Diabetes UpdateMaximizing options to achieve optimal blood glucose control

Carla Cox, PhD, RD, CDE

Objectives

1. Be able to identify 3 lifestyle recommendations that could change your patients life with diabetes

2. Be able to list 3 classes of diabetes medications and their target tissues and when to consider using them

3. Understand the potential for technology to enhance your patients ability to partner in the management of their blood glucose

What ARE those BG Goals?

American diabetes Association

FASTING 2 hour pp< 130 mg/dl

< 180 mg/dl

American Academy of Clinical Endocrinologists

FASTING 2 hour pp< 110 mg/dl

< 140 mg/dl

What ARE those BG Goals?

< 7% (with clinical judgment on co-morbid conditions)

ADA

What ARE those BG Goals?

What’s the data?

• 50% of Kaiser Permanente Northwest patients who initiated metformin-sulfonylurea combination therapy failed to maintain A1C levels below 8%....and it was 3 YEARS before insulin was added and at that time mean A1C of 9% (Nichols et al, 2007)

• UK population using 2 agents had A1C of at least 8% for 6.9 YEARS before further intensification of therapy with mean A1C of 9.1% (Khunti et al, 2013)

WE NEED TO DO BETTER THAN THIS!

Lifestyle

Lifestyle: Food

Food

• It’s not just about the carbs anymore!

Quality

Not evil, not promoting

health

Think and teach balance: A fruit or vegetable with every meal – and don’t forget the whole grains!

Lifestyle: Exercise

Exercise – American College of Sports Medicine

Minimum• Aerobic Exercise 150 minutes per week

(3-5 days per week)• Strength training 2-3 times per week• Stretching 5 days of the week

Exercise – diabetes specific

• Exercise most days of the week

• Include strength and aerobic exercise when possible – think about the order

Exercise – diabetes specific

• Consider timing of the meal with exercise and present medication regimen

• Follow minimum standards of ACSM (no evidence that stretching per se is needed)

Benefits• Helps to maintain/reach a healthy weight • Treatment of osteoarthritis and rheumatoid

arthritis• Greater emotional health and better sleep!

Benefits• Reduced risk of developing:

• Diabetes• Heart disease• Stroke• Cancers• High blood pressure

Monitoring

Monitoring

Using the data

DATE Fasting 2 hour post breakfast

Dinner 2 hour post dinner

10/16 165 144 185 100

10/17 182 150 110 99

10/18 130 160 240 185

10/19 155 140 126 210

More data: 4 cookies for afternoon snack 10/16 ; ice cream sundae 10/18

More data: Took a walk 10/17 afternoon and had 2 cookies for afternoon snack

Using the data – what should we change?

DATE Fasting 2 hour post breakfast

Dinner 2 hour post dinner

10/16 165 144 185 100

10/17 182 150 110 99

10/18 130 160 240 185

10/19 155 140 126 210

More data: 4 cookies for afternoon snack 10/16 ; ice cream sundae 10/18

More data: Took a walk 10/17 afternoon and had 2 cookies for afternoon snack

MedicationsRemember – the goal is BG control, not necessarily how we get there!

Medications

1921 – Insulin is discovered (thank you dogs!)

1923 – Insulin is produced by Eli Lilly

1936 – first slower insulin (NPH type)

• 1955 – Sulfonylureas• 1983 – 2nd generation

of Sulfonylureas• 1997 -

Thiazolidinediones

When lifestyle doesn’t do it (or doesn’t happen)

Medications

• Biguanide• Metformin/biguanide

• Secretagogues• Glucatrol/Glipizide• Amaryl/glimiprimide

• Meglitinides• Prandin/repaglinide• Starlix/nateglinide

• TZD• Actos/Pioglitazaone

• Alpha-Glucosidase Inhibitors• Precose/acarbose• Glyset/miglitol

• GLP-1 (incretins and incretin mimetics)• Byetta/exenatide (BID)• Victoza/liraglutide (1/day)• Bydureon/exenatide (weekly)• Tanzeum/albiglutide (weekly) • Trulicity/dulaglutide (weekly) (11/18)

• DPP-4• Januvia/sitagliptin• Onglyza/saxagliptin• Tradjenta/linagliptin• Nesina/alogliptin

• SGLT-2 (sodium-glucose co-transporter)• Invocana/Canagliflozin• Farxiga/Dapagliflozin• Jardiance/Empagliflozin

• Combination drugs (such as Janumet)• Insulin

• Basal• Bolus• Premixed

When lifestyle doesn’t do it (or doesn’t happen) - 2014

GLP-1 receptor agonists A1C 1-1.5

http://www.globalrph.com/DPP-4-inhibitors.htm

Who should NOT use this medication

• Monitor with renal insufficiency (CrCl < 30 mL/min)• Patients with history or risk of pancreatitis (insufficient

clinical evidence to support this)• Patients with personal or family history of thyroid c-cell

tumors (not seen in humans)• Individuals with stomach or intestinal issues may not be

candidates

DPP-4 inhibitors A1C .5-1http://www.globalrph.com/DPP-4-inhibitors.htm

Who should not use this medication

• Reduce dose in renal insufficiency (with the exception of Trajenta)

SGLT-2 inhibitorsA1C .7-1

Who should not use this medication

• Patients with hypovolemia• Caution with the elderly – especially using diuretics• Patients with GFR below 45 mL/min

(Farxiga/Dapagliflozin) – below 60 mL/min)

Phillips et al, We can change the natural history of type 2 diabetes, Diabetes Care 2014;37-2668-2676

Phillips et al, We can change the natural history of type 2 diabetes, Diabetes Care 2014;37-2668-2676

Medication review

• Cefalu W, Del Prato S, LeRoith D et al. Beyond Metformin: Safety Considerations in the Decision-Making Process for Selecting a Second Medication for Type 2 Diabetes Management: Reflections from a Diabetes Care Editors Expert Forum. Diabetes Care 2014;37:267-2659.

Using technology

Using technology – reading the downloads

Delivering insulin anddiscovering results

• Insulin delivery• Pens - .5 – 1 unit• Pumps (including V-Go)

• U-500 insulin option• Blood glucose results

• Meters• Sensors (additional layer)

Pens, pumps, sensors

14455-AW R2 03/11

Backcountry management: 4 days backpacking

1 a.m 7 a.m. 11 a.m. 1 pm. 3 p.m 6 pm. 9 p.m. 11 p.m.

130

300 169 116 139 136 116

264 180 241 118 201 201 191 142

335 362 346 192 100 145 162 110

339 322 186 115 96 132 144 102

229 214 152

3 Week CGMS

Sensor data

A1C testing

• There is a relationship between frequency of A1C testing and better BG management results• Those testing annually had a 1.5% increase• Those testing every 3 months had a 3.8% decrease • Those who tested more often did not improve beyond the

quarterly checks

Diabetes Care 2014;37:2731-2737

Case #1

• Patient is 54 year old patient with A1C of 8.5%. He has abdominal obesity and is sedentary. No significant joint problems. He works 50 hours per week, and works around the house on the week-ends. He is presently on Metformin and Glipizide. Renal and liver function tests are WNL. He denies symptoms such as frequent urination, thirst, excessive fatigue

• What do you do?

Case #1

• Patient is 54 year old patient with A1C of 8.5%. He has abdominal obesity and is sedentary. No significant joint problems. He works 50 hours per week, and works around the house on the week-ends. He is presently on Metformin and Glipizide. Renal and liver function tests are WNL

• Consider referral to diabetes education – even a 2nd time• Add a medication – which one?• Make sure he is monitoring effectively (pre and post meal)• Have him return for f/u or follow up with SOMEONE in

1-2 weeks

Case #1

• Patient returns 6 months later (having not returned as requested) A1C of 11%. He did not see the educator, and continues to have abdominal obesity and be sedentary. No significant joint problems. He is presently on Metformin and Glipizide and takes the GLP-1 you started him on. Renal and liver function tests remain WNL. He has not been monitoring but now has tingling in his feet, blurry vision and is exhausted all the time. He appears ready to make some changes

• Referral to diabetes education – yet again• Add a medication – which one?• Make sure he is monitoring effectively (pre and post meal)• Have him return for f/u or follow up with SOMEONE in 1-2 weeks.

Consider having an office person follow up with a phone call.

Case #2

• Patient is a 45 year old female. BMI 24. She reports feeling tired and unable to think very well. Some significant thirst. She is active playing hockey in the winter and running and hiking all summer. She has no family history of diabetes, but a finger stick in the office reveals a BG of 376 mg/dl.

Case #2

• Patient is a 45 year old female. BMI 24. She reports feeling tired and unable to think very well. Some significant thirst. She is active playing hockey in the winter and running and hiking all summer. She has no family history of diabetes, but a finger stick in the office reveals a BG of 376 mg/dl.

• What should you do?• Refer to diabetes educator• Start patient on what medication?• Should you consider any specific tests for this patient?

Case #2

• Patient is a 45 year old female. BMI 24. She reports feeling tired and unable to think very well. Some significant thirst. She is active playing hockey in the winter and running and hiking all summer. She eats reasonably, but has lost 20 pounds recently without really trying. She has no family history of diabetes, but a finger stick in the office reveals a BG of 376 mg/dl.

• You check an A1C and it is 10%• You started her on Metformin and glipizide and nothing

happens• What do you do now?

Case #2

• Patient is a 45 year old female. BMI 24. She reports feeling tired and unable to think very well. Some significant thirst. She is active playing hockey in the winter and running and hiking all summer. She eats reasonably, but has lost 20 pounds recently without really trying. She has no family history of diabetes, but a finger stick in the office reveals a BG of 376 mg/dl.

• Back up – • This patient may have LADA and require insulin!• Look at the profile of the patient• Consider referral to endocrinology• THESE PATIENTS ARE FREQUENTLY MISSED!

Conclusion

• Diabetes is a tedious but manageable disease – it takes time and successful monitoring to find the way!• Physical activity • Eating healthfully and moderate, but high quality

carbohydrates• Monitoring• Medications• Technology

• BG evaluation – trends and patterns

QUESTIONS?