or distress (DDS-2) symptoms at screening in an academic primary care clinic. At baseline and at 12-month follow-up: A1c, RRD (sub-score of DDS-17), self-care behav...

Research paper thumbnail of Trends and Racial/Ethnic Disparities in Diabetic Retinopathy Among Adults with Diagnosed Diabetes in North Carolina, 2000–2015

North Carolina Medical Journal, 2019

D iabetic retinopathy (DR) is the most common microvascular complication of diabetes mellitus (DM... more D iabetic retinopathy (DR) is the most common microvascular complication of diabetes mellitus (DM) and is the leading cause of blindness in the United States [1]. The prevalence of DM has increased rapidly in the United States. In 2015, an estimated 30.3 million people or 9.4% of the US population had DM [2]. By the year 2050, it is expected that about 48.3 million adults will be affected by DM [3]. The burden of DR may increase as more people have DM. It is estimated that about 16.0 million adults aged ≥ 40 years are projected to have DR by 2050 [4]. DR prevalence and complications are higher among racial/ethnic minority populations, including African Americans, Hispanics, and American Indians [5]. North Carolina is one of the 15 southern states identified as being in the "diabetes belt" by the Centers for Disease Control and Prevention [6]. North Carolina has the 13th highest prevalence of DM in the United States. An estimated 750,000 (1 in 10) adults in North Carolina have been diagnosed with DM [7]. By 2025, the number of people with DM in North Carolina is projected to increase to almost 1.9 million, with an annual cost to the state of $17.9 billion (including both medical and non-medical costs) [8]. Racial and ethnic disparities in DM prevalence are also significant in North Carolina. In 2013, 11.0% of non-Hispanic white adults had DM compared to 15.4% of non-Hispanic black adults [9]. The early stages of DR are often asymptomatic. Thus, early detection and treatment is imperative to preventing vision loss. Population-based studies on DR trends in the United States [10-12] are very limited. Little data exists on DR status in North Carolina [13]. The target of Healthy People 2020 is to reduce DR to 30.8 per 1,000 in the population aged 18 years and older with DM [14]. The purpose of this study is to describe the trends of DR in adults with DM and to assess racial/ethnic disparities in DR in the past 15 years in North Carolina. An update on the current status of DR will provide useful information for both eye care professionals and other medical providers in their practice and inform public health officials in the design or modification of interventions and policies regarding DR and DM. Methods Data For this study, data from the Behavioral Risk Factor Surveillance System (BRFSS) was analyzed. The BRFSS is an annual state-based, random-digit-dialed telephone survey of the non-institutionalized, US civilian population aged 18 years and older. The BRFSS questionnaire consists of 3 sections: a core survey, optional modules, and stateadded questions [15]. BRFSS has been proven to provide valid national and state estimates of health and risk factors [16]. In the BRFSS Core Questionnaire, respondents

Research paper thumbnail of Abstract MP48: Control of Cardiovascular Risk Factors Among Older Adults With Incident Diabetes: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Circulation, 2019

Background: Control of risk factors is important for the primary prevention of cardiovascular dis... more Background: Control of risk factors is important for the primary prevention of cardiovascular disease among adults with diabetes. The objective of this study was to determine whether management of clinical (hemoglobin A1c <8%; BP <130/80 mm Hg; and statin use) and lifestyle factors (not currently smoking; physical activity on 4+ days/week; and moderate or no alcohol use) varied by race and sex among older adults with incident diabetes. Methods: This study included 1,420 Black and White adults from the REGARDS Study with incident diabetes at the follow-up exam (2014-16). Incident diabetes was defined as fasting glucose>=126 mg/dL, random glucose>=200 mg/dL, or use of diabetes medications among those without diabetes at baseline (2003-07). Modified Poisson regression was used to obtain prevalence ratios (PR) for the control of risk factors for Black versus White adults and assess race-sex interactions. Results: The mean age was 71.5 years, 53.6% were female, 46.1% were Bla...

Research paper thumbnail of The effect of a practice-based multicomponent intervention that includes health coaching on medication adherence and blood pressure control in rural primary care

The Journal of Clinical Hypertension, 2018

High blood pressure (hypertension [HTN]) is a prevalent chronic condition, affecting with 1 in 3 ... more High blood pressure (hypertension [HTN]) is a prevalent chronic condition, affecting with 1 in 3 (34%) adult Americans 20 years and older. 1 It is the most frequent chronic medical condition among adults aged 65 years and older 2 and is a leading risk factor for many cardiovascular conditions, including heart attack, stroke, aneurysm, and heart failure. 1,3 In the US, the estimated direct and indirect cost of HTN for 2012-2013 was 51.2billionandmayincreasetoanestimated51.2 billion and may increase to an estimated 51.2billionandmayincreasetoanestimated200 billion by 2030. 1 From NHANES data, 17.2% of US adults are not aware that they have high blood pressure (BP). 4 Moreover, HTN is not well-controlled, 75.7% were currently taking medication to lower their BP, but only 51.9% of those who took antihypertensive drug treatment achieved

Research paper thumbnail of Practice Level Costs of Office-Based Hypertension Performance Improvement

Journal of Healthcare Management, 2017

Primary care practice leaders who consider engaging in quality improvement (QI) need to understan... more Primary care practice leaders who consider engaging in quality improvement (QI) need to understand the practice level costs incurred when asking staff to take on new tasks. The Heart Healthy Lenoir study is a prospective cohort trial in which QI methods were used to enhance hypertension (HTN) care and reduce racial disparities in blood pressure control in small rural primary care practices in North Carolina. As part of this effort, we performed an activity-based costing analysis to describe the costs incurred to develop, implement, and maintain key tasks. We interviewed 20 practice stakeholders and phone-based health coaches during 2012-2014. We calculated the time invested by individuals to perform each task within each study phase and applied national hourly wages to generate cost estimates. Our descriptive analyses focus on four of the most widely used practices. Activities included time to abstract HTN control data, participate in project meetings, identify patients with uncontrolled HTN, create standardized work, and provide additional health coaching

Research paper thumbnail of Lessons Learned From Implementing Health Coaching in The Heart Healthy Lenoir Hypertension Study

Progress in Community Health Partnerships: Research, Education, and Action, 2016

elephone health coaching between office visits is a useful adjunct to office-based care. In patie... more elephone health coaching between office visits is a useful adjunct to office-based care. In patients with chronic illness, telephone coaching improves health behaviors and health status. 1 Coaching can be especially helpful for vulnerable populations, including patients with multiple comorbidities, advanced age, and patients with low literacy by facilitating enhanced access to care. 1 Evolving primary care models, including a patient-centered medical home 2 and

Research paper thumbnail of ACE inhibitors

Postgraduate Medicine, 1990

The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure has r... more The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure has recently recommended angiotensin-converting enzyme (ACE) inhibitors, beta blockers, and diuretics as potential first-step agents for the pharmacologic treatment of hypertension. ACE inhibitors should be considered an important option in most patients because of their safety profile, absence of adverse metabolic effects, and positive cardiac and renal effects. If the response to an ACE inhibitor is inadequate, a diuretic or another agent can be added, and this combination should be effective and well tolerated in 85% to 90% of patients. ACE inhibitors can be used to treat congestive heart failure and to prevent the renal complications of hypertension and diabetes mellitus, significantly expanding their use in patients with these high-risk conditions. They also can be used concurrently with other antihypertensive agents, digitalis, cardiac glycosides, and lithium and are not contraindicated in most of the diseases commonly seen in hypertensive patients.

Research paper thumbnail of Cognitive Behavioral Intervention Produces Comparable Reductions in Regimen-Related Distress in Insulin Users and Nonusers—Twelve-Month Results from COMRADE

Diabetes, Jul 1, 2018

Complex treatment and monitoring behaviors that accompany insulin use can be associated with high... more Complex treatment and monitoring behaviors that accompany insulin use can be associated with higher levels of regimen-related distress (RRD), poor glycemic control, and lower medication adherence. Whether cognitive behavioral intervention can provide comparable impact on distress levels in insulin-using and non-insulin using patients is poorly described. COMRADE was a prospective randomized controlled trial that evaluated the effectiveness of a 16-session severity tailored cognitive behavioral intervention plus lifestyle change counseling (n = 67; IG=intervention group) delivered by trained staff compared to usual care (n = 72; CG=control group), in 139 rural adult patients (mean age = 52.6 ± 9.5 years.; 72% black; BMI = 37.0 ± 9.0) with uncontrolled (mean A1c = 9.6 ± 2.0) type 2 diabetes and co-morbid depressive (PHQ-2) or distress (DDS-2) symptoms at screening in an academic primary care clinic. At baseline and at 12-month follow-up: A1c, RRD (sub-score of DDS-17), self-care behaviors (SDSCA), and medication adherence (ModMAS) were measured using validated instruments. This analysis specifically examined changes in RRD in insulin users (n = 41, 61%) vs. oral medications and lifestyle change users (n = 26, 39%) in the intervention arm only. While A1c was higher in insulin users at baseline as expected, there were no other significant differences between insulin-users and non-users at baseline. Cognitive behavioral intervention produced comparable improvement in RRD (-1.1 ± 1.1 vs. -1.0 ± 0.9; p = 0.6), self-care behaviors (+1.0 ± 1.3 vs. +1.3 ± 1.3; p = 0.4) and medication adherence (+1.0 ± 1.9 vs. +1.0 ± 2.2; p = 0.9) in insulin users vs. non-users. Insulin users had a greater reduction in A1c (-1.1 ± 1.9 vs. -0.6 ± 1.5; p = 0.3). Tailored cognitive behavioral intervention produces comparable improvements in RRD, self-care behaviors, medication adherence and A1c in insulin users and non-users. Disclosure K. Littlewood: None. S. Patil: None. D.M. Cummings: None. L. Lutes: None. B. Hambidge: None. M. Carraway: None. A. Adams: None. C. Solar: None. S. Edwards: None. P. Gatlin: None.

Research paper thumbnail of Primary Care Fellowship in Diabetes: An Innovative Program in Postgraduate Diabetes Education

Teaching and Learning in Medicine, Oct 26, 2009

To address the need of caring for the growing number of patients with diabetes, East Carolina Uni... more To address the need of caring for the growing number of patients with diabetes, East Carolina University implemented a 1-year fellowship in diabetes. Most of the region has been designated as Health Professional Shortage Areas. The objective of the fellowship is to educate primary care physicians to serve as regional specialists in diabetes. The program is administered by physicians, educators, and representatives of the university&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s affiliated teaching hospital. The curriculum includes clinical, didactic, and experiential learning strategies in outpatient and inpatient settings. Adult and pediatric endocrinologists, obstetricians, and generalists mentor and evaluate the fellows. This innovative training program has improved the availability of high-quality diabetes care for underserved patients in the region. Mean glycemic control in fellows&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; patients improved and other clinical endpoints were also met. A 1-year diabetes fellowship is a replicable solution to address the need for diabetes care specialists.

Research paper thumbnail of Case 41: Effects of Glucagon-Like Peptide-1 Receptor Agonist (GLP-1RA) in an Individual With Type 2 Diabetes on High-Dose Insulin Therapy

American Diabetes Association eBooks, 2021

Research paper thumbnail of Comparing SGLT-2 inhibitors to DPP-4 inhibitors as an add-on therapy to metformin in patients with type 2 diabetes: A systematic review and meta-analysis

Diabetes & Metabolism, Mar 1, 2018

Type 2 diabetes is a chronic and progressive disease involving the liver, muscle, pancreatic b-ce... more Type 2 diabetes is a chronic and progressive disease involving the liver, muscle, pancreatic b-cells, pancreatic a-cells, gut, adipose tissue, kidney, and the brain, collectively referred to as the ''ominous octet'' [1]. Thus, multiple medications with different sites of action in these tissues can be used to achieve adequate glycaemic control. Most current guidelines recommend metformin

Research paper thumbnail of The efficacy and safety of DPP4 inhibitors compared to sulfonylureas as add-on therapy to metformin in patients with Type 2 diabetes: A systematic review and meta-analysis

Diabetes Research and Clinical Practice, Aug 1, 2015

The Efficacy and Safety of DPP4 Inhibitors compared to Sulfonylureas as add-on Therapy to Metform... more The Efficacy and Safety of DPP4 Inhibitors compared to Sulfonylureas as add-on Therapy to Metformin in Patients with Type 2 diabetes: a Systematic Review and Meta-analysis  Meta-analysis comparing DPP-4 inhibitors vs. Sulfonylureas added to metformin  Sulfonylureas lower HbA1c more early; this difference is lost at one year follow-up  Sulfonylureas are less expensive but have a greater risk of hypoglycemia  DPP-4 inhibitors cause little hypoglycemia and weight loss instead of weight gain

Research paper thumbnail of Comparing once-weekly semaglutide to incretin-based therapies in patients with type 2 diabetes: a systematic review and meta-analysis

Diabetes & Metabolism, Apr 1, 2019

Our aim was to compare once-weekly semaglutide to incretin-based therapies - defined as either di... more Our aim was to compare once-weekly semaglutide to incretin-based therapies - defined as either dipeptidyl peptidase-4 inhibitors (DPP-4i) or other glucagon-like peptide-1 receptor agonist (GLP-1RA) - in patients with type 2 diabetes. We searched for randomized trials comparing once-weekly semaglutide to other incretin-based therapies in patients with type 2 diabetes. We pooled trials that compared semaglutide to other GLP-1RA together while those comparing semaglutide to DPP-4i together. The primary outcome was the change in haemoglobin A over time. Five trials met our inclusion criteria. There was a significantly greater reduction in haemoglobin A favouring semaglutide when compared to other GLP-1RA or DPP-4i [MD (95% CI) = -0.38% (-0.62, -0.15) and -1.14% (-1.53, -0.75) respectively]. There was a significantly greater weight loss favouring semaglutide when compared to other GLP-1RA or DPP-4i [MD (95% CI) = -2.50 kg (-3.91, -1.09) and -3.19 kg (-3.66, -2.72) respectively]. The proportion of patients achieving glycaemic goals and goal weight loss was greater in semaglutide-treated patients when compared to either other GLP-1RA or DPP-4i. However, semaglutide-treated patients had a significantly higher incidence of gastrointestinal side effects. While both once-weekly semaglutide and other incretin-based therapies can reduce haemoglobin A, semaglutide causes a more potent haemoglobin A reduction and greater weight loss when compared to other incretin-based therapies. However, this potent effect of semaglutide was associated with a higher incidence of gastrointestinal side effects. Additional studies are needed to determine whether this marked reduction in both haemoglobin A and body weight may translate into improved cardiovascular outcomes.

Research paper thumbnail of Transitioning to non-insulin therapy in a patient receiving high dose insulin

Journal of the American Association of Nurse Practitioners, Jun 1, 2020

In people with type 2 diabetes with evidence of obesity-related insulin resistance, use of insuli... more In people with type 2 diabetes with evidence of obesity-related insulin resistance, use of insulin to treat hyperglycemia has not been shown to reduce macrovascular complications, despite widespread use for many years. However, newer classes of diabetes medications, designed to address the prevalent pathophysiologic defect of type 2 diabetes, have emerged. Consequently, in many patients, reduction of insulin doses or even total elimination is possible after the addition of these newer agents. The authors suggest a cautious approach in which people with type 2 diabetes and established cardiovascular disease who are on high insulin doses (>1.0 unit/kg/day) be treated with diabetes medications that showed evidence of cardiovascular benefit (such as glucagon-like peptide-1 receptor agonists [GLP-1RAs]), on whom close monitoring is crucial because they may be at particular risk for developing hypoglycemia. This approach can be labor intensive and may be challenging for busy primary care providers for who may have limited time to evaluate and follow the patient. The authors present a case report of adding a GLP-1RA to high insulin doses. If the hemoglobin A1c is <8.0% when GLP-1RA is added, insulin doses should be reduced by 20%. Patients should be monitored at least every 4 weeks initially until it is confirmed there is no hypoglycemia risk. If glycemic targets (defined as fasting or preprandial glucose level between 80 and 130 mg/dl) are consistently achieved, providers may consider proactively reducing insulin doses by 10-20% to avoid hypoglycemia. The authors recommend creating appropriate goals and expectation before initiating this process.

Research paper thumbnail of The Time Is Now: Diabetes Fellowships in the United States

Current Diabetes Reports, Sep 23, 2017

Purpose of Review Diabetes is a complex and costly chronic disease that is growing at an alarming... more Purpose of Review Diabetes is a complex and costly chronic disease that is growing at an alarming rate. In the USA, we have a shortage of physicians who are experts in the care of patients with diabetes, traditionally endocrinologists. Therefore, the majority of patients with diabetes are managed by primary care physicians. With the rapid evolution in new diabetes medications and technologies, primary care physicians would benefit from additional focused and intensive training to manage the many aspects of this disease. Diabetes fellowships designed specifically for primary care physicians is one solution to rapidly expand a well-trained workforce in the management of patients with diabetes. Recent Findings There are currently two successful diabetes fellowship programs that meet this need for creating more expert diabetes clinicians and researchers outside of traditional endocrinology fellowships. We review the structure of these programs including funding and curriculum as well as the outcomes of the graduates. Summary The growth of the diabetes epidemic has outpaced current resources for readily accessible expert diabetes clinical care. Diabetes fellowships aimed for primary care physicians are a successful strategy to train diabetes-focused physicians. Expansion of these programs should be encouraged and support to grow the cadre of clinicians with expertise in diabetes care and improve patient access and outcomes.

Research paper thumbnail of Endocrinologists’ Opinions of Diabetology as a Primary Care Subspecialty

Clinical Diabetes, Apr 1, 2018

Research paper thumbnail of Abstract MP01: Multiple Social Determinants of Health Disparities Increase the Risk of Diabetes and Mortality in the Reasons for Geographic and Racial Differences in Stroke Study

Circulation, 2020

Introduction: The Healthy People 2020 initiative proposed that social determinants contribute to ... more Introduction: The Healthy People 2020 initiative proposed that social determinants contribute to disparities in health outcomes. While studies have documented the influence of individual social determinants of health (SDOH) on health outcomes, few studies have examined how the aggregation of multiple SDOH within the same person affect health. Hypothesis: We hypothesized that as the number of individual-level and neighborhood-level SDOH increased, the relative risk of incident diabetes and mortality also increased. Methods: This study included 15,310 black and white adults aged > 45 years at baseline (2003-2007) who did not have prevalent diabetes and who completed the 10 year follow-up exam (2014-2016) or died prior to follow-up in the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study. Exposures included 6 SDOH which have been associated with increased health risks: annual household income 126 mg/dL, random blood glucose >200 mg/dL, or taking diabetes med...

Research paper thumbnail of Does the Association Between Hemoglobin A1c and Risk of Cardiovascular Events Vary by Residential Segregation? The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

Diabetes Care, 2021

OBJECTIVE To examine if the association between higher A1C and risk of cardiovascular disease (CV... more OBJECTIVE To examine if the association between higher A1C and risk of cardiovascular disease (CVD) among adults with and without diabetes is modified by racial residential segregation. RESEARCH DESIGN AND METHODS The study used a case-cohort design, which included a random sample of 2,136 participants at baseline and 1,248 participants with incident CVD (i.e., stroke, coronary heart disease [CHD], and fatal CHD during 7-year follow-up) selected from 30,239 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants originally assessed between 2003 and 2007. The relationship of A1C with incident CVD, stratified by baseline diabetes status, was assessed using Cox proportional hazards models adjusting for demographics, CVD risk factors, and socioeconomic status. Effect modification by census tract-level residential segregation indices (dissimilarity, interaction, and isolation) was assessed using interaction terms. RESULTS The mean age of participants in the r...

Research paper thumbnail of Elevated depressive symptoms and risk of all-cause and cardiovascular mortality among adults with and without diabetes: The REasons for Geographic And Racial Differences in Stroke (REGARDS) study

Journal of Diabetes and its Complications, 2020

Aims: To examine the association of elevated depressive symptoms with all-cause and cardiovascula... more Aims: To examine the association of elevated depressive symptoms with all-cause and cardiovascular disease (CVD) mortality and determine whether these associations differ for those with and without diabetes. Methods: We included 22,807 black and white men and women aged 45-98 years at baseline (2003-2007) from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study. Elevated depressive symptoms were defined as a score ≥4 on the 4-item Centers for

Research paper thumbnail of Risk factor control among Black and White adults with diabetes onset in older adulthood: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study

Preventive Medicine, 2020

The objective of this study was to determine whether attainment of clinical and lifestyle targets... more The objective of this study was to determine whether attainment of clinical and lifestyle targets varied by race and sex among adults with diabetes onset in older adulthood. This study included 1,420 black and white adults from the REGARDS study without diabetes at baseline (2003-07) but with diabetes onset at the follow-up exam (2013-16). Attainment of clinical targets (A1c <8%; blood pressure <140/90 mm Hg; and statin use) and lifestyle targets (not smoking; physical activity>=4 times/week; and moderate/no alcohol use) was assessed at the follow-up exam. Modified Poisson regression was used to obtain prevalence ratios (PR) for meeting clinical and lifestyle targets stratified by race and sex, separately. The mean age was 71.5 years, 53.6% were female, and 46.1% were black. The majority were aware of their diabetes status (85.7%) and used oral or injectable hypoglycemic medications (64.8%). Overall, 39.4% met all 3 clinical targets and 18.8% met all 3 lifestyle targets. Meeting A1c and blood pressure targets were similar by race and sex. Statin use was more prevalent for men than women among white adults (PR=1.13; 95% CI=0.99-1.29) and black adults (PR=1.23; 95% CI=1.06-1.43). For lifestyle factors, the non-smoking prevalence was similar by race and sex, while white men were more likely than white women to be physically active. Although the attainment of each clinical and lifestyle target separately was generally high among adults with diabetes onset in older adulthood, race and sex differences were apparent. Comprehensive management of clinical and lifestyle factors in people with diabetes remains suboptimal.

Research paper thumbnail of Cognitive Behavioral Intervention Produces Comparable Reductions in Regimen-Related Distress in Insulin Users and Nonusers—Twelve-Month Results from COMRADE

Diabetes, 2018

Complex treatment and monitoring behaviors that accompany insulin use can be associated with high... more Complex treatment and monitoring behaviors that accompany insulin use can be associated with higher levels of regimen-related distress (RRD), poor glycemic control, and lower medication adherence. Whether cognitive behavioral intervention can provide comparable impact on distress levels in insulin-using and non-insulin using patients is poorly described. COMRADE was a prospective randomized controlled trial that evaluated the effectiveness of a 16-session severity tailored cognitive behavioral intervention plus lifestyle change counseling (n = 67; IG=intervention group) delivered by trained staff compared to usual care (n = 72; CG=control group), in 139 rural adult patients (mean age = 52.6 ± 9.5 years.; 72% black; BMI = 37.0 ± 9.0) with uncontrolled (mean A1c = 9.6 ± 2.0) type 2 diabetes and co-morbid depressive (PHQ-2) or distress (DDS-2) symptoms at screening in an academic primary care clinic. At baseline and at 12-month follow-up: A1c, RRD (sub-score of DDS-17), self-care behav...

Research paper thumbnail of Trends and Racial/Ethnic Disparities in Diabetic Retinopathy Among Adults with Diagnosed Diabetes in North Carolina, 2000–2015

North Carolina Medical Journal, 2019

D iabetic retinopathy (DR) is the most common microvascular complication of diabetes mellitus (DM... more D iabetic retinopathy (DR) is the most common microvascular complication of diabetes mellitus (DM) and is the leading cause of blindness in the United States [1]. The prevalence of DM has increased rapidly in the United States. In 2015, an estimated 30.3 million people or 9.4% of the US population had DM [2]. By the year 2050, it is expected that about 48.3 million adults will be affected by DM [3]. The burden of DR may increase as more people have DM. It is estimated that about 16.0 million adults aged ≥ 40 years are projected to have DR by 2050 [4]. DR prevalence and complications are higher among racial/ethnic minority populations, including African Americans, Hispanics, and American Indians [5]. North Carolina is one of the 15 southern states identified as being in the "diabetes belt" by the Centers for Disease Control and Prevention [6]. North Carolina has the 13th highest prevalence of DM in the United States. An estimated 750,000 (1 in 10) adults in North Carolina have been diagnosed with DM [7]. By 2025, the number of people with DM in North Carolina is projected to increase to almost 1.9 million, with an annual cost to the state of $17.9 billion (including both medical and non-medical costs) [8]. Racial and ethnic disparities in DM prevalence are also significant in North Carolina. In 2013, 11.0% of non-Hispanic white adults had DM compared to 15.4% of non-Hispanic black adults [9]. The early stages of DR are often asymptomatic. Thus, early detection and treatment is imperative to preventing vision loss. Population-based studies on DR trends in the United States [10-12] are very limited. Little data exists on DR status in North Carolina [13]. The target of Healthy People 2020 is to reduce DR to 30.8 per 1,000 in the population aged 18 years and older with DM [14]. The purpose of this study is to describe the trends of DR in adults with DM and to assess racial/ethnic disparities in DR in the past 15 years in North Carolina. An update on the current status of DR will provide useful information for both eye care professionals and other medical providers in their practice and inform public health officials in the design or modification of interventions and policies regarding DR and DM. Methods Data For this study, data from the Behavioral Risk Factor Surveillance System (BRFSS) was analyzed. The BRFSS is an annual state-based, random-digit-dialed telephone survey of the non-institutionalized, US civilian population aged 18 years and older. The BRFSS questionnaire consists of 3 sections: a core survey, optional modules, and stateadded questions [15]. BRFSS has been proven to provide valid national and state estimates of health and risk factors [16]. In the BRFSS Core Questionnaire, respondents

Research paper thumbnail of Abstract MP48: Control of Cardiovascular Risk Factors Among Older Adults With Incident Diabetes: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Circulation, 2019

Background: Control of risk factors is important for the primary prevention of cardiovascular dis... more Background: Control of risk factors is important for the primary prevention of cardiovascular disease among adults with diabetes. The objective of this study was to determine whether management of clinical (hemoglobin A1c <8%; BP <130/80 mm Hg; and statin use) and lifestyle factors (not currently smoking; physical activity on 4+ days/week; and moderate or no alcohol use) varied by race and sex among older adults with incident diabetes. Methods: This study included 1,420 Black and White adults from the REGARDS Study with incident diabetes at the follow-up exam (2014-16). Incident diabetes was defined as fasting glucose>=126 mg/dL, random glucose>=200 mg/dL, or use of diabetes medications among those without diabetes at baseline (2003-07). Modified Poisson regression was used to obtain prevalence ratios (PR) for the control of risk factors for Black versus White adults and assess race-sex interactions. Results: The mean age was 71.5 years, 53.6% were female, 46.1% were Bla...

Research paper thumbnail of The effect of a practice-based multicomponent intervention that includes health coaching on medication adherence and blood pressure control in rural primary care

The Journal of Clinical Hypertension, 2018

High blood pressure (hypertension [HTN]) is a prevalent chronic condition, affecting with 1 in 3 ... more High blood pressure (hypertension [HTN]) is a prevalent chronic condition, affecting with 1 in 3 (34%) adult Americans 20 years and older. 1 It is the most frequent chronic medical condition among adults aged 65 years and older 2 and is a leading risk factor for many cardiovascular conditions, including heart attack, stroke, aneurysm, and heart failure. 1,3 In the US, the estimated direct and indirect cost of HTN for 2012-2013 was 51.2billionandmayincreasetoanestimated51.2 billion and may increase to an estimated 51.2billionandmayincreasetoanestimated200 billion by 2030. 1 From NHANES data, 17.2% of US adults are not aware that they have high blood pressure (BP). 4 Moreover, HTN is not well-controlled, 75.7% were currently taking medication to lower their BP, but only 51.9% of those who took antihypertensive drug treatment achieved

Research paper thumbnail of Practice Level Costs of Office-Based Hypertension Performance Improvement

Journal of Healthcare Management, 2017

Primary care practice leaders who consider engaging in quality improvement (QI) need to understan... more Primary care practice leaders who consider engaging in quality improvement (QI) need to understand the practice level costs incurred when asking staff to take on new tasks. The Heart Healthy Lenoir study is a prospective cohort trial in which QI methods were used to enhance hypertension (HTN) care and reduce racial disparities in blood pressure control in small rural primary care practices in North Carolina. As part of this effort, we performed an activity-based costing analysis to describe the costs incurred to develop, implement, and maintain key tasks. We interviewed 20 practice stakeholders and phone-based health coaches during 2012-2014. We calculated the time invested by individuals to perform each task within each study phase and applied national hourly wages to generate cost estimates. Our descriptive analyses focus on four of the most widely used practices. Activities included time to abstract HTN control data, participate in project meetings, identify patients with uncontrolled HTN, create standardized work, and provide additional health coaching

Research paper thumbnail of Lessons Learned From Implementing Health Coaching in The Heart Healthy Lenoir Hypertension Study

Progress in Community Health Partnerships: Research, Education, and Action, 2016

elephone health coaching between office visits is a useful adjunct to office-based care. In patie... more elephone health coaching between office visits is a useful adjunct to office-based care. In patients with chronic illness, telephone coaching improves health behaviors and health status. 1 Coaching can be especially helpful for vulnerable populations, including patients with multiple comorbidities, advanced age, and patients with low literacy by facilitating enhanced access to care. 1 Evolving primary care models, including a patient-centered medical home 2 and

Research paper thumbnail of ACE inhibitors

Postgraduate Medicine, 1990

The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure has r... more The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure has recently recommended angiotensin-converting enzyme (ACE) inhibitors, beta blockers, and diuretics as potential first-step agents for the pharmacologic treatment of hypertension. ACE inhibitors should be considered an important option in most patients because of their safety profile, absence of adverse metabolic effects, and positive cardiac and renal effects. If the response to an ACE inhibitor is inadequate, a diuretic or another agent can be added, and this combination should be effective and well tolerated in 85% to 90% of patients. ACE inhibitors can be used to treat congestive heart failure and to prevent the renal complications of hypertension and diabetes mellitus, significantly expanding their use in patients with these high-risk conditions. They also can be used concurrently with other antihypertensive agents, digitalis, cardiac glycosides, and lithium and are not contraindicated in most of the diseases commonly seen in hypertensive patients.