ManagingType2DiabetesinSpecialPopulations

Patient‐CenteredTreatmenttoImproveOutcomes

DaleC.Moquist,MDTexasFamilyMedicineSymposiumJune5,2016

ExpertPanelIldikoLingvay,MD,MPH,MSCSAssociateProfessor,DepartmentofInternalMedicine/DivisionofEndocrinologyDepartmentofClinicalSciencesUniversityofTexasSouthwesternMedicalCenterDallas,TX

JerryMcCauley,MD,MPH,FACPRobertCapizziProfessorofMedicine;Director,DivisionofNephrologySidneyKimmelMedicalCollageatThomasJeffersonUniversityPhiladelphia,PA

EverettSchlam,MDAssistantDirector,MountainsideFamilyPracticeResidencyProgramClinicalAssistantProfessor,DepartmentofFamilyMedicineUMDNJ– NewJerseyMedicalSchoolVerona,NJ

PennyTenzer,MD,FAAFPProfessor,ofClinicalFamilyMedicine;ViceChairofAcademicAffairs;DirectorofCMEandMedicalEducation;ChiefofService,FamilyMedicineUniversityofMiamiMillerSchoolofMedicineMiami,FL

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DisclosuresIldikoLingvay,MD,MPH,MSCS,hasreceivedconsultingfeesfromAstraZenecaandJanssenPharmaceuticals.JerryMcCauley,MD,MPH,FACP,reportsnofinancialrelationships.EverettSchlam,MD,hasreceivedconsultingfeesfromGalderma.PennyTenzer,MD,FAAFP,hasreceivedconsultingfeesfromAstraZenecaandExactScience.

TheresaBarrett,PhD,JackDouglass,CharlesGoldthwaite,PhD(Planners)andEverettSchlam,MD(reviewer)reportnofinancialrelationships.

ConflictshavebeenresolvedaccordingtoNJAFPpolicy.

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SpeakerDisclosure

Dr.Moquisthasdisclosedthathehasnoactualorpotentialconflictofinterestinrelationtothistopic.

Wewillusegenericnamesformedicationswithtradenamesinparentheses

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Support

Thisprogramissupportedbyaneducationalgrantfrom

JanssenPharmaceuticals,Inc.,administeredby

JanssenScientificAffairs,LLC.

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LearningObjectives• Employculturallycompetent,patient‐centeredtreatmentstrategiestomanagetype2diabetesinelderly,overweight/obese,orLatino/Latinapatients.

• Employstrategiestoovercomebarriersthattraditionallyinhibittheinitiationofcareinthesepopulations.

• Designsafeandeffectivetreatmentstrategiesthataretailoredtotheindividualneedsofpatientsinthesepopulations.

• Integrateemergingantihyperglycemicagentsintopatient‐centeredtype2diabetesmanagementplansforpersonsinthesepopulations.

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Housekeeping

• Completethepre‐testquestionsnow.• Thereisaspacetorecordyouranswersforthecasestudy.

• Completethepost‐testattheendofthesession.• Completetheevaluationformandclaimyourcredit.

• Returntheformtoastaffmemberorattheregistrationdesk.

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TheImpactofType2Diabetes

TheDiabetesEpidemic• ~29millionindividualsntheUShavediabetes(8.1millionareundiagnosed).1

• 7th leadingcauseofdeathintheUS1

• InTexas2• Acrossallraces– 10.6%ofadultshavediabetes

• AmongHispanics– 11.6%havediabetes

Sources: 1CDC. National diabetes statistics report, 2014; 2  2012 Diabetes Fact Sheet—Texas, www.dshs.state.tx.us

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ComplicationsofType2Diabetes

HeartCoronaryarterydiseaseCardiovasculardisease

BloodVesselsPeripheralarterydiseaseIntermittentclaudication

KidneysMicroalbuminuriaNephropathy

NervesNeuropathyGastroparesis

HyperglycemiaHyperglycemia

EyesRetinopathyGlaucoma

Source: ADA.DiabetesCare.2010;33(Suppl1):S11‐S61.

Type2DiabetesisLinkedwithCVDRiskFactors

• Obesity• Insulinresistance• Hypertension• Dyslipidemias

Sources: AmericanDiabetesAssociation.DiabetesCare2016;39(Suppl1):S23‐S35;NationalCholesterolEducationProgram(NCEP)AdultTreatmentPanel(ATP)III.Circulation 2002;106:3143‐3421.

IdentificationofoneCVDriskfactorshouldpromptthesearchforothersandpromptthehealthcareprovidertobeginproactive,aggressivetreatmenttoreduceCVDrisk.

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EstablishingGlycemicControlisEssentialtoManageDisease

• Microvascularandmacrovascularbenefitsareassociatedwithglycemiccontrol.1‐8

• Targetglucoselevelsshouldbeindividualized.

• Hypoglycemiashouldbeavoided.

Sources: 2000;321:405‐12;4DiabetesControlandComplicationsResearchGroup.NEnglJMed1993;329:977‐86;5DCCT/EpidemiologyofDiabetesInterventionsandComplicationsResearchGroup.NEnglJMed2000;342:381‐89;6GaedeP,etal.NEnglJMed2003;348:383‐93;7LawsonML,et.al.DiabetesCare1999;22(suppl2):B35‐B39;8NathanDM,etal.NEnglJMed2005;353:2643‐53.

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AmericanDiabetesAssociationGlycemicRecommendations

Source: AmericanDiabetesAssociation.DiabetesCare2016;39(Suppl1):S39‐S46.

A1c <7.0%

Preprandialplasmaglucose 80‐130mg/dL

Peakpostprandialplasmaglucose <180mg/dL

Individualizebasedonage/lifeexpectancy,durationofdiabetes,comorbidities,knownCVDoradvancedmicrovascularcomplications,hypoglycemiaunawareness,andpatientpreferences.Moreorlessstringentgoalsmaybeappropriateforsomepatients.

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EstimatedAverageGlucose(eAG)

• HemoglobinA1C:MaySeemArbitrarytoPatients

• AmericanDiabetesAssociationRecommendstheuseofeAG:Expressedasmg/dl.

• Formula:– 28.7XA1C—46.7=eAG

DiabetesCare2008;31:1473‐1478

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A1C &CorrespondingeAGHemoglobinA1C % eAG(mg/dl)

6 1266.5 1407 1547.5 1698 1838.5 1979 2129.5 22610 240

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DesigninganEffectiveInterventionforType2Diabetes

LookingBeyondA1c

• Cardiovascularriskmanagement(e.g.,hypertension,dyslipidemia,microalbuminuria)

• Normalizingbloodglucoselevel• Patientpreferencesandindividualizedgoals

• Lifestyleinterventions(diet,activity)foroverweight/obeseindividualsgearedtowardaninitiallossof5‐10%ofbaselinebodyweight

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ComponentsofaDiabetesManagementProgram

MedicalNutritionTherapy

DiabetesSelf‐ManagementEducation

Pharmacotherapy

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WhatisDiabetesSelf‐ManagementEducation(DSME)?

• Aninteractive,ongoingeducationalprocesstohelppatientsmakeinformedself‐managementdecisions

• Patientreceivesindividualassessmentandidentifiespersonalself‐managementgoals

• Patientandeducatordevelopplanwithinterventionsandperiodicreassessment

• Providermustconsiderpatient’sattitudeandbeliefsaboutdiabeteswhentailoringastrategy

Source: ADA.DiabetesCare2016;39(Suppl1):S23‐S35.

ADADSMECriteria• Describingthediabetesdiseaseprocessandtreatmentoptions• Incorporatingnutritionalmanagementandphysicalactivityintolifestyle

• Usingmedicationssafelyand formaximumtherapeuticeffectiveness

•Monitoringbloodglucose andotherparametersandinterpretingtheresultsforself‐managementdecision‐making

• Preventing,detecting,andtreatingacuteandchroniccomplications

• Developingpersonalstrategiestoaddresspsychosocialissues/concernsandtopromotehealthandbehaviorchange.

Source: HaasL,et.al.DiabetesCare2014;37(Suppl1):S144‐S153.

MedicalNutritionTherapy

• OptimizeBGcontrol• Improvebloodlipids• Controlbloodpressure

Achieveconsistentcarbohydrateintake

Monitorbloodglucoseto

adjusttherapy

Achievemodestweightloss

Increasephysicalactivity

Mealtiming/portioncontrol

Modifyfatandcaloriecontent

Source: HaasL,et.al.DiabetesCare2014;37(Suppl1):S144‐S153. 21

LifestyleModifications• Modestweightloss(5‐10%ofbodyweight)lowersriskforCVDandtype2diabetes1‐2

• Lossmaybeachievedandmaintainedsafelybycombiningdietaryadjustmentsandregularphysicalactivity

• Mustbetailoredtothepatient’sneeds• Oftenrequireadjustmentsforoptimization• Theprovidermusttakeanactiveroleindesign

Sources: 1RatnerR,et.al.DiabetesCare 2005;28:888‐894;2DiabetesPreventionProgramResearchGroup.NEnglJMed 2002;346:393‐403. 22

CaloricIntakeandBalancedDiet

• Caloricbalanceisthemajordeterminantofweightloss

• Caloricintakemustbereducedmoderatelyandgradually

• Vitaminsupplementsmaybenecessary• Nutritionalbalanceandweightmanagementarecomplementarygoalstoweightloss

Source: RosenbaumM,et.al.NEnglJMed1997;337:396‐407. 23

PromotingHealthyWeightLoss

3,500caloriesOnepoundofadiposetissue

Deficitof500‐1,000cal/day

Lossof1‐2lbs/week

Sources: RosenbaumM,et.al.NEnglJMed1997;337:396‐407;NHLBI.NationalHeartLungandBloodInstitute.ManagingOverweightandObesityinAdults:SystematicEvidenceReviewfromtheObesityExpertPanel;2013.

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Take‐HomeIdeasforthePatient• Drinkaproteinshakeforbreakfastratherthansodasorjuice

• Plan/preparemealsathomevstake‐out• Payattentiontoportion/servingsizes• Selecthigh‐fiberfoodswhenpossible• Choosebroiled,boiled,orsteamedfoodinsteadoffried

• Considercalorie‐controlledmealsaspartofanoveralldiet.

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BenefitsofPhysicalActivity

• DecreasesriskforCVD,type2diabetes,dyslipidemiaofoverweightandobesity

• Gradedlipoproteinresponse(triglycerides,LDL,HDL)• Increasesmetabolicrate• Increasesmusclemass

Sources: RatnerR,et.al.DiabetesCare 2005;28:888‐94;WeiM,et.al.JAMA1999;282:1483‐492;TuomilehtoJ,et.al.NEnglJMed 2001;344:1343‐50;KrausWE,et.al.NEnglJMed 2002;347:1483‐92. 26

PhysicalActivityRecommendations

• Evaluatepatientforcardiovascularfitnesspriortocommencement

• Stressthatactivitymustbebalancedwithdiet• Targetregimentopatient’sbaselinefitnessandactivitylevel

• Suggest30minutesofmoderatelyvigorousphysicalactivity,performeddaily

• Stressthatactivityaccumulates duringday

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IncorporatingActivityIntoDailyRoutines

• Usestairsinsteadofelevator• Parkfartherawayfromworkorshopping• Walkatlunchtime• Exitpublictransportationonestopaheadofusual• Useapedometertocountsteps• Limittelevisionviewingto1hour/day• WhenwatchingTV,standorwalkduringcommercials

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SpecialConsiderationsfortheElderly

• Tailoredexerciseprescriptionsarehighlyeffectivefortheelderly– Improvedglycemiccontrol– Improvedindependence,self‐esteemandqualityoflife

• Forfrailandvulnerablefocusonresistiveactivities– Lightweights(cannedgoodsorwaterbottles)

• Moderatetohighintensityexerciseisgenerallyconsideredsafe• Balanceexercisesmayprovebeneficial• Caution– beawareof:

– Higherpossibilityofhypoglycemia(especiallywithinsulin)– Orthostatichypotensionthatmayworsenbydehydration– Contraindicationsforthepracticeofeachexercise– Interactionsandlimitationsimposedbymedications– Geriatricsyndromesandchroniccomorbidities

Source: Ferriollietal.2014.DiabetesandExerciseintheElderly.InJ.H.Goedecke&E.O.Ojuka(Eds.),DiabetesandPhysicalActivity.Basel:Karger.

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SharedDecision‐MakinginDiabetesManagement

• Personalizedmanagementplan• Self‐managementeducation• Adherencetotreatment• Appropriatefollow‐upandmonitoring

Source: InzucchiSE,etal.DiabetesCare2015;38:140‐49.

TheADA/EASDrecommendationssupportashareddecision‐makingapproachthatappliestoprimarycarepractices.

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ManagementRequiresActivePatientParticipation

• Maintaindailydiet/exercisediary• Identify/avoidcompromisingsituations

• Establishaself‐managementplanbasedonwhatthepatientfeelscanbeconfidentlyachieved

• Recognizesuccessatfollow‐upvisits

• Setrealisticgoalsbasedonpatientinput

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PharmacotherapyConsiderations

Pharmacotherapy

• Sulfonylureas(SUs)• Metformin• Thiazolidinediones(TZDs)• Dipeptidylpeptidase‐4(DPP‐4)inhibitors

• Sodium‐glucosecotransporter‐2(SGLT2)inhibitors

• Glucagon‐likepeptide(GLP‐1)receptoragonists

• Insulin•Rapid‐acting•Short‐acting•Intermediate‐acting•Long‐acting(basal)

OralAntihyperglycemics

ParenteralAgents

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AvoidingHypoglycemia• Mayoccursuddenly• Symptomsincludehunger,dizziness,confusion,palpitations

• Severehypoglycemiacanleadtoseizuresorcoma• Maycausefalls,motorvehicleaccidents,orinjury• Treatedbyingestingglucose‐ orcarbohydrate‐containingfoods

“Severeorfrequenthypoglycemiaisanabsoluteindicationforthemodificationoftreatmentregimens,includingsettinghigherglycemicgoals.”1

Source: 1ADA.DiabetesCare2016;39(Suppl1):S39‐S46. 34

HypoglycemiaandtheElderly• Hypoglycemiacanprofoundlyimpactelderlypatients,whomaybeparticularlyvulnerabletoitsconsequences:• Limitedcapacitytorecognizesymptoms• Clinicalcomplicationsandcomorbiditiesthatcanbeexacerbatedbyhypoglycemia.

• Elderlypatientswhoexperiencehypoglycemicepisodesmayriskpotentiallyseriousphysicalinjuryfromfallsorotheraccidents.

Source: ADA.DiabetesCare2016;39(Suppl1):S81‐S85. 35

CommonAgents:WeightandHypoglycemiaRisk

Source: ADA.DiabetesCare2016;39(Suppl1):S52‐S59.

AgentClass EffectonWeight HypoglycemiaRiskMetformin Neutral/loss LowSulfonylurea Gain ModerateThiazolidinedione Gain LowDPP‐4Inhibitor Neutral LowSGLT2Inhibitor Loss LowGLP‐1 agonist Loss LowInsulin Gain High

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Metformin

• ExtensiveExperience• NoHypoglycemia• GISideEffects:Cramping&Diarrhea• VitaminB12 Deficiency• LacticAcidosisRiskisRare

– UseeGFRtoEstimateRenalFunction– DoNotUseSerumCreatininetoEstimateRenalFN– SafeLevelisGFR>30ml/min

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MetformininCKD

CKDStage eGFR Maximum TotalDailyDose

1and2 60 2550mgm

3A 45‐60 2000mgm

3B 30‐45 1000mgm

4 15‐30 DoNotUse

5 <15 DoNotUse

38Source:InzucchiS.MetformininPatientsWithType2DiabetesandKidneyDisease:ASystematicReview.JAMA2014;312(24):2668‐2675.

Thiazolidinediones• Maycauseedema1

• Associatedwithhigherriskofheartfailureinadultswithoratriskfortype2diabetes1

• IncreaseRiskofBoneFracturesinWomen• PioglitazoneassociatedwithreductioninCVevents(MI,stroke,mortality)inPROActivestudy(n=5,238)2

• NoEvidenceofBladderCancer

Sources:1HernandezAV,et.al.AmJCardiovascDrugs2011;11:115‐128;2DormandyJA,etal.Lancet2005;366:1279‐1289.

UseclinicaljudgementwhenconsideringTZDsforpatientswithtype2diabetes,especiallyinthesettingofpreexistent

congestiveheartfailure.

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SGLT2Inhibitors• BlocksGlucoseReabsorptioninNephron• IncreaseinUTIsandGenitalMycoticInfections• EMPA‐REGOUTCOMEtrial(n=7,020)ofindividualswithtype2diabetesatriskforCVevents

• Comparedtoplacebo,empagliflozinwasassociatedwithlowerratesof:• PrimarycompositeCVoutcome• Deathfromanycause

• ThisrelationshipcurrentlyunderinvestigationforotherSGLT2inhibitors

Source:ZinmanB,et.al.NEnglJ Med2015;373:2117‐2128. 40

SGLT‐2Inhibitors• DiureticEffect:WatchforDehydration

– EspeciallyinElderly• DecreaseWeightandBloodPressure• IncreaseHDLCholesterol• CurrentMeds:

– Canagliflozin:IncreasedFractures– Dapagliflozin– Empagliflozin:DecreasedRiskofCVDeath

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SGLT2Inhibitors:SafetyWarning

• OnMay15,2015,theUSFDAissuedasafetywarningstatingthatSGLT2inhibitorsmayleadtoketoacidosis.

• OnDecember4,2015,thiswarningwasextendedtoincludeseriousurinarytractinfections(UTIs).

Sources: USFDA.http://www.fda.gov/Drugs/DrugSafety/ucm446845.htm(May15,2015); http://www.fda.gov/Drugs/DrugSafety/ucm475463.htm(December4,2015).

• Nochangestotheprescribinginformationweremadewiththeseannouncements.

• FDArecommendsthatcliniciansevaluatepatientsforacidosisorseriousUTIsanddiscontinueSGLT2inhibitorsifconfirmed.

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DipeptidylPeptidase4Inhibitors• NoHypoglycemia&WeightNeutral• NoOverallCardiovascularRiskorBenefit• WellTolerated:PossibleBenefitinElderly• UseCautiouslyinPatientsWithHXofHF• SideEffects:URI,SoreThroat,Diarrhea,Pancreatitis

• Meds:– Sitagliptin– Saxagliptin– Linagliptin– Alogliptin

Source:FDAIssuedWarningonSaxagliptin&AlogliptinCausingHeartFailureinCertainPatients.April5,2016. 43

GLP‐1ReceptorAgonists• ActivatesGLP‐1Receptors&IncreasesInsulin

• SlowsGastricEmptying• LessHypoglycemiaRiskThanInsulin• WeightLoss• DecreaseinPostprandialGlucose• SideEffects:Nausea,Vomiting,Diarrhea,Hypoglycemia,Pancreatitis,ThyroidTumor

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GLP‐1Agonists• Injectable:AdjustForRenalClearance• Expensive• DifferentProducts

– Exenatide:GivenBID– Liraglutide:LicensedforWeightLoss– Albiglutide:WeeklySC– Dulaglutide:WeeklySC

• LowerHgbA1CButnoChangeinVascularOutcomes

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PossibleOptionsWithMetformin• DoNOTUseLASulfonylureas:Hypoglycemia• AddDPP‐4

– NoHypoglycemicRisk– UseCautiouslyinPatientsWithHF

• AddSGLT2Inhibitors– DemonstratedEfficacy– ClinicalExperience:WeightLoss– DoNotUseWithGLP‐1

• MayTryThiazolidinedione– HighEfficacy,LowHypoglycemicRisk,&Generic– WatchforEdema,HF,&Fractures

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Source:InzucchiSEetal.DiaCare2015;38:140‐149

©2015byAmericanDiabetesAssociation47

DeliveringCulturally‐InformedCare:TheProvider‐PatientPartnership

TheCulturally‐InformedOffice• Language‐ andtopic‐appropriatematerials• Stafftomatchpopulationserved• Bilingualorlanguage‐appropriatewallpostersandsigns• Writtentextgearedforcomprehension• Atrainedmedicalinterpreteroraccesstointerpretationservices

• Stafftrainedtoovercomeculturalmisconceptions• Recognitionofculturally‐observedholidays

Establishingaculturally‐informedofficeisthefirststeptowardprovidingculturally‐appropriatecare.

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EffectofRegularPrimaryCare• 2138DiabeticPatients• FollowedFrom1995thru2010• SouthcentralFoundation:NonprofitHealthCorporation• GivePrepaidPrimaryCareto60,000AlaskanNatives• 60%Female&AverageAgeof52atFirstEncounter• RegularPrimaryCare:AtLeast1VisitQ6MonthsFor2Consecutive6‐MonthIntervals

• 89%IncreasedLikelihoodofBPControl• 177%IncreasedLikelihoodofGlycemicControl• IncreasingtheDistanceby10MilestoRPCReducedLikelihoodofRegularPrimaryCare

50Source:SmithH.TheEffectofRegularPrimaryCareUtilizationonLong‐TermGlycemicandBloodPressureControlinAdultsWithDiabetes.JABFMJanuary‐February2015;28:28‐37

ConsiderationsforProvidingCulturally‐AppropriateCare(1)

• Educationlevelandhealthliteracy(e.g.,abilitytounderstandconcepts)

• Familyintegrationandsupportsystems(church,community)

• Culturaljudgmentsaboutdiseaseandnormsregardingbodyimage

• Knowledgeaboutdiabetes• Learningstylesandmotivationalstrategies

Source: JuckettG.AmFamPhysician 2013;87:48‐54.

ConsiderationsforProvidingCulturally‐AppropriateCare(2)

• Spiritualbeliefs(e.g.,beliefthateventsarepredeterminedbyfate)

• Nutritionalpreferences• Alternative/herbalpracticesandfolkremedies• Languageissues

Source: JuckettG.AmFamPhysician 2013;87:48‐54.

PartneringwithMinorityPatients

Culturally‐informedcareisbasedonapartnership betweenthepatientandthe

healthcareprovider.

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PartneringwithMinorityPatients• Appreciatevaluesystemassociatedwithpatient’sculturalheritage

• Emphasizeholisticcarebyrecognizingbiologic,psychologic,andfaith‐basedcomponents

• Provideframeworktounderstandlevelofdiseaseseverityandrealistictreatmentoptions

• Promotetrustthroughengagedattitude• Avoidpaternalisticstance

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Cross‐CulturalInterviewing• Establishtrustthrough“smalltalk”• Useopenbodylanguage• Speakslowlyanddirectlytothepatient(ratherthantotheinterpreter)

• Useshortsentencesandanormaltoneofvoice• Avoiduseofidioms• Askpatientswhatillnessmeanstothemandabouttheircurrenttreatments

• Providetreatmentinstructionsinwriting• Havepatientrepeatinstructionsinhis/herownwords

Source: JuckettG.AmFamPhysician 2005;72:2267‐2274. 55

Cross‐CulturalInterviewQuestions

• Whatisyournativecountry?• Howlonghaveyoubeenhere?• Whatdoyouthinkiswrong?• Whatdoyoucalltheillness?• Whatdoyouthinkhascausedtheillness?• Whydoyouthinkthattheillnessbeganwhenitdid?• Whatproblemsdoyouthinkthattheillnesscauses?

Source: JuckettG.AmFamPhysician 2005;72:2267‐2274. 56

Cross‐CulturalInterviewQuestions

• Howsevereisyourillness?• Whatkindoftreatmentdoyouthinkisnecessary?• Whatarethemostimportantresultsyouhopetoreceivefromthistreatment?

• Whatdoyoufearmostabouttheillness?• Howdoyoucopewithyourfeelings?• Whatcanyouchange?• Whattypesofsupportdoyouhavetohelpyoudealwiththisillness?

Source: JuckettG.AmFamPhysician 2005;72:2267‐2274. 57

The“Teach‐Back”Approach

“Teachingback”Havethepatientrepeatyourstatementsintheirownwords.

• Assessespatient’shealthliteracyandlanguageproficiency

• Promotesunderstandingofculturalissues

• Mayfacilitateadherencetoanintervention.

Source: JuckettG.AmFamPhysician 2013;87:48‐54. 58

DeliveringCulturally‐InformedCaretoLatinoPatients

• Listenforsomaticpresentationofcomplaints• Recognizethatdiseasemaybeperceivedasinternal/externalimbalance(e.g.,bodyandsoul)

• Beawareoffolk‐healingtraditions• Incorporatesupportsystemsintotreatment(family,clergy,socialworkers,counselors)

• Recognizecentralroleofmalefamilymembers• Providetrainedmedicalinterpreterwhenneeded

Source: JuckettG.AmFamPhysician 2013;87:48‐54. 59

CommonLatinoSomaticComplaints• Nervios (nerves;nervous,tense,irritable)• Débil (fearofbecomingweak)• Sofocada/sofocado (shortnessofbreath;outofbreath;chestpressure)

• Nerviosa /nervioso(tense,nervous)• Dolordecerebro(headache)• Empacho (stomachache;bellypain)• Malaire(“badair”;abnormalcirculationofairinthebodyasacauseofdisease)

• Susto (“soulloss”;fright;changesinappetite;difficultysleeping;headache)

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OnlineResourcesOrganization URL

AmericanDiabetesAssociation www.diabetes.org

AmericanAcademyofFamilyPhysicians www.aafp.org

AmericanAssociationofDiabetesEducators www.diabeteseducator.org

AmericanAssociation ofClinicalEndocrinologists www.aace.com

AcademyofNutritionandDietetics www.eatright.org

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CaseStudyMartin

CaseStudy:Martin• 65‐year‐oldHispanicnotdiagnosedwithdiabetes(BMI=35.0kg/m2)

• CurrentlytakesACEinhibitorandcalcium‐channelblocker

• Frequentlywakesatnighttourinate• Recentlylostthreepounds• Doesnotwantmedicationthatcausesweightgain

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CaseStudy:Martin

Martin’slaboratoryworkupvaluesinclude:• A1c:9.2%• Randomplasmaglucose:229mg/dL• Bloodpressure:130/80mmHg• eGFR:79mL/min/1.73m2

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CaseStudy:Martin

1.AccordingtoADAguidelines,whichofthefollowingisareasonableA1c goalforMartin?

1. 5.8%2. 6.0%3. 6.5%4. 7.0%5. 8.0%

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CaseStudy:Martin2.HowshouldyouinitiallycounselMartinatthispoint?

1. HelphimlocateaCertifiedDiabetesEducatorandadietitian

2. Discussimportanceofmaintainingahealthylifestyle

3. Tellhimthathewilllikelyneedtoincorporatepharmacotherapytomanagehisdisease

4. Askaboutsymptomsofdiabeticketoacidosis5. Alloftheabove

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CaseStudy:Martin

Martinreportsthatheismotivatedtomanagehisweightandgetintoshape,ashehasrecentlybegundatingayoungerwoman.Healsostatesthathe“coulddobetter”withregardtohisdiet,andhedrinkssixsodasperdaywhileatwork.Youaskhimaboutthetypesofactivitythatheenjoys.

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CaseStudy:Martin

1. Takingthestairsratherthantheelevatoratwork2. Parkingfartherawayfromthebuildingatwork3. Considerjoiningalocalsportsleague4. Wearingapedometerorfitnesstrackertomeasure

stepsperday5. Alloftheabove

3.Whatcouldyourecommendforhimtoincorporatephysicalactivityintohisdailyroutine?

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CaseStudy:Martin

AlthoughyouwillconnectMartinwithaCDEforacomprehensivenutritionevaluation,youalsorecommendseveralsmalladjustmentstohisdiet,suchasswitchingfromsodatocoffeeortea,limitingfast‐foodintakeandsnacks,andcontrollingportionsizeswheneatingatrestaurants.Thisisalsoagreattimetodiscussoptionsformedications.

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CaseStudy:Martin4.WhichofthefollowingclassesofantihyperglycemicagentsareNOT associatedwithweightgain?

1. Sulfonylurea2. SLGT2inhibitor3. Thiazolidinedione4. Metformin5. 2 and4only

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CaseStudy:Martin5.BasedonMartin’sstatus,whichofthefollowingisasuitableinitialinterventiontohelpMartinmanagehisdiabetesandlowerhisCVDrisk?

1. Nochangesatpresent2. Lifestylechangesonly3. Lifestylechangesplusmetformin4. Lifestylechangesplusmetforminandasecond

agent5. Lifestylechangesplusbasalinsulin

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CaseStudy:Martin

Yourecommenddualtherapy,butMartinoptsinitiallyformetforminonly.YouscheduleaconsultwithaCDEinoneweekandfollowupwithMartininthreemonthstoassesshisprogress.

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CaseStudy:MartinAthisfollow‐upvisit,Martinhaslostfivepounds,andhisA1c isnow8.3%.Hereportsnoadditionalpolyuriaornocturia.Goingforward,youshouldconsiderthefollowingwithMartin:• Initiateasecondagenttosustainhismomentum,offeringseveraloptions,dependinguponwhetherhewishestouseanoralorparenteralagent.

• Scheduleafollow‐upvisitinthreemonths

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Conclusions• Achievingglycemiccontrolisessentialtomanagediabetesanditscomplications.

• Managementismulti‐facetedandinvolvesbehavioralmodificationsandinterdisciplinarycare.

• TreatmentmustbeindividualizedandaimedatadditionalfactorsthataffectCVhealth(e.g.,bloodpressure,lipidprofiles,weight).

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Conclusions

• Hypoglycemicepisodesshouldbeminimized.• Patientsshouldbeinvolvedinthediseasemanagementprocessasearlyaspossible,informedwithculturally‐appropriateconsiderations.

• Attentivenesstospecificpatientcharacteristicswillhelptheproviderdesigneffectiveinterventions

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MedicationsGeneric TradeName

Canagliflozin InvokanaDapagliflozin FarxigaEmpagliflozin JardianceSitagliptin JanuviaLinagliptin TradjentaAlogliptin NesinaExenatide ByettaLiraglutide VictozaAlbiglutide TanzeumDulaglutide Trulicity

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Questions

TolearnmoreaboutdiabetesmanagementinspecialpopulationsandearnadditionalCME

credit,visit

www.njafp.org/education

Don’tforgottocompleteyourevaluationandclaimcredit.Returnthecompletedformtoastaffmember.

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