PharmacistsAn Integral Member of

The Diabetes Care Team

WelcomeWe will begin shortly.

Today’s Speaker

Mary Nelson

BScPhm, RPh

Pharmacist at Burlington Family Health Team

Mary Nelson Disclosures

• I have no current or past relationships with commercial entities,

however I have the following professional involvement:- Editorial Board of Canadian Pharmacists Journal

- Participated in Mentor Session for Canadian Pharmacists

Conference 2018

- Presentations for pharmacists on methadone and

buprenorphine on behalf of OPA

- Work part-time at a Family Health Team

• I am not a CDE

• I received an honorarium from CPhA for this presentation

Learning Objectives

• Understand the impact of type 2 diabetes in Canada

• Be familiar with recent changes in the Diabetes Canada Guidelines

• Be more knowledgeable and confident in helping clients with diabetes to manage their disease

Terminology

• Diabetic

• Patient with diabetes

• Person living with diabetes

Impact on HealthFamily History • Genetics

• Ethnic groups- African, Arab, Asian, Hispanic, Indigenous, South Asians,

• Low socioeconomic status

Physiology • PCOS, pregnancy• Chronic pancreatitis• Renal function

Environmental • Healthy behaviour interventions - diet and exercise

• Smoking

• World wide high blood glucose is the 3rd highest risk factor for premature mortality

• after hypertension and tobacco use

• Main contributors to growth• high rates of obesity• sedentary lifestyle• aging population

Statistics

Canada at a Glance

International Diabetes Federation Atlas 8th ed 2017

Canada at a Glance

2017 2045

# undiagnosed diabetes/1000 793 (30.5%) 963 (30.5%)

# deaths due to diabetes/1000 11.3

Proportion of deaths due to diabetes < 60 yrs 37.4%

Annual healthcare expenditure (million USD) $16,970 $ 18,274

Annual health care expenditure/person (USD)* $6,520 $5,785

# children/adolescents (0-19) with type 1 18,925

* 2 times higher healthcare expenditure than people without diabetes

International Diabetes Federation Atlas 8th ed 2017

Diabetes-Related Complications

Diabetic retinopathy

• Leading cause of blindness

in working age adults1

• Overall prevalence of 38.6% for any

diabetic retinopathy2

Diabetic nephropathy• Leading cause of ESRD3

• Accounts for ~40% of new

cases of ESRD in the US4

Depression• Prevalence of 17.6%7

Diabetic neuropathy• Present in 60–70% of people

with diabetes12

• Leading cause of non-traumatic lower extremity

amputations13

Cardiovascular disease• Accounts for ~50% of all

diabetes fatalities10

• Risk of stroke increases 3% each year and triples with

diabetes ≥10 years11

.

Cancer• Diabetes (primarily type 2) is a risk factor for bladder, breast, colorectal,

endometrium, hepatocellular,

non-Hodgkin’s lymphoma, pancreatic and

prostate cancer6

Erectile dysfunction• Prevalence varies between 20–75%5

• 2–3 times more likely to occur in men with

(vs. without) diabetes5

Sleep apnea• Prevalence may be up to 23%8

• Up to 40% of people with sleep apnea will have

diabetes9

Booth et al. ; Hux et al; and Oliver et al., Diabetes in Ontario: An ICES Practice Atlas. 2003. www.ices.on.ca

In CanadaPeople with Diabetes Account For…

1/3

of all heart attacks & strokes

2/5

of all heart failure admissions

2/3 1/2

of all non-traumatic amputations

all patients starting dialysis

Historically• Slow to diagnose

• borderline diabetes

• sugars a little elevated

• Treat to fail• start with one medication and continue until it fails

• Monotherapy

• Insulin resistance• inactivity

• abdominal fat

Reprinted from Primary Care, 26, Ramlo-Halsted BA, Edelman SV, The natural history of type

2 diabetes. Implications for clinical practice, 771–789, © 1999, with permission from Elsevier.

Development and Progression of Type 2 Diabetes and Related Complicationsa

aConceptual representation.

Insulin level

Insulin resistance

Hepatic glucose production

Postprandialglucose

Fasting plasma glucose

Beta-cell function

Progression of Type 2 Diabetes Mellitus

Impaired Glucose Tolerance

Diabetes Diagnosis

Frank Diabetes

4–7 years

Development of Macrovascular Complications

Development of Microvascular Complications

Ominous Octet

Adapted from DeFronzo RA. Diabetes 2009;58:773-95.

Diagnosis of Diabetes

Test Result Comments

Fasting Plasma Glucose > 7.0 mmol/L No caloric intake for at least 8 hrs

A1C > 6.5% in adultsUsing standardized validated assay

and not for suspected type 1

2-hr Plasma Glucose in a 75-g

Oral Glucose Tolerance Test> 11.1 mmol/L

Random Plasma Glucose > 11.1 mmol/LAny time of day without regard to

interval since last meal

2018

Diagnosis of Prediabetes*Test Result Prediabetes Category

Fasting Plasma Glucose

(mmol/L)

6.1 - 6.9 Impaired fasting glucose (IFG)

2-hr Plasma Glucose in a 75-g

Oral Glucose Tolerance Test

(mmol/L)

7.8 – 11.0 Impaired glucose tolerance (IGT)

Glycated

Hemoglobin

(A1C) (%)

6.0 - 6.4 Prediabetes

* Prediabetes = IFG, IGT or A1C 6.0 - 6.4% high risk of developing T2DM

2018

A1C Level and Future Risk of Diabetes Systematic Review

A1C Category (%) 5-year incidence of diabetes

5.0-5.5 <5 to 9%

5.5-6.0 9 to 25%

6.0-6.5 25 to 50%

Zhang X et al. Diabetes Care. 2010;33:1665-1673.

A1C Targets

≤6.5Adults with type 2 diabetes to reduce the risk of CKD and retinopathy if at

low risk of hypoglycemia

Avoid higher A1C to minimize risk of symptomatic hyperglycemia and acute and chronic complications

≤7.0 MOST ADULTS WITH TYPE 1 OR TYPE 2 DIABETES

7.1

8.5

7.1-8.0%: Functionally dependent*

7.1-8.5%:

• Recurrent severe hypoglycemia and/or hypoglycemia unawareness

• Limited life expectancy

• Frail elderly and/or with dementia**

* Based on class of antihyperglycemic medication(s) utilized and person’s characteristics

** see Diabetes in Older People chapter

CKD; chronic kidney disease

A1C measurement not recommended. Avoid symptomatic hyperglycemia and any

hypoglycemiaEnd of life

2018

Moorhouse P, Rockwood K. J R Coll Physicians

Edinb 2012;42:333-340.

Frailty Scale

Diabetes Management

•macrovascular disease• heart attack, stroke

• microvascular disease• eye, kidney, nerves

• Minimize side effects• weight gain, hypoglycemia

• hospitalization for heart failure

ABCDES3 of Diabetes Care

✓A • A1C – optimal glycemic control (usually ≤7%)

✓B • BP – optimal blood pressure control (<130/80)

✓C • Cholesterol – LDL <2.0 mmol/L or >50% reduction

✓D • Drugs to protect the heartA – ACEi or ARB │ S – Statin │ A – ASA if indicated │SGLT2i/GLP-1 RA with demonstrated CV benefit if type 2 DM

with CVD and A1C not at target

✓E • Exercise / Healthy Eating

✓S • Screening for complications

✓S • Smoking cessation

✓S • Self-management, stress and other barriers

2018

Diabetes• CVD is leading cause of death in diabetes

• 2-4 times > than people without diabetes

• 80 – 90% of patients with type 2 diabetes are overweight

• obesity is an independent risk factor for CVD

• Hypertension is a strong risk factor for development and progression of diabetic kidney disease

• Heart failure occurs 2-4 times more frequently in patients with diabetes and at an earlier age

Modest Weight Loss Can Make a Difference• Weight loss of only 5-10% improves:

• insulin sensitivity • glycemic control • blood pressure• lipid levels

• Goal is to prevent weight gain and promote weight loss

• Negative energy balance of 500 kcal/day to achieve 0.45 kg weight loss/week

Physical Activity

• Minimum of 150 minutes moderate to vigorous intensity aerobic exercise/week

• 30 minutes/day x 5 days per week• can accumulate up to 30 minutes

• Resistance exercise 2-3 times/week

• Increases effectiveness of endogenous and exogenous insulin

Improving Glycemic Control Reduces Risks

43%

Lower extremity

amputation or fatal peripheral

vascular disease

37%

Microvascular disease

19%

Cataract extraction

14%

Myocardial infarction

16%

Heart failure

12%

Stroke

UKPDS Group. Lancet 1998; 352:854-865

Every 1% drop in A1C can reduce long-term diabetes complications

CDA Key Message

• Importance of individualizing therapy for the person with diabetes

Diabetes Pharmacotherapy

✓ CHOOSE initial therapy based on glycemia✓ START with Metformin +/- others ✓ INDIVIDUALIZE therapy choice based on characteristics of the

patient and the agent✓ In a patient with clinical cardiovascular disease, chose an agent

with demonstrated CV OUTCOME BENEFIT (empagafloxin , canagaflozin, liraglutide, dulaglutide*, semaglutide*)

✓ REACH TARGET within 3-6 months of diagnosis

* Not include in 2018 Guideline as not published in time

Pharmacologic Effects of Diabetes Drugs

metformin GLP-1 receptor agonist

metformin

SGLT-2 inhibitor

thiazolidinedione

DPP-4 inhibitorGLP-1 receptor agonist

DPP-4 inhibitorGLP-1 receptor agonist

insulin secretagogue

insulin

α glucosidase inhibitor

Diabetes Medication Effect on A1cDrug Class A1c Lowering*

Acarbose

DPP-4 Inhibitors

GLP-1 Receptor Agonists to

Insulin

Insulin Secretagogue• meglitinide• sulfonylurea

SGLT-2 Inhibitors to

TZDs

* Relative lowering when added to metformin guidelines.diabetes.ca

Diabetes Medication Effect on WeightDrug Class Weight

Acarbose Neutral

DPP-4 Inhibitors Neutral

GLP-1 Receptor Agonists

Insulin

Insulin Secretagogue• meglitinide• sulfonylurea

SGLT-2 Inhibitors

TZDs

guidelines.diabetes.ca

Diabetes Medication Causing HypoglycemiaDrug Class Hypoglycemia

Acarbose Rare

DPP-4 Inhibitor Rare

GLP-1 Receptor Agonists Rare

Insulin Yes

Insulin Secretagogue• meglitinide• sulfonylurea

YesYes

SGLT-2 Inhibitors Rare

TZDs Rare

guidelines.diabetes.ca

Insulin KineticsSe

rum

insu

lin le

vel

Basal

Analogue

Human Basal

Intermediate

Bolus Analogue

Rapid Acting

Human Bolus

Short Acting

Physiologic

Insulin

Basal Analogue Intermediate Acting

• flatter pharmacodynamic profile moreclosely mimics basal physiologic rate

• longer duration of action• reduced risk for hypoglycemia• improve fasting blood glucose• less variability in insulin absorption• can’t be mixed with other insulins

• shorter duration of action• may require BID dosing• inadequate re-suspension

can lead to variability in absorption

• costs less

Basal vs Intermediate Acting Insulin

Rapid Acting Analogue Short Acting

• improve A1c and post prandialglucose

• lower risk for hypoglycemia• better flexibility with timing of

meals- given within 10-15 min of eating

• faster correction of hyperglycemia• less variability in insulin absorption

• provides more basal coverage• more post prandial hypoglycemia• costs less• needs to be given 30 min before

meal

Rapid Acting vs Short Acting Insulin

• New• 8 – 10 units daily

• doesn’t need to be dosed at HS

• On previous NPH/Lente/Ultralente• daily – same dose daily

• BID – decrease total dose by 20% and titrate up

• Increase by 1-2 units/day to target FBS < 7.0• exception for degludec – 4 units weekly or 2 units twice weekly

• if BS has been running high for a long time, patient may feel hypoglycemic at 7.0 – target higher FBS initially

Starting Basal Analogues

Simplifying Insulin Initiation• Pens facilitate self-injection

• dial-a-dose• visual, tactile and audible cues• less pain and bruising• pen needle tips are finer

- 32G x 4 mm

• Convenient for patients• new basal insulins are ready to inject

- no mixing before use• once daily• pen in use at room temp

• Prefilled pens• only dial to what is left in pen

Counsel all

Patients About

Sick Day

Medication List

2018

When you are ill, particularly if you become dehydrated due to vomiting or diarrhea, some medicines could cause your kidney function to worsen or result in side effects.

If you become sick and are unable to drink enough fluid to keep hydrated, you should STOP the following medications:

S Sulfonylureas - gliclazide, glimepiride, glyburide

A ACE Inhibitors - benzapril, captopril, cilazapril, enalapril, fosinopril, lisinopril, perindopril, quinapril,

ramipril, trandolapril

D Diuretics - chlorthalidone, ethacrynic acid, furosemide, hydrochlorothizide, indapamide,

metolazone, spironolactone

M Metformin

A Angiotensin Receptor

Blockers

- candsartan, eprosartan, irbesartan, losartan, telmisartan, valsartan

N Non-Steroidal Anti-

inflammatory

- ASA, celecoxib, diclofenac, diflunisal, etodolac, floctafenine, flurbiprofen, ibuprofen,

indomethacin, ketoprofen, ketorolac, mefenamic acid, meloxicam, nabumetone,

naproxen, piroxicam, sulindac, tenoxicam, tiaprofenic acid

S SGLT-2 Inhibitors - canagliflozin, dapagliflozin, empagliflozin

Insulin should not be stopped, but you may need to reduce the dose, so talk with your doctor or pharmacist. Also don’t forget to restart these medications once you are over your illness.

SADMANS

Antihyperglycemic Agents and Renal Function

eGFR (mL/min/1.73 m2): <15 15–29 30–44 ≥ 60CKD Stage 5 4 3b 1 or 2

Acarbose

Dapagliflozin

Empagliflozin

Pioglitazone

Use alternative agent Dose adjustment not requiredDose adjustment required

Canagliflozin* 25 100 mg daily

Caution

Metformin

Linagliptin

Sitagliptin 5050 mg daily25 mg daily

Saxagliptin 502.5 mg daily

Alogliptin

Exenatide

Liraglutide

Repaglinide

Gliclazide

Glyburide

Alpha-glucosidase Inhibitors

Glimepiride

Biguanides

DPP-4

Inhibitors

SGLT2

Inhibitors

Insulin

Secretagogues

GLP-1

Receptor

Agonists

Insulins

RosiglitazoneThiazolidinediones

500-1000 mg daily

Dulaglutide

50Exenatide QW 50

Lixisenatide

Fluid retention

45-593a

30

45

15

15

30

3030

15

Do not initiate

3030 60

60

6060

60

60

3060

45

30

15

* May be used for cardiorenal benefits in those with clinical CVD, A1C above target and eGFR >30 mL/min/1.73m2

6030 12.5 mg daily6.25 mg daily

60

30

30

45

45

• For People with Diabetes• Tools and Resources

• Management

• My Diabetes Care: Not Just About Blood Sugar

• Just the Basics

• Glycemic Index

• Sugars and Sweetners

• Lows and Highs: Blood Sugar Levels

• Getting Started with Insulin

• Drive Safe with Diabetes• 5 to drive

CDA Pamplets

guidelines.diabetes.ca

• Go to resource• patients

• physicians

• Early identification• CANRISK questionnaire

• Improve adherence• fixed dose combinations

• simplify regimens

• insulin or GLP-1 starts

• ensure proper injection technique

• Meter training• involve technician/assistant

Pharmacist’s Role

• Help patients to know• rationale for their regimen

• value of testing at different times

• Blood work• what do the numbers mean

• collaborating with family physician, specialists

• Minimize risks• especially hypoglycemia

• Assist with travel• especially when crossing time zones

Pharmacist’s Role cont’d

Target before meals 4 7

Target 2h after meals 5 10

Insulin Breakfast Supper Bedtime

Dose Before 2h after Before 2h after

05-Dec Wednesday

06-Dec Thursday

07-Dec Friday

08-Dec Saturday

09-Dec Sunday

10-Dec Monday

11-Dec Tuesday

12-Dec Wednesday

13-Dec Thursday

14-Dec Friday

15-Dec Saturday

16-Dec Sunday

17-Dec Monday

18-Dec Tuesday

Patient: Date:Current A1c: Date: Target < 7.0%Current LDL: Date: Target < 2.0Current BP: Date: Target < 130/80Current FBS: Current GFR: Current ACR: Changes recommended today: ____________________________________________________________________________________________________________________________________________________________________________________Please make appointment for:□ Dr. _________________Diabetes Clinic in 3 or 6 months□ Follow up with Dr. ______________ in __________□ Follow up with dietician in 3 or _____months□ Follow up with pharmacist in 3 or ___months□ Follow up with ____________ in __________

Patient Results and Comments

Pharmaceutical OpinionPatient is currently taking metformin 500 mg BID, the highest dose tolerated because of GI side effects, along with Januvia 100 mg QAM. Average blood sugar readings as follows:Fasting AM 8.5 (7.9 – 9.4) – 6 readingsFasting supper 6.7 (5.3 – 7.9) – 4 readingsPost prandial supper 9.6 (7.3 – 11.2) – 4 readings

Janumet XR provides slow release metformin, which many patients find easier to tolerate in terms of GI effects. If you would agree to switch the patient from his current metformin and Januvia regimen, I would suggest he take just 1 Janumet XR 50/1000 mg daily x 1 week. If he tolerates that, then he can increase to 2 tablets daily, and these can be taken at the same time to help with adherence. I will follow up with him in a couple of weeks and let you know if he is tolerating the medication, and the impact it has on his blood sugar.

Switch Januvia 100 mg QAM and metformin 500 mg BID to Janumet XR 50/1000 mg Titrate to 2 tablets QAM as directed

Quantity Repeat Yes No MD Signature

180 x1

Please don’t hesitate to contact me if you have any question or concerns.

Sincerely,Mary Nelson, BScPhm, RPh

Diabetes Pharmacists NetworkThe Banting & Best Diabetes Centre (BBDC) at the University of Toronto launched the Diabetes Pharmacists Network in 2014 to bring together pharmacists from across Canada who are interested in advancing diabetes care.

“Neither evidence nor clinical judgment

alone is sufficient.

Evidence without judgment

can be applied by a technician.

Judgment without evidence can be applied by a friend.

But the integration of evidence and judgment is what the healthcare provider does in order to dispense the best

clinical care.”

(Hertzel Gerstein, 2012)

Factors Associated with Different Forms of DM

Diabetes Care 2016: 39: 179-85

Future Diabetes Classification

SAID SIDD SIRD MOD MARD

Severe Auto-Immune Diabetes

Severe InsulinDeficient Diabetes

Severe Insulin Resistant Diabetes

Mild ObesityRelated Diabetes

Mild Age Related Diabetes

• early onset• relatively low BMI• poor metabolic control• insulin deficiency• presence of GADA

• early onset• relatively low BMI• poor metabolic control• low insulin secretion• GADA* negative

• high insulin resistance• high HOMA2**-IR index• high BMI

• obesity• not insulin resistant

• older patients• not insulin resistant

Lancet Diabetes Endocrinol 2018: 6: 361-9*Glutamate decarboxylase antibodies** Homeostatic model assessment 2

Prevalence of Future Classifications

Questions

Please type your questions in the “Questions” window in the control panel and click Send

Thank you!

This presentation and any resources will be available online to CPhA members at

http://www.pharmacists.ca/pharmacy-practice-webinar-archive/