Motivational Interviewing Improves CPAP Adherence

SOURCE: Bakker JP, Wang R, Weng J, et al. Motivational enhancement for increasing adherence to CPAP: A randomized controlled trial. Chest 2016;150:337-345.

Even though obstructive sleep apnea (OSA) causes immediate (daytime sleepiness, memory impairment, decreased functionality) and long-term (hypertension, increased cardiovascular event rate) problems, it may come as a surprise that the majority of users of continuous positive airway pressure (CPAP) machines do not even achieve four hours of use nightly, on average. This is particularly concerning since benefits of CPAP on adversities related to OSA are most substantial when using CPAP for 5.5 hours or more per night.

Motivational interviewing is a technique that has been successfully employed to improve outcomes ranging from smoking cessation to compliance with antihypertensive medication. Practitioners of motivational interviewing believe patients naturally often feel some ambivalence about interventions offered to them and that by helping the patient identify such ambivalence, steps can be taken to address obstacles to success. Central to the mechanism of motivational interviewing success is the role of the interviewer as facilitator rather than director. That is, patients are encouraged both to identify their own sources of ambivalence and also to explore which obstacles they might wish to address, as well as how they might best address them. Considering that the textbook explaining motivational interviewing (Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. Third Edition. Guilford Press; 2012) encompasses more than 400 pages, the above explanation obviously is a dramatic over-simplification. Nonetheless, practitioners of motivational interviewing techniques (psychologists, physicians, and other clinicians) often find it a useful tool.

In a 12-month, randomized, controlled trial of motivational interviewing vs. placebo (n = 83), Bakker et al found that recipients of motivational interviewing demonstrated (on average) more than 90 minutes greater utilization of CPAP per night than those in the placebo group. This benefit was achieved through two in-person, hour-long motivational interviewing sessions with a psychologist, followed by six phone sessions over 32 weeks (10-30 minutes each) with the same psychologist.

Empagliflozin Improves Renal Outcomes in Type 2 Diabetes

SOURCE: Wanner C, Inzucchi SE, Lachin JM, et al. Empagliflozin and progression of kidney disease in type 2 diabetes. N Engl J Med 2016;375:323-334.

Sodium glucose transporter 2 (SGLT2) inhibitors are the newest class of medications approved to treat type 2 diabetes (T2DM). Although there have been isolated reports of acute kidney injury associated with SGLT2 treatment, FDA registration trials have noted a short-term decline in glomerular filtration rate, which returns to normal over ensuing weeks. The EMPA-REG trial (n = 7,020) was performed primarily as a cardiovascular safety trial for the SGLT2 inhibitor empagliflozin, as mandated for all new pharmacologic agents indicated for T2DM. In addition to the cardiovascular risk reduction reported in earlier published EMPA-REG results, renal outcomes were another important pre-specified endpoint.

New or worsening nephropathy was meaningfully reduced by empagliflozin treatment (hazard ratio = 0.61, a 39% reduction). Similarly, the incidence of a doubling of serum creatinine was reduced by almost half, and likelihood of initiation of renal replacement treatment was reduced by more than half.

In addition to favorable effects on glucose control and cardiovascular outcomes, treatment with empagliflozin was associated with meaningful reductions in adverse renal outcomes.

Patients Make Multiple Errors in Inhaler Use

SOURCE: Sanchis J, Gich I, Pedersen S; Aerosol Drug Management Improvement Team (ADMIT). Systematic review of errors in inhaler use: Has patient technique improved over time? Chest 2016;150:394-406.

Despite various technical advances in inhaler devices, the skill with which patients actually use such devices has shown little improvement over four decades. Certainly, most clinicians have experienced or will experience suboptimal outcomes attributable to non-nefarious misuse of intended treatments.

Inhalation devices include metered dose inhalers (MDI), breath-activated MDIs, dry powder inhalers, and MDIs with inhalation chambers. Sanchis et al reported on data from patients in 144 publications about observed inhaler technique (n = 54,354).

Although the steps for each device vary, errors in use (failure to place teeth/lips on mouthpiece, failing to fully exhale before inhalation, failure to breath-hold after medication inhalation, etc.) were the rule rather than the exception.

Only 31% of users exhibited correct inhaler technique, with an equal number demonstrating poor technique. The authors documented that skillfulness of technique has not improved over 40 years of observation. Obviously, something has to change in the process of educating patients about inhaler technique if clinicians expect different results in the future.