4.23.2010Diabetes

8/13/2019 4.23.2010Diabetes

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Clinical Update in Type 2 Diabetes

• A Case Discussion

• Dr. Yancey R. Holmes, MD, FACE

• Ohio Valley Endocrinology

8/13/2019 4.23.2010Diabetes


Topics for Discussion

Glycemic Targets

Therapeutic Agents

Case Discussion

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Glycemic Targets

American Diabetes Association

American Association of Clinical

EndocrinologistsHbA1c

Fasting glucose

Post prandial glucoseHypoglycemia

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Pharmacologic Agents

Sulfonylureas and Meglitinides

Metformin

Alpha-glucosidase InhibitorsThiazolidinediones

Dipeptidyl Pepdidase-4 Inhibitors

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Welchol

Incretin Mimetic

GLP-1 AgonistsGLP-1 AnalogsAmylin Analogs

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Human Insulin

Regular

NPHAnalog Insulin

Rapid

BasalMix

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Special Considerations

Heart Disease

Renal Impairment

Liver DiseaseFrailty

Weight Gain

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Case Discussion

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Case 1

56 year old man referred by cardiologist

Diabetes diagnosed during hospitalization

for acute MI associated with pulmonary

edema

BMI 32 NYHA Class III functional status

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Case 1

HbA1c 8.6%

Serum creatinine 1.3

Discloses that he “ain’t takin’ no damn

shots!”

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Case 1 Discussion

Drug naive patient with ischemic heart

disease and systolic dysfunction

Confrontational needle-phobe

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Case 1

Metformin: Will it get to goal?

Sulfonylurea: Hypoglycemia concerns?

TZD’s: Fluid retention?

DPP-4 Inhibitors?

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Case 2a

42 year old woman referred by friend

Strong family history. Symptoms of post

prandial fatigue.

Currently at her highest body weight.

Exercise is infrequent

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Case 2a

Metformin

Sulfonylurea

TZDDPP-4

Injections???

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Case 2b

After successful adoption of healthy lifestyle

changes and metformin she maintains

HbA1c less than 6.5% over the next three

years

She presents for follow up to discuss

options to address weight gain and diabetes

BMI 32

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Case 2b

9 months ago HbA1c 7.3%

Metformin was titrated to 1000 mg bid


Back on track with exercise and associated 6

pound weight loss

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Case 2b


Recent job change, stressed out. Feels

certain she can get back on track withoutadditional medicaiton

Now HbA1c 7.8%

Weight is up 12 pounds from last visit

Very frustrated with weight gain and

constant hunger

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Case 2b

Metformin titration to 2500 mg?

Addition of Sulfonylurea?

Addition of TZD?Addition of DPP-4 Inhibitor?

Addition of Basal Insulin

Addition of a GLP-1 Agent

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Case 3a

40 year old man currently on Metformin

and SU maximal dose

FBG 160-180

PPG 160-200

HbA1c 8.2%

BMI 27

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Case 3a

Addition of third oral agent?

Addition of GLP-1/Amylin

Introduction of insulin?

Human vs. Analog?

What kind of dosing regimen?

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Case 3b

Addition of basal insulin helped maintain

good glycemic control over the next 18

months

Now HbA1c 7.8%

FBG 100-140

PPG 180-220

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Case 3b

Oral agents?

Mealtime insulin

Mealtime amylin

Should anything be discontinued?

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Case 4a

38 year old man presents forassessment after family member testsa blood sugar of 400

He has already adopted many gooddietary changes and saw the educatorat the health department

Blood sugars range from 180-250HbA1c 9.8%

BMI 31

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Case 4a

Metformin with continued lifestyle

modification?

Combination agent?

Insulin?

GLP-1/Amylin?

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Case 4b

After 5 years of maintaining HbA1c <7% on

combination Metformin+TZD blood sugars

are elevated

HbA1c 8.2%

15 pound weight gain over past 3-6 months

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Case 4b

Third oral agent?

Insulin?

GLP-1/Amylin?

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Case 5

60 year old woman with type 2diabetes for 2 years treated with SU

HbA1c has ranged from 8.2-6.8% over

that time. Currently it is 7.5%Recent attempts to titrate SU have leadto frequent hypoglycemia, particularlywith exercise

She has been trying to exercise to stopher steady weight gain of 20 poundsover the past year

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Case 5

Metformin?

DPP-4?

TZD?

Insulin?

GLP-1/Amylin?

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Case 6

36 year old woman recently relocated to

your area presents for first visit

Diabetes diagnosed last year.

Subacute onset of symptoms with passive

15 pound weight loss

Started on Metformin and titrated to 1000

mg twice daily with good response

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Case 6

Over past two months she has had

recurrence of symptoms

Blood sugars frequently in the 300+ range

No change in routine

Has experienced a 25 pound passive weight

loss

HbA1c now 10.5%

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Case 6

Additional oral therapy?

GLP-1/Amylin?

What is her diagnosis?

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Thank you

4.23.2010Diabetes

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