Insulin Pen

Fixed-Ratio Combinations of Basal Insulin and GLP-1 Receptor Agonists: Clinical Evidence and Practical Barriers for T2DM Management in Primary Care Settings

Online Course | Specialties: Family Medicine, Internal Medicine, Primary Care
Released: 10/29/2020
Expires: 10/28/2021
Max Credits: 0.75
Jump to Education

Lawrence Fisher, PhD, ABPP
Professor Emeritus
Departments of Family and Community Medicine
University of California, San Francisco
San Francisco, CA

Susan Jung Guzman, PhD
Cofounder, Director of Clinical Education
Behavioral Diabetes Institute
Founder and Consulting Psychologist
Diabetes Psychology Associates
San Diego, CA

Jay H. Shubrook Jr, DO, FACOFP, FAAFP, BC-ADM
Professor, Primary Care Department
Director, Clinical Research and Diabetes Services
College of Osteopathic Medicine
Touro University California
Vallejo, CA

Mark W. Stolar, MD
Associate Professor of Clinical Medicine
Feinberg School of Medicine
Northwestern University
Chicago, IL

Activity Planners
Iwona Misiuta, PhD, MHA
Clinical Content Manager
Baltimore, MD

Laura Rafferty, ELS
Senior Managing Editor
Baltimore, MD

Samantha Gordon, MS
Accreditation Manager
Baltimore, MD

Kathryn Schaefer, MSN, RN, CPHRM
Associate Director, Education Quality and Compliance
East Lansing, MI

Amy Sison
Director of CME
Baltimore, MD

Haifa Kassis, MD
Boston, MA

Learning Objectives
Upon completion, participants should be able to:

  • Describe the benefits of earlier treatment intensification with injectable fixed-ratio combination therapies versus a traditional stepwise approach to T2DM management
  • Differentiate among fixed-ratio combination formulations in terms of safety, efficacy, indications, clinical trial data, and patient factors
  • Outline the effects of and improvement strategies for common T2DM barriers to integrating evidence-based care in the management of T2DM

Target Audience
This activity is intended for primary care clinicians.

Statement of Need
Currently, only 50% of the more than 21 million patients with type 2 diabetes mellitus (T2DM) in the United States are meeting guideline-recommended hemoglobin A1C targets. Numerous studies have shown that delays in treatment initiation and intensification for patients with T2DM occur all too frequently. The earlier use of injectable combination therapy affords clinicians the ability to simultaneously address multiple pathophysiologic defects associated with T2DM and potentially delay disease progression. However, major barriers exist regarding the earlier use of combination therapy, such as concerns about patient adherence, cost, side effects, and poor disease knowledge among many patients. Newer titratable combination insulin formulations may play an important part in the mitigation of some of these concerns; furthermore, they may be able to reduce clinical inertia and achieve treatment goals sooner. Clinicians should be well versed in the clinical evidence on fixed-ratio combinations, including benefits and limitations, as well as be able to identify patients who may benefit from these treatment advances. Additionally, clinicians should be aware of strategies to overcome barriers to treatment intensification with injectable combination medications.

Providership Statement
Provided by Med-IQ. 

Accreditation/Designation Statements
Med-IQ is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Med-IQ designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME MOCSuccessful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 MOC points from the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

CLAIMING MOC POINTS: If you intend to claim MOC points for your participation, you will need to provide your unique, six-digit ABIM ID Number. Please note, your name, ABIM ID number, birthdate and completion status will be shared with ABIM through the ACCME PARS system. Your points will be automatically submitted to the ABIM on your behalf; please allow 4 weeks for your points to display on the ABIM website.

MIPSCompletion of this accredited CME activity meets the expectations of an Accredited Safety or Quality Improvement Program (IA_PSPA_28) for the Merit-based Incentive Payment Program (MIPS). 

Med-IQ is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

This nursing activity has been approved for up to 0.75 contact hour.

Medium/Method of Participation
This is a 0.75-credit CME activity. To receive credit, read the introductory CME material, read the publication, and complete the evaluation, attestation, and post-test, answering at least 70% of the post-test questions correctly.

Initial Release Date: October 29, 2020
Expiration Date: October 28, 2021
Estimated Time to Complete This Activity: 45 minutes

Disclosure Policy
Med-IQ requires any person in a position to control the content of an educational activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as those in any amount occurring within the past 12 months, including those of a spouse/life partner, that could create a conflict of interest (COI). Individuals who refuse to disclose will not be permitted to contribute to this CME activity in any way. Med-IQ has policies in place that will identify and resolve COIs prior to this educational activity. Med-IQ also requires faculty to disclose discussions of investigational products or unlabeled/unapproved uses of drugs or devices regulated by the US Food and Drug Administration.

Disclosure Statement
The content of this activity has been peer reviewed and has been approved for compliance. The faculty and contributors have indicated the following financial relationships, which have been resolved through an established COI resolution process, and have stated that these reported relationships will not have any impact on their ability to give an unbiased presentation.

Lawrence Fisher, PhD, ABPP
Consulting fees/advisory boards: Ascensia Diabetes Care, Eli Lilly and Company

Susan Jung Guzman, PhD, has indicated no real or apparent conflicts.

Jay H. Shubrook Jr, DO, FACOFP, FAAFP, BC-ADM
Consulting fees/advisory boards: Bayer HealthCare Pharmaceuticals, Eli Lilly and Company, Novo Nordisk, Sanofi-aventis U.S. Inc.

Mark W. Stolar, MD, has indicated no real or apparent conflicts.

The writer, peer reviewers, and activity planners have no financial relationships to disclose.

Statement of Evidence-Based Content
Educational activities that assist physicians in carrying out their professional responsibilities more effectively and efficiently are consistent with the ACCME definition of continuing medical education (CME). As an ACCME-accredited provider of CME, it is the policy of Med-IQ to review and ensure that all the content and any recommendations, treatments, and manners of practicing medicine in CME activities are scientifically based, valid, and relevant to the practice of medicine. Med-IQ is responsible for validating the content of the CME activities it provides. Specifically, (1) all recommendations addressing the medical care of patients must be based on evidence that is scientifically sound and recognized as such within the profession; (2) all scientific research referred to, reported, or used in CME in support or justification of a patient care recommendation must conform to generally accepted standards of experimental design, data collection, and analysis.

Med-IQ is not liable for any decision made or action taken in reliance upon the information provided through this activity.

Contact Information
For questions or comments about this activity, please contact Med-IQ. Call (toll-free) 866 858 7434 or email

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The information provided through this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient’s medical condition.

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Acknowledgment of Commercial Support
This activity is supported by an educational grant from Sanofi US.

© 2020 Med-IQ, Inc.

The following material has been developed to accompany this activity:

Reaching Your Blood Glucose Goals: Type 2 Diabetes and Fixed-Ratio Combination Injectables

Note: This material is not accredited for CME and, therefore, does not offer any CME/CE credit.


Here are the key takeaways from this activity. Deeper insights and evidence, plus an opportunity to receive credit, are available at the "Continue" button below.

  • By combining the complementary modes of actions of basal insulin and GLP-1 receptor agonists, fixed-ratio combinations can target at least 8 of the pathophysiologic mechanisms in T2DM
  • The use of fixed-ratio combinations in patients who require a combination of basal insulin and a GLP-1 receptor agonist eliminates the need for multiple daily injections and simplifies treatment
  • In 2016, 2 titratable fixed-ratio combinations (iDegLira: insulin degludec plus liraglutide; iGlarLixi: insulin glargine plus lixisenatide) were approved as adjuncts to diet and exercise for the management of inadequately controlled glucose in adults with T2DM
  • Many patient-related barriers to treatment intensification stem from a lack of sufficient education about disease progression and available treatment options

View reference list.

Click "Continue" to proceed through this activity and/or receive credit. To receive credit and a certificate, you must complete all of the chapters in this activity.

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Unless otherwise indicated, photographed subjects who appear within the content of this activity or on artwork associated with this activity are models; they are not actual patients or doctors.

The information provided through this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient’s medical condition.

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