Michele Brannan, MPAS, PA-C

Chronic obstructive pulmonary disease (COPD) and its subtypes, such as chronic bronchitis and emphysema, affect more than 5% of the population and is the third-ranked cause of death in the United States. In 2012, COPD caused 3 million deaths—6% of worldwide deaths that year.

Due to its high prevalence and chronicity, the disease represents a large burden of care on the health care system. In 2010, the disease resulted in an estimated cost of $32.1 billion in the United States.

There is substantial overlap between the COPD subtypes and other airflow-limiting diseases, such as asthma, bronchiectasis, and bronchiolitis.

Chronic bronchitis is specifically defined as a chronic productive cough lasting 3 months in each of 2 successive years in cases where other causes of cough have been excluded.

An acute exacerbation of COPD is defined as an increased sputum production, an increase in dyspnea, a change in the color of the sputum from clear to white to green or yellow, or an increase in a cough.

It may be triggered by a viral or a bacterial infection or environmental pollutants. Allergens, chemical toxins, air pollution, and noncompliance to drug therapy are also well-known risks. Exacerbations manifest in airway inflammation, hyperinflation, and reduced air flow and gas exchange. With worsening COPD, exacerbations become more prevalent.

Acute exacerbations of chronic bronchitis, the focus of this article, typically manifest in worsening cough, increases or changes in sputum production, and worsened dyspnea. A thorough medical histo- ry should include the following features:

• Comparison to the patient’s baseline symptoms

With cough being the most common sign of chronic bronchitis, and a cough also representing a common complaint for which patients seek treatment in the clinic, it is no wonder the paths collide. Oftentimes, differentiating between a chronic cough that is at its baseline, a chronic cough that is an exacerbation, and an acute cough proves difficult even for the astute clinician, who needs to tease out details regarding the complaint.

One of the first questions in obtaining the history involves acquiring a time frame. Not only is it important to find out how long a patient’s current cough has been ongoing, it is also key to know how common a cough is to the patient.

Consider 2 different examples of obtaining a history with a complaint of cough:

These 2 different basic conversations show the importance of obtaining a detailed history. If, with the first inquiry, the health care provider merely stopped with the patient’s answer of “About a week,” it can be interpretedas an acute cough, such as that which occurs with sinusitis or a common cold. However, further probing, as seen with example 2, suggests a more chronic problem that requires completely different treatment.

The 3 most prominent symptoms of COPD are chronic cough, dyspnea, and sputum production. Less common are wheezing and chest tightness, and each of these symptoms can present with varying degrees of intensity. The variation can be over the course of a day or week-to-week. Morning is usually the worst time of day for these patients.

Assessment includes not only symptom presence and severity, but also an inquiry of how much a change from baseline it is. Let’s revisit the 2 clinical scenarios:

It is easy—and important&mdash;to see how much the patient’s breathing is affecting his or her activities of daily life, and how much of a change from baseline it is, with more specific questioning. Sputum should be characterized by its amount and purulence and whether or not there is blood. However, it should be noted that colored mucus is not necessarily indicative of a bacterial infection.

It’s also important to take note if the patient has had an extensive history of prior exacerbations. When the patient presents in the clinic, it is paramount to assess risk factors when obtaining the history. These include:

•Smoking history, including age at initiation and average amount

Carefully assess for comorbid conditions, which can confuse the COPD picture. These include heart failure, cardiovascular disease, bronchiectasis, deconditioning, lung cancer, and anxiety, among others. Consider an alternate diagnosis from chronic bronchitis exacerbation if symptoms such as fevers, night sweats, chest pain, hypotension, or edema are present. Beyond the vitals, a physical examination should include inspecting the head, ears, nose, throat, and neck. The chest might reveal wheezing and tachypnea, course cough, and accessory muscle use for a chronic bronchitis exacerbation. Crackles are often heard. On cardiovascular exam, pay attention for tachycardia or arrhythmia.

Tests should also include a pulse oxygen saturation, and a chest radiograph should be ordered to rule out an infiltrative process or effusion, particularly in patients with fever or hemoptysis. Laboratory studies may include serum electrolytes and a complete blood count (to identify polycythemia or anemia). In severe cases, arterial blood gas analysis provides information if there is concern for hypercapnia or hypoxemia. Spirometric testing is typically not recommended for acute exacerbations of chronic bronchitis because results can be inaccurate in such a setting.

Other tests, such as electrocardiogram or brain natriuretic peptide, are obtained contingent upon the clinical presentation of the patient. Sputum cultures are not of much use for COPD exacerbations unless there is strong suspicion of bacterial infection not responding to initial antimicrobial therapy. When suspected, obtain an influenza swab.

GOLD guidelines that recommend hospitalization are as follows

• Inadequate response to outpatient management

• Significant change from baseline symptoms

• Severe underlying COPD, defined as forced expiratory volume in 1 second (FEV1) <50%

• New onset of cyanosis or peripheral edema, or other profound signs

• Comorbid conditions, such as pneumonia, heart failure, diabetes, or renal failure

Treatment for chronic bronchitis exacerbations includes beta-agonists, anticholinergic agents, oral glucocorticoids, and other ancillary support. Intensification of bronchodilator therapy with inhaled short-acting albuterol or levalbuterol is a mainstay of therapy due to its rapid onset of action and efficacy. Although most studies have not proven that nebulizer administration of beta-agonists is superior to the handheld inhalers, several patients prefer the nebulizer, and it should be considered for exacerbations.

Long-acting bronchodilators are successful in reducing exacerbations and hospitalizations, as well as improve symptoms.

Short-acting anticholinergics, such as ipratropium, are also effective bronchodilators and typically used in combination with the inhaled beta-agonists.

A metered dose inhaler should administer ipratropium with 2 puffs every 4 to 6 hours. The soft mist inhalers (eg, Respimat) endorse the combination to be dosed at 1 inhalation every 6 hours.

GOLD tells us that combination bronchodilators, compared with single bronchodilator therapy, of different pharmacologic classes may prove more efficacious and reduce adverse effects.

Current GOLD guidelines suggest taking prednisone at 40 mg daily for 5 days.

However, depending on severity and known prior response to therapy, clinical practice often denotes a higher or longer course of oral glucocorticoids.

Outpatient treatment of chronic bronchitis exacerbations does not come with well-established data to support antibiotic treatment. As such, GOLD guidelines do not recommend antibiotic treatment except for situations where there is suspected concurrent infection. Clinically, in those with mild exacerbations (ie, those with increased dyspnea, increased sputum volume, or increased sputum puru- lence, but not all 3), antibiotics are typically not indicated.

If antimicrobial therapy is being considered and local antibiotic resistance patterns are being taken into account, antibiotics targeting

should be considered. Macrolide antibiotics, doxycycline, trimethoprim-sulfamethoxazole, or a cephalosporin are recommended for COPD exacerbations in most uncomplicated cases. In more complicated patients, amoxicillin-clavulanate or levofloxacin or moxifloxacin are the recommended agents.

Adjunctive care for chronic bronchitis exacerbations includes cigarette smoking cessation, avoidance of environmental triggers, and, for those who qualify, oxygen therapy. Rehabilitative services, such as exercise training programs to improve exercise tolerance and reduce dyspnea, are valuable for long-term benefit. Similarly, maintenance of health status can be afforded if the patient continues his or her exercise training at home.

Supplemental oxygen should be titrated to a goal of 88% to 92%. Long-term oxygen administration for chronic respiratory failure has been shown to improve survival in patients with severe disease and resting hypoxemia, defined as an oxygen saturation at or below 88%.

Michele Brannan, MPAS, PA-C, earned her bachelor’s degree in health science and her master of physician assistant studies degree from Gannon University. She started her career working in cardiology at St. Louis University before joining Alton Internal Medicine in Alton, Illinois, where she has practiced for more than 10 years.

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Articles

Chronic obstructive pulmonary disease and its subtypes, such as chronic bronchitis and emphysema, affect more than 5% of the population and is the third-ranked cause of death in the United States.

Chronic Bronchitis

With the summer in full swing, patient education hasaligned itself with anticipated ailments related to sun exposure. Thankfully, there are several protective measures that only require a little forethought, such as packing extra sun-screen and fluids for a day outside in the heat.

It is important to first acknowledge that sun protection should be regarded year-round. Clinical and epidemiological evidence shows that malignant melanoma—the deadliest form of skin cancer&mdash;is seen in patients who have experienced repeated intense exposuren to sunlight.

This implies that sunlight in the summer months alone is not the only factor at play. In fact, ultraviolet (UV) radiation levels can be high even on cloudy days.

This is responsible for sunburn, photoaging, and skin cancer. Five percent of UV radiation is called UV-B,

which causes sunburn, hyperpigmentation, and skin cancer. The rest of UV radiation is called UV-A; of this type, UV-A1 (long wavelength) is less potent than its counterpart, UV-A2 (short wave-length), which can have detrimental effects similar to UV-B. In the continental United States, the hours between 10am and 4pm present the most dangerous UV exposure.

Repeated or extensive exposure to sunlight is a definite risk factor for melanoma.

Tanning bed use, especially before age 35, also increases melanoma risk.

Notably, exposure to UV radiation is the most important risk factor for basal cell skin carcinoma (BCC). Cutaneous squamous cell carcinoma (SCC) is less common on non-sun exposed areas of the skin, while sunexposed sites are the most common locations for SCC.

The global incidence of malignant melanoma continues to rise and is increasing faster than any potentially preventable cancer in the United States.

Of the non-melanoma skin carcinomas, the majority of the rest are BCC, according to the American Cancer Society. Moreover, there appears to be a high prevalence of non-melanoma skin cancer in the United States.

These contain filters to reflect or absorb UV radiation. In 2011, the FDA administered guidelines for labeling sunscreen products. Now, only sunscreens that pass the FDA’s test for protection against both UV-A and UV-B radiation can be labeled “broad spectrum.” Furthermore, only products that meet FDA standards and are at least SPF 15 can be designated as those that decrease the risks of skin cancer and photo aging. The FDA also mandated that sun protection factor (SPF) be capped at 50 and sunscreens with a higher SPF be labeled as “50+.”

A sunscreen termed “water-resistant” means the SPF is maintained for 40 minutes of water activity. Very water-resistant” implies 80 minutes. The FDA has expunged all labels of “sweat-proof” and waterproof.”

Sunscreens are typically formulated with organic and inorganic filters. The former absorbs UV and converts it to heat. Avobenzone is an example of an organic filter. Inorganic filters, such as zinc ide and titanium dioxide, reflect and scatter UV light. Inorganic sunscreens are generally more stable and have low irritating and sensitizing potential. This type also offers broad-spectrum against both UV-A and UV-B. The combination of both organic and inorganic filters affords maximum efficacy against the entire UV spectrum.

SPF is often a confusing concept for the average patient because the relationship between SPF and protection is not linear. The notion that SPF 30 is twice as effective as SPF 15 is a myth that may need explaining to the patient. When properly applied, a sunscreen with SPF 15 protects the skin from 93% of UV-B radiation, while SPF 30 provides 97% protection.

All individuals, regardless of skin phototype, are subject to the adverse effects of UV radiation. Subsequently, everyone can benefit from sunscreen use. However, light-skinned individuals are more susceptible to both chronic and acute skin changes from skin exposure, and thus they reap the most benefit from routine SPF product use. In response to the question, “Who needs sunscreen?”, the American Academy of Dermatology (AAD) states, “Everyone.”

Key words for the astute clinician to impart on patients are “repeatedly” and “liberally.” Sunscreens must be applied in this fashion to be protective. Timing is also important, and sunscreens should be applied 15 to 30 minutes ahead of planned sun exposure to allow time for maximum absorption. Then, reapplication is necessary every 2 hours. All sunscreens wash off with swimming and sweating, and despite a label of “water-resistance,” products still need to be reapplied.

To achieve the full SPF value, 2 mg/cm of sunscreen is needed, which is approximately the amount required to fill a 1-oz (30-mL) shot glass. It has been reported that most patients do not apply a sufficient amount of sunscreen in order for it to be effective; hence, SPF30 or more, instead of SPF 15, is recommended for adequate protection.

Accordingly, the AAD recommends broad-spectrum protection with SPF 30 or higher and water resistance.

One of the most profound benefits of diligent sunscreen use is the prevention of skin cancer. Regular use of sunscreen has been found to reduce the incidence of malignant melanoma.

Strong evidence exists that sunscreens prevent the development of actinic keratoses and SCC.

Study results have also shown a statistically insignificant reduction in BCC incidents with sunscreen use.

Sunscreen may prevent chronic skin photo damage or photo aging, and thus pigmentation and wrinkling, as well as photodermatoses.

Rarely, sunscreens can elicit an allergic reaction or contact dermatitis. Nevertheless, they are generally very effective in photo protection when applied appropriately.

Other methods of sun protection are barriers such as clothes, hats, and sunglasses. Tightly woven fabric is more effective in protecting skin, and a dry shirt is more effective than a wet one. Darker colors are also generally better than lighter ones in protecting individuals from the sun. The Skin Cancer Foundation has formulated a list of recommended sun protection products and, further, has designated new Seals of Recommendation, which are bro- ken down into those for daily use, and those for active use. A product finder search is available through this foundation that relays the product’s SPF and the seal it was granted.

Sunglasses are highly advisable to protect eyes and reduce cataract risk, as well as prevent periorbital skin dam- age. Recommend that patients choose sunglasses that block UV-A and UV-B rays. Most sunglasses sold in the United States meet this standard.

Another important yet simple barrier about which to remind patients is shade. However, shade is likely insufficient alone to protect from the sun, so concomitant sunscreen is advisable.

Although the human body remains remarkably resilient in the cold, it cannot tolerate temperatures many degrees above normal. Heat-related illness is a concern for all those who spend time in the warm outdoors, and it is an even more profound danger for athletes and outdoor laborers. Proper hydration is paramount to staying safe in the sun.

The CDC has reported an increase in the trend of exertional heat illness in the United States. There was a reported average of 9237 cases of exertional heat illness among high school athletes per year from 2005 to 2009.

Risks factors for heat illness include the following:

• certain drugs such as antihistamine, decongestants, beta-blockers, diuretics, anticholinergics, anti- epileptics, tricyclic antidepressants, lithium

Patient education should include warning signs for heat illness, which include lightheadedness, fatigue, flushed skin, decreased appetite, thirst, muscle cramps, and dark-colored urine.

The American College of Sports Medicine (ACSM) suggests 16 to 20 oz. of fluid 1 to 2 hours before outdoor activity and 6 to 12 oz. of fluid every 15 minutes, once the individual is outside. Another 2 to 3 cups (16—24 oz.) after returning from outside is recommended afterward, as well.

Generally speaking, it is important to advise patients to drink before, during, and after outdoor activities.

For athletes exercising in hot temperatures, the ACSM states that “matching fluid intake with water lost through sweat is one of the most critical factors in preventing heat illness.” They instruct athletes to consume at least half of their body weight in ounces 20 minutes before exercising and another 8 to 10 oz every 15 minutes during practice.

Again, rehydrating after the workout is important.

If exertion is not at high levels and an individual intends to be out in the sun and heat for 1 hour or less, a liberal amount of water generally suffices to maintain hydration. However, should activity be more aggressive or last longer than 60 minutes, then sports drinks are the recommended choice for prevention of dehydration. Most sports drinks offer a mix of sugars (such as glucose, sucrose, or fructose) plus electrolytes and, most importantly, sodium; most are isotonic in that they have a similar concentration of salt and sugar as the human body.

On the contrary, available fitness waters do not typically offer significant carbohydrates, which, if depleted during vigorous exercise, are necessary to replace. Fitness waters do, nonetheless, have fluids to help maintain hydration.

It is important for patients to understand that drinks such as alcohol, and caffeinated beverages, such as tea, coffee, and colas, are not recommended for hydration purposes. Each of these tends to instead pull water from the body and induce dehydration. Fruit juices also tend to be heavier in carbohydrates and low in sodium and, as such, are not ideal for rehydration.

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With the summer in full swing, patient education has aligned itself with anticipated ailments related to sun exposure.

How to Stay Safe in the Summer Sun

is a term that means “poisonous tree.” It is also the genus that includes the most common culprits in allergic plant contact dermatitis, such as poison ivy.

dermatitis can result from a variety of plants, including western and eastern poison ivy (

Patients’ reactions to these plants can vary as much as the plants themselves, rendering the common phrase “leaves of 3, leave them be” oversimplified.

Nevertheless, this adage is most applicable to poison ivy, as it has 3 leaflets with flowering branches.

An estimated 25 to 40 million Americans require medical treatment after plant exposure.

There is a natural tendency for outdoor workers to have plant dermatitis.

Unlike some types of dermatitis, the rash of poison ivy is not selective to any particular skin type, so individuals of any ethnicity can be affected.

By the time they are 8 years old, most children are sensitized, and it appears that allergic reactions from the plant tend to wane with age, so the elderly are affected less often.

Poison ivy dermatitis is a type IV hypersensitivity, cell-mediated, allergic reaction to the urushiol compound. Because urushiol is a potent antigen, a single exposure can cause clinical signs such as a pruritic rash. The allergen can be found on the leaves, stem, fruit, and even the root of the plant, and there is greater uptake when exposure occurs after the plant is broken or bruised, such as after a rainfall or cutting the plant. When the toxic plant oil makes contact with skin, clothing, pets, or other fomites, the allergen easily penetrates the epidermis and is taken up by the Langerhans cells. Now covered in antigen, these cells activate T lymphocytes in regional lymph nodes before circulating throughout the body. Once clonally-expanded T lymphocytes are present, re-exposure to the poisonous plant elicits cytokine release and subsequent symptoms in 12 to 48 hours. Interestingly, those with a history of poison ivy dermatitis may be at risk for cross-reaction with other urushiol-containing plants such as mango trees.

Patients typically present to their health care provider when the pruritus and dermatitis become overwhelming. The initial redness may transform into papules, plaques, and/or bullae. The characteristic linear configuration is often present where the plant made contact with the skin.

After exposure, initial symptoms usually develop within 4 to 96 hours and peak within 1 to 14 days. However, new lesions may present up to 21 days after exposure. The severity of the rash and when it develops in a certain area of the body are contingent upon the amount of urushiol present on exposure, the thickness of the stratum corneum of the area involved, and the patient's individual sensitivity. The longer the oils are on the skin, the more likely and more severe the allergic response tends to be. These factors can give the impression that the rash is spreading.

In addition to pruritic erythema and papules/vesicles, poison ivy can yield edema in the exposed area. Urticaria and erythema multiforme have been known to occur with urushiol exposure in severe cases.

Patients often believe that blister fluid causes spreading of the rash, yet the fluid is not known to be antigenic. Moreover, once the oils are washed off the skin, poison ivy cannot spread to others, which is another common misnomer among patients. Nevertheless, patients can continue to come in contact with contaminated items such as clothing, pets, and tools, thus perpetuating the dermatitis. Without treatment, poison ivy dermatitis is typically self-limiting within 1 to 3 weeks.

Because of a disruption in the skin barrier, the most common complication of poison ivy dermatitis is secondary bacterial infection with

Depending on the affected site, the bacteria can also be polymicrobial.

Poison ivy dermatitis sequelae can include postinflammatory hyperpigmentation, which is more common in darker-skinned patients and typically resolves with time.

Although the diagnosis of poison ivy rash is largely clinical, the following diagnostic differentials should still be considered:

Allergic contact dermatitis: other allergens, such as gold or nickel, can cause a rash that resembles poison ivy.

Phytophotodermatitis: the lesions are present in only sun-exposed areas and may or may not blister.

Arthropod reactions: pruritic burrows from scabies can resemble poison ivy dermatitis, although scabies does not involve blisters or vesicles. Like plant dermatitis, bedbug rash can also be linear and pruritic.

Nummular dermatitis: this dermatitis of unknown etiology results in intensely pruritic patches of eczema and can include papules, scaling, and oozing.

Herpes zoster: both zoster rash and poison ivy dermatitis can result in vesicles, although the former has a characteristically unilateral and dermatomal distribution.

Prevention and treatment go hand-in-hand as the most effective treatment in the identification and avoidance of poisonous plants.

Patients need to be made aware that the plant allergens can have an effect year-round and that allergenicity can persist even after plant death. Patients should be counseled about protective barriers against poison ivy. The allergenic sap can be kept at bay by wearing heavy-duty vinyl gloves; it can seep through rubber and latex gloves and penetrate some clothing. Still, physical barriers afford some form of protection and are wise to use.

Patient education is paramount to appropriate self-management of poison ivy dermatitis. Educational handouts with colored photos of the various plants are helpful. Patients should be advised to remove any contaminated clothing and to wash the skin with soap and water as soon as possible. Removing debris and residual plant resin from beneath the fingernails is also beneficial, though harsh scrubbing can intensify the ensuing dermatitis and is not advised.

In a volunteer study involving approaches to postcontact prevention of poison ivy dermatitis, Tecnu, Goop, and Dial were compared with a positive control. Results showed 70%, 61.8%, and 56.4% protection, respectively, which is an insignificant difference among the 3 products. However, the results also showed that each product does help prevent the development of dermatitis after exposure.

Bentoquatam (Ivy Block) is a barrier cream with the best evidence for prevention of poison ivy dermatitis. Results of a small, controlled trial showed that only 32% of subjects developed dermatitis at the site treated with the cream. Bentoquatam seems also to lessen the severity of the dermatitis. To be effective, however, it needs to be reapplied every 4 hours.

Unlike with other allergens, desensitization programs have not been found to be effective in the management of poison ivy dermatitis.

Although few clinical trials have examined poison ivy dermatitis, clinical experience is vast and the measures recommended herein are generally effective. Symptomatic relief is a starting point for treatment and consists of cool compresses and oatmeal baths. Calamine lotion has also been helpful against the pruritus.

The itching related to poison ivy dermatitis is not histamine-mediated, although antihistamines have been used to combat the pruritus in common practice. Specifically, sedating antihistamines are beneficial in relieving nocturnal itching that causes insomnia.

Either alone or in combination, topical and systemic steroids have become a mainstay of therapy for poison ivy dermatitis. Topically, the high-potency corticosteroids are most helpful in symptom management. Clobetasol propionate 0.05% ointment has proven to be the only topical steroid that can modify the disease course. Use of super-potent topical corticosteroids for less than a week will likely not cause significant atrophy in that time frame. Once the characteristic bullae have formed, topical steroids do little to help.

Systemic corticosteroids may be indicated with facial or genital involvement, or in cases of severe dermatitis. Despite a lack of evidence-based studies defining the exact amount of steroids needed, clinical experience dictates that too short a course may cause rebound dermatitis because of continued cytokine activation from T lymphocytes.

One small, randomized, controlled trial compared a long versus short course of oral prednisone in patients with severe poison ivy. One group received 40 mg of prednisone for 5 days and the other group received the same regimen, plus a 10-day taper, for a total treatment time of 15 days. Nonadherence rates, rash return, medication side effects, time to improvement, and complete healing of the rash were not significantly different between the 2 groups. In addition, patients receiving the long-course regimen were significantly less likely to use other medications for symptom relief (22.7% vs. 55.6%), reducing the need for excess nonprescription medications.

With the easy-to-remember 1 mg/kg/day dosing, up to 60 mg a day, oral prednisone has been suggested with a long taper (eg, 14 to 21 days). Intramuscular administration of steroids is useful in patients who cannot tolerate parenteral dosing. Again, published data are lacking on the ideal steroid dose for patients with poison ivy dermatitis.

Secondary bacterial infection must be considered if painful erythema, induration, or pus develops. Antimicrobial coverage should be directed against gram-positive organisms.

must be considered first, along with methicillin-resistant

earned her bachelor’s degree in health science and her masters of physician assistant studies degree from Gannon University. She started her career working in cardiology at St. Louis University before joining Alton Internal Medicine in Alton, Illinois, where she has practiced for more than 10 years.

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Dickey RF. Parenteral short-term corticosteroid therapy in moderate to severe dermatoses. A comparative multiclinic study.

Toxicodendron, a term that means â€œpoisonous tree,â€ is the genus that includes the most common culprits in allergic plant contact dermatitis, such as poison ivy.

What to Do When Poison Ivy Allergy Presents

Advanced practice clinicians are in a unique position to facilitate a patient's engagement in his or her health care.

Busy advanced practice clinicians are duty-bound to provide their patients not only with the medicines to treat disease, but also the know-how to use them properly. This is particularly important in the management of diabetes. Diabetes, which afflicted over 29 million Americans in 2012 and was the seventh leading cause of death in 2010, is a chronic metabolic disease requiring continuous education and engagement by the clinician with the patient.

With the complexity of the disease, it is can be difficult for the advanced practice clinician to allocate time to adequately educate a patient, especially in the fast-pasted outpatient setting of the retail-based clinic. A noteworthy study by Rhoades et al published observational data from 60 routine primary care office visits that evaluated the length of time that resident physicians and patients spoke and the number of interruptions. Results showed that patients spoke without interruption for an average 12 seconds after the resident entered the room. One-fourth of the time, residents interrupted patients before they finished speaking. With the average time spent with the patient at 11 minutes, the patient spoke for a total of about 4 minutes. Not surprisingly, increased frequency of interruptions was associated with less favorable patient perceptions of the visit.

The establishment of a trusting relationship between provider and patient is monumental in enhancing adherence. Advanced practice clinicians, such as physician assistants and nurse practitioners, are in an excellent position to provide stellar care and education to patients with diabetes, and often, midlevels have more time in the clinic to spend with the individual.

Assessing a patient’s knowledge and understanding of the disease is important. Furthermore, it is wise to assess the patient’s appreciation of the lifelong consequences of diabetes, particularly if uncontrolled. Health care providers are well aware of the morbidity of diabetes, but it is recommended that they talk with their patients to assess their understanding of potential future complications of the disease. Such an assessment not only provides insight into the patient’s thought process, knowledge, and level of education, but it allows the provider to begin a conversation that could ultimately yield a stronger patient— provider bond.

There are identifiable risk factors for poor follow-through and nonadherence. Elderly and adolescent patients tend to be less adherent with their care plans. In addition, a complex medication administration or dosing schedule significantly reduces the likelihood that a patient will follow directions. The presence of multiple chronic conditions can also impair follow-through. This is of substantial import, as patients rarely have just 1 condition; they often contend with several, as is the case in patients with metabolic syndrome, a cluster of diseases that can include diabetes, hypertension, and obesity. Other notable risk factors include a lack of financial and social resources, high medicine cost, low education level, a patient’s lack of understanding of the disease, and an inadequate relationship between patient and provider.

Warning signs of poor patient adherence specific to diabetes include uncontrolled blood glucose (BG), labile and erratic fluctuations in BG, multiple cancelled or missed appointments for office visits and testing, and lack of follow-through with self-monitoring of BG.

Long-term adherence to oral glucose- lowering agents has been reported to be 36% to 93%, and insulin adherence in type 2 diabetes ranges from 62% to 80%.

Poor follow-through has been shown to correlate with worse glycemic and lipid control.

Despite these statistics, the best efforts of advanced practice clinicians are still fruitful when key points are made clear to the patient. Moreover, a multidisciplinary approach is paramount in inducing adherence. A collaborative team of physicians, advanced practice clinicians, pharmacists, nurses, certified diabetic educators, and dietitians is, without doubt, the key to improvement in clinical outcomes. The pharmacist on the health care team can play an important role in encouraging the use of tools that improve medication adherence. Aids such as pill boxes, medication reminders, and blister packaging are helpful. Many pharmacies provide delivery of medications and supplies and offer medication adherence services.

With regard to insulin, the advanced practice clinician needs to match the patient’s need to his or her lifestyle. The most physiologic insulin regimen is the basal-bolus schedule that carries the advantage of being able to adjust the dose of the rapid-acting according to meal timing and content. Pre-mixed insulin (neutral protamine hagedorn [NPH]/ regular) can be chosen if the person is unable to arbitrate dose calculations or prefers to inject fewer times per day. For example, the elderly patient experiencing hardship with carbohydrate counting may be best suited to a twiceâ€‘daily regimen such as the NPH/regular combination, whereas the college graduate requiring tight control will likely do best with multiple daily injections associated with carbohydrate counting and correction boluses. An insulin pump may not be suitable for a collegiate swimmer with diabetes, whereas the middle-aged, poorly-controlled patient with type 2 diabetes would find the pump befitting.

The clinician should educate the patient on how to properly administer insulin. The demonstration pens provided by pharmaceutical companies are very helpful. During an office visit, the clinician can use the saline pen to inject herself as a true demonstration, then have the patient make his or her own first injection during the same visit. This reduces anxiety when the patient has to do it at home and away from direct clinical support.

The health care clinician should explain the risk factors for hypoglycemia (eg, missed or irregular meals) and hyperglycemia (eg, missed insulin doses and infection). Premade handouts on what to do in these situations are a good start. Actively writing a list with the patient in the room of which foods constitute 15 g of glucose, however, may be more engaging than simply handing out a piece of paper. Having the patient jot these down may be even better.

Concerns that providers may not think about or may find trivial can often be monumental to the patient. The average patient will not know, for example, what to do with the syringe after it is used or how to dispose of it. He or she also needs to be educated on which areas of the body are acceptable injection sites. Simply framed tools that the patient can relate to, such as thinking of one’s abdomen as a clock and moving the needle around the clock to change injection locations, are beneficial. It is effective to anticipate patients’ needs and concerns when events arise, such as what to do when at a restaurant and how to manage diabetes when sick.

Assessing patient fears over insulin and diabetes management, as a whole, is critical. There are patients who associate insulin initiation with dialysis and blindness, and there are many who have a fear of needles. It is the job of the health care provider to address these fears by first listening to patients without interruption. Some of the needle fear may be mitigated with the use of newer injectable noninsulin type 2 diabetes medicines, such as liraglutide and exenatide, which are provided in prefilled disposable pens.

During the visit, clinicians should address possible adverse effects of medications and prepare patients for what to expect. A clinician may be thorough in explaining that metformin can cause diarrhea, but only skim over what the patient should do if her or she becomes acutely ill or is planned for a computed tomography scan with contrast.

It is the clinician’s job to not only educate, but encourage patients. Making it clear to patients that controlling blood sugar will extend life expectancy and delay or prevent comorbidity is essential. As serious as diabetes can be, clinicians need to express that there is treatment and there is hope. It is important to show the patient how the insulin is working to lower BG and to explain the proven clinical benefits of insulin therapy. Many pharmaceutical companies have insulin programs and support lines that are easily accessible to patients.

Michele Brannan, MPAS, PA-C

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