8/9/19

1

Successful Type 2 Diabetes Management in Primary Care

September 7, 2019Vanessa Bolyard DNP, APRN, FNP-C

Objectives

▰ Pathophysiology of Type 2 diabetes

▰ Current guidelines in Type 2 diabetes management

▰ Explore different classifications of pharmacological management

▰ Explore non-pharmacological interventions2

Pathophysiology

▰ Diabetes - Group of metabolic disorders of fat, carbohydrates and protein metabolism that results from defects in insulin secretion, insulin action (sensitivity), or both.

3 (DiPiro, 2017)

Ominous Octet

4

* SGLT-2 inhibitor

Current Guidelines

▰ American Diabetes Association (ADA)

▰ American Association of Clinical Endocrinologists (AACE)

5

ADA Algorithm

6

8/9/19

2

7

AACE Algorithm

8

9

Pharmacological Management of Type 2 Diabetes

▰ Biguanides

▰ Sulfonylureas

▰ Thiazolidinediones (TZD)

▰ Dipeptidyl peptidase - 4 inhibitors (DPP-4)

▰ Glucagon-like peptide - 1 agonist (GLP-1)

▰ Sodium glucose co-transporter - 2 (SGLT2)

▰ Insulin10

11

Biguanides: Metformin

▰ Decreases hepatic glucose production and intestinal glucose absorption; increases insulin

sensitivity

▰ Metformin (Glucophage), Metformin XR (Glucophage XR)

▰ Usually first choice in Type II DM

▰ Used in pre-diabetes (HgbA1c 5.7-6.4)

▰ Usually does not cause hypoglycemia

▰ GI upset – start low and

titrate up▰ XR forms have less

GI effects

▰ Can cause decrease in Vit. B12

▰ Avoid in renal impairment

▰ Hold before iodinated

contrast study, may resume 48 hours after if renal function normal

(DiPiro, 2017)12

8/9/19

3

Sulfonylureas

u Binds to the beta-cells of the pancreas and stimulates insulin secretion

u Metabolized CYP450: 2C9

u Glimepiride (Amaryl)

u Glipizide (Glucotrol, Glucotrol XL)

u Glyburide (DiaBeta)

▰ Mainly metabolized CYP450: 2C9

▰ Associated with

photosensitivity

▰ Hypoglycemia is common side effect

▰ Weight gain

▰ Renal insufficiency and liver disease patients

have higher risk of hypoglycemia

13 (DiPiro, 2017)

TZD

u Enhances insulin sensitivity in muscle and fat by increasing glucose

transporter expression and suppress hepatic glucose production

u Pioglitazone (Actos)

u Rosiglitazone (Avandia)

u Weight gain seen

u First generation thiazolidinediones associated

with hepatotoxicity. Newer TZDs used with caution in liver insufficiency

▰ Black box warning: thiazolidinediones cause or exacerbate CHF – especially if

given with insulin

u Controversial studies: Higher MI rates seen with rosiglitazone

(Avandia) but not higher risk of mortality.

u Risk of bladder cancer

higher with pioglitazone (Actos)

14 (DiPiro, 2017)

DPP-4

u Inhibits dipeptidyl peptidase-IV, enzyme that breaks down GLP-1,

thus enhancing GLP-1 effects of glucose dependent insulin

secretion and suppression of glucagon secretion.

u Sitgliptin (Januvia)

u Alogliptain (Nesinsa)

u Saxagliptin (Onglyza)

u Linagliptin (Tradjenta)

▰ Weight neutral

▰ No GI effects

▰ Linagliptin (Tradjenta)

interacts with ACE-I causing increased risk of angioedema

15 (DiPiro, 2017)

GLP-1

▰ Binds to and activates GLP1 receptors resulting in glucose-dependent*

insulin secretion, slowed gastric emptying*, suppression of glucagon

secretion and promotion of satiety.

▰ Daily administration▰ Exentide (Byetta)▰ Liraglutide (Victoza)

▰ Lixisenatide (Adlyxin)

▰ Once weekly administration▰ Exentide Er (Bydureon)▰ Dulaglutide (Trulicity)

▰ Semaglutide (Ozempic)

16 (DiPiro, 2017)

SGLT-2

u Inhibits Na-Glucose cotransporter 2 in the proximal tubule,

reducing glucose reabsorption and increasing urinary

glucose excretion

u Dapagliflozin (Farxiga)

u Canagliflozin (Invokana)

u Empagliflozin (Jardiance)

u Ertugliflozin (Steglatro)

▰ Used in DM II

▰ Promotes weight loss

▰ Do not use with renal

impairment

▰ Higher risk for genitourinary yeast and

bacterial infections

17 (DiPiro, 2017)

Insulin

▰ Basal insulins (long acting)▰ Insulin glargine (Lantus, Basaglar, Toujeo*)▰ Insulin detemir (Levemir)▰ Insulin degludec (Tresiba)

▰ Bolus insulins (short or rapid acting)▰ Insulin lispro (Humalog)▰ Insulin aspart (Novolog)18

(DiPiro, 2017)

8/9/19

4

At Risk

▰ Identify those at risk for developing diabetes

▰ Overweight BMI >=25 kg/m² with one or more of the following risk factors

▰ First-degree relative▰ History of CVD▰ HTN >140/90

▰ HDL level <35 mg/dL and/or triglyceride level >250 mg/dL

▰ Physical inactivity▰ Women with PCOS▰ Women with

history of gestational diabetes

▰ Acanthosis nigricans

19(ADA, 2019)

Non Pharmacological

▰ Lifestyle modifications▰ Diet▰ Exercise▰ Smoking cessation

▰ Additional support▰ Dietician▰ Organizations▰ Support groups▰ Group visits

▰ Prevention▰ Blood pressure control▰ Lipid management▰ Chronic kidney disease▰ Retinopathy▰ Neuropathy

20

21

Assess Key Patient

Characteristics Consider Specific Factors That

Impact Choice of Interest

Shared Decision Making to Create a Management Plan

Agree on Management PlanImplement Management Plan

Ongoing Monitoring and Support

Including

Review and Agree on Management Plan

Goals of Care:Prevent Complications Optimize Quality of Life

(ADA, 2019)

Key Points

▰ HgbA1c is not just average blood glucose, can tell when the glucose is rising most and where the “problem” area is

▰ Look at fasting and postprandial glucose levels

▰ Closer HgbA1c is to goal – more of the HgbA1c is postprandial glucose▰ HgbA1c < 7.3% - 70% of the number accounts for postprandial glucose

22(Monnier & Colette, 2006)

Key Points

▰ Post prandial glucose levels most appropriate in determining cardiovascular risks

▰ ASCVD – coronary heart disease, cerebrovascular disease or peripheral arterial disease – leading cause of morbidity and mortality for individuals with diabetes

23

(Cabalot et. al., 2006)

(ADA, 2019)

Key Points

▰ Assessing patient’s current condition along with co-morbidities guides pharmacological interventions▰ Contraindications for kidney disease and cardiovascular disease▰ Potential benefits for kidney disease and cardiovascular disease▰ Risk of hypoglycemia▰ Weight gain or loss▰ Side effects▰ Cost

24

8/9/19

5

Key Points

▰ Most success comes from an agreed, thoughtful, individualized plan between provider and patient.▰ May be some compromise

▰ Must explore patient’s willingness and ableness with:▰ Disease Process▰ Prevention▰ Medications▰ Food▰ Activity 25

References▰ American Diabetes Association. (2019). Standard of medical care in diabetes – 2019 abridged for primary care providers. Clinical Diabetes,

37(1). Retrieved from https://clinical.diabetesjournals.org/content/37/1/11

▰ Arcangelo, V. P., Peterson, A. M., Wilbur, V. & Reinhold, J. A. (2017). Pharmacotherapeutics for advanced practice: A practical approach, 4th Ed., Wolters

Kluwer: Philadelphia, PA.

▰ Cabalot, F., Petrelli, M., Traversa, K., Bonomo, e., Fiora, M., Conti, M….Trovati, M. (2006). Postprandial blood glucose is a stronger predictor of

cardiovascular events than fasting blood glucose in type 2 diabetes mellitus, particularly in women: Lessons from the San Luigi Gonzago diabetes

study. Journal of Clinical Endocrinology & Metabolism, 91(3).

▰ DiPiro, J. T., Talbert, R. L., Yee, G. C., Matzke, G. R.. Wells, B. G. & Posey, L. M. (2017). Pharmacotherapy: A pathophysiologic approach,

10th Ed., Mcgraw Hill: New York, NY.

▰ Garber, A. J., Abrahamson, M. J., Barzilay, J. I., Blonde, L., Bloomgarden, Z. T., Bush, M. A….Umpierrez, G. E. (2019). Consensus statement by the American

association of clinical endocrinologists and American college of endocrinology on the comprehensive type 2 diabetes management algorithm –

2019 executive summary. Endocrine Practice 25(1). doi.org/10.4158/CS-2018-0535

▰ Kuritzky, L., Reid, T. S. & Wysham, C. H. (2019). Practical guidance on effective basal insulin titration for primary care providers. Clinical

Diabetes May, https://doi.org/10.2337/cd18-0091

▰ Monnier, L. & Colette, C. (2006). Contributions of fasting and postprandial glucose to hemoglobin A1c. Endocrine Practice, 12(Sup. 1).

26