Meds Management ADA EASD 2018 - Diabetes Education …...ADA /EASD –Either SGLT2 or GLP1 ADA /...
Transcript of Meds Management ADA EASD 2018 - Diabetes Education …...ADA /EASD –Either SGLT2 or GLP1 ADA /...
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2018 Type 2 Meds Management ADA/EASD
www.DiabetesEd.net
Beverly Dyck Thomassian, RN, MPH, BC-ADM, CDEPresident, Diabetes Education Services
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Diabetes Meds Management for T2. Objectives
1. Describe the main action of the
different categories of type 2 diabetes
medications.
2. Discuss using the 2019 ADA & EASD
Guidelines to determine best
therapeutic approach.
3. Using the ADA and EASD
Guidelines, describe strategies to
initiate and adjust insulin therapy.
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Please download and review
Poll Question 1
� Do you discuss medication adjustment with
your patients?
A. Yes – frequently
B. Yes – sometimes
C. Not usually
D. Not at all
Path to Type 2 Diabetes
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Patti Labelle
"divabetic”
“I have diabetes, it
doesn’t have me”
BMI Categories
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Natural Progression of Type 2 Diabetes
-20 -10 0 10 20 30
Years of Diabetes
Relative β-Cell
Function
PlasmaGlucose
Insulin resistance
Insulin secretion
126 mg/dLFasting glucose
Postprandial glucose
Prior to diagnosis After diagnosis
Adapted from Bergenstal et al. 2000; International Diabetes Center.
Poll Question 2
� Which of the following match ADA's and EASD
philosophy regarding hyperglycemia
management?
A. Encourage compliance
B. Start with metformin and lifestyle
C. Maintain A1c less then 6.5%
D. Avoid SGLT-2 Inhibitors if GFR is less than 60
Antihyperglycemic Therapy – 1st Step
� Metformin plus
� Lifestyle Changes� Weight control
� Healthy eating
� Activity
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Medication Taking Behaviors� 23% of time, if A1c, B/P, lipids
above target - due to med taking behavior
� Adequate medication taking is defined as 80%
� If pt taking meds 80% of time and treatment goals not met, intensification should be considered.
� Barriers to taking meds include:� Forgetting to fill Rx, fear, depression, health
beliefs, medication complexity, cost, system factors, etc
� Work on targeted approach for specific barrier
Diabetes Agents Considerations
� Diabetes medications can be
used as monotherapy, in combo
or with insulin
� Meds reduce A1c 0.5 – 2.0%
� Each new added class drops A1c
an additional 0.7- 1.0%
� Not to be used during
preconception, pregnancy or
when breastfeeding
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Clinical Inertia Happens
� Reassess every 3-6
months
peripheralglucose uptake
hepatic glucose production
pancreatic insulinsecretion
pancreatic glucagonsecretion
gutcarbohydratedelivery &absorption
incretineffect
HYPERGLYCEMIA
?
Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
Multiple, Complex Pathophysiological Abnormalities in T2DM
_
_
+renal glucose excretion
Biguanide derived from:Goat’s Rue Galega officinalis,French Lilac
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Approved for CV Disease
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peripheralglucose uptake
hepatic glucose production
pancreatic insulinsecretion
pancreatic glucagonsecretion
gutcarbohydratedelivery &absorption
incretineffect
HYPERGLYCEMIA
?
Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
Multiple, Complex Pathophysiological Abnormalities in T2DM
_
_
+renal glucose excretion
Dopamine R agonists
T Z D sMetformin
S U sGlinides
DPP-4 inhibitors
GLP-1Ragonists
A G I s
Amylinmimetics
Insulin
SGLT2 Inhibitors
Glycemic Targets - ADA
� Adult non pregnant A1c goals
� A1c < 7% - a reasonable goal for
adults.
� A1c < 6.5% - may be appropriate for
those without significant risk of
hypoglycemia or other adverse effects
of treatment.
� A1c < 8% - may be appropriate for
patients with history of hypoglycemia,
limited life expectancy, or those with
longstanding diabetes and vascular
complications.
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American Association of Clinical
Endocrinology (AACE) Glycemic Goals
� Before meals� Less than 110
� After meals� Less than 140
Step Wise Approach to Hyperglycemia
ADA 2018� Step 1 – Metformin + Lifestyle
� Step 2 - If A1c target not achieved after 3 months, Metformin + another med� If CV Disease, consider adding a second agent with CV risk
reduction (based on drug effects and patient factors).
� SGLT-2 Inhibitors – empagliflozin (Jardiance) and canagliflozin (Invokana)
� GLP-1 Receptor Agonist – liraglutide (Victoza)
� Step 3 - If A1c target still not achieved after 3 months, combine metformin plus two other (3 drugs)
� Step 4 - If A1c target is still not achieved after 3 months, add combo injectable therapy to 3 drug combination.
Treating Hyperglycemia with Meds
� For all of the following case
studies, we assume we are
providing ongoing education on
lifestyle – including referral to a
RD and diabetes educator.
� In describing what meds match
the patient best, I am speaking
as an advocate for patients and
a consultants to providers.
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Poll Question 3
� What factors do you consider when deciding
what is the best medications for patients?
(multiple answers)
A. cost
B. risk of hypoglycemia
C. impact on body weight
D. kidney function
E. person’s willingness to take med
Cardiovascular Disease is the
Leading Cause of Death in
Diabetes
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Heart Disease & DM = 3-5xs Risk� CHF
� 7.9 % w/ diabetes vs.
� 1.1 % no diabetes
� Heart attack � 9.8 % w/ diabetes vs.
� 1.8 % no diabetes
� Coronary heart disease � 9.1 % w/ diabetes vs.
� 2.1 % no diabetes
� Stroke � 6.6 % w/ diabetes vs.
� 1.8 % no diabetes� 2007 AACE
To determine next med step, Assess for CVD
� 15-25% of people with diabetes
have ASCVD (Atherosclerotic Cardiovascular Disease)
� When adding meds, consider presence or absence of established� ASCVD
� HF (Heart Failure) and
� CKD (Chronic Kidney Disease)
� Recent trials demo that SGLT2 and GLP-1s improve CV outcomes� Also decrease heart failure and improve
kidney function.
ASCVD Defined in Outcomes Trials
� Established CVD
� Previous event - Heart attack, Stroke,
or required revascularization procedure
� Clinically significant
atherosclerosis
� Transient ischemic attack, hospitalized
for unstable angina, amputation,
congestive heart failure, >50% stenosis
of any artery, coronary artery disease
� CKD with GFR < 60
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Bottom Line – Diabetes and CVD
� If not meeting A1c target
on metformin
� Add SGLT2 or GLP-1 RA to
treatment regimen
� There is no evidence to
date of CV protective
benefit of using these meds
in people with A1c <7 and
no history of ASCVD.
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People with ASCVD + Heart Failure
� Use SGLT2 Inhibitors
� People with diabetes are at risk
of HF
� Use of SGLT2 decreases
hospitalization for HF
� 5.5 vs 8.7 event per 1000 pt years
(EMPA-REG Trial and CANVAS
Program)
Diabetes + CKD – Consider SGLT2
� Diabetes + CKD = increase
CVD Risk
� In several studies, participants on
SGLT2 with GFRs of 30-60 (stage
3) reduced ASCVD risk
� In addition to reducing ASCVD
risk, those on SGLT2 and GLP-1s
had improved renal function
� Slowed kidney disease or death
� Most consistent improvement with
SGLT2s
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Poll question 4
� For someone trying NOT to gain weight, which
medication(s) would you consider?
A. Sulfonylureas
B. Metformin
C. GLP-1 Receptor Agonists
D. SGLT-2 Inhibitors
E. DPP-IV Inhibitors
When goal is to avoid weight gain
� These meds are weight neutral� Metformin
� DPP-IV Inhibitors: sitagliptin, saxgliptin, linagliptin, alogliptin
� Acarbose
� These meds associated with wt loss� GLP-1 agonists (exenatide, liraglutide,
dulaglutide, semaglutide)
� SGLT-2 Inhibitors (Canagliflozin, Dapagliflozin, Empagliflozin, Ertugliflozin)
� Symlin (Pramlintide)
When goal is to avoid Hypoglycemia
� Avoid sulfonylureas
� Careful insulin dosing
� May need to up adjust glucose goals
� Monitor kidney function
� Reinforce for patients on insulin to “PIE”
� Poke
� Inject
� Eat
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Poll Question 5
� Which are your meds of choice for
someone who is cash pay?
(multiple)
A. Januvia
B. Glipizide
C. Lantus
D. NPH
E. Metformin
Metformin / Sulfonylureas generic3 month supply for about $10Walmart, Target, others
NPH, Reg and 70/30 ReliOn Insulin $25 a vial (1000 units) at Walmart
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When goal is to minimize cost
� Go generic.
� Oral Meds -Metformin and Sulfonylureas� Walmart, Target and others
� 3 mo supply of following meds for ~ $10
� Metformin and Metformin XR
� Glipizide, Glyburide, Glimepiride
� Insulins – Oldies but Goodies � NPH, Regular, 70/30 mix
� $25 a vial at Walmart – ReliOn
� Also have ReliOn� Syringes, meters, strips
Life Study
� 61 year old overweight woman with type 2
diabetes 3 months. Has been trying to control
diabetes with diet and exercise. GFR in 90s.
Worried about weight gain.
� Most recent A1c 7.2%
� ADA /EASD
� AACE
� Cash pay
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Life Study - Answer
� 61 year old overweight woman with type 2
diabetes 3 months. Has been trying to control
diabetes with diet and exercise. GFR in 90s.
Worried about weight gain.
� Most recent A1c 7.2%
� ADA / EASD - Metformin
� AACE - Metformin
� Cash pay - Metformin
Life Study
� 67 year old overweight man with type 2 on
metformin 2000mg daily for past 6 months.
Had revascularization surgery last year.
GFR >60. Most recent A1c 8.1%.
� What is next step?
� ADA /EASD – has good insurance
� ADA / EASD – big copay
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Life Study
� 67 year old overweight man with type 2 on
metformin 2000mg daily for past 6 months.
Had revascularization surgery last year.
GFR >60. Most recent A1c 8.1%.
� What is next step?
� ADA /EASD – Either SGLT2 or GLP1
� ADA / EASD – Sulfonylurea?
Insulin (NPH, Reg, 70/30)?
Life Study� 54 year old, smokes, hx of
stroke.
� GFR in 60s.
� Not checking BG, even though he has glucose meter.
� On Metformin 500mg BID for past 4 months.
� Had bad experience with hypoglycemia on glyburide.
� Most recent A1c 8.9%� ADA / EASD
� Big deductible
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Life Study� 54 year old, smokes, hx of
stroke.
� GFR in 60s.
� Not checking BG, even though he has glucose meter.
� On Metformin 500mg BID for past 4 months, GI upset
� Had bad experience with hypoglycemia on glyburide.
� Most recent A1c 8.9%� ADA / EASD
� Big deductible
Solution:• Change to Metformin XR and double
doseIf that still doesn’t work
• Add SGLT-2 or • Add GLP-1 • If $ an issue, consider adding
SU or insulin
Life Study
� 71 year old woman with type 2 diabetes for
past year. BMI 27. Has been trying to control
diabetes by limiting carbs and exercise.
Creat 1.6, GFR high 40s, with CHF. Good social
support.
� Most recent A1c 7.6%
� She has great insurance or
� She is cash pay
� Other referrals
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• Reduced life expectancy
• Higher CVD burden
• Reduced GFR
• At risk for adverse events from
polypharmacy
• More likely to be compromised
from hypoglycemia
Less ambitious targets
A1c <7.5–8.0%
Focus on drug safety
Diabetes Care 2012;35:1364–1379
Diabetologia
2012;55:1577–1596
Older Adults - Considerations
Life Study
� 71 year old woman with type 2 diabetes for
past year. BMI 27. Has been trying to control
diabetes by limiting carbs and exercise.
Creat 1.6, GFR high 40s with CHF. Good social
support.
� Most recent A1c 7.6%
� Great insurance – SGLT2
� Cash pay – Sulfonylurea
� Other referrals?
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What next?
� 69 year old male, BMI 28, on Metformin 2000mg a day, Glipizide 40mg a day and Empagliflozin 25mg a day.
� A1c 10.1%. GFR 50s.
� Pt c/of foot pain, polyuria, 11 yr diabetes� ADA / EASD What next?
� Insurance
� No insurance
PocketCard – Great Study Tool
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What next?� 69 year old male, BMI 28, on
Metformin 2000mg a day, Glipizide 40mg a day and Empagliflozin 25mg a day.
� A1c 10.1%. GFR 50s.
� Solutions� Insurance – Add Basal + GLP-1 combo or
� Start basal insulin, then add GLP-1, then bolus insulin (stop glipizide)
� No insurance – Stop Glipizide?, keep metformin add 70/30 insulin � Add 70/30 insulin 1-2 times a day
� 100kg x 0.5 = 50 units daily (30units am/ 20units dinner)
Case Study
� 70 yr old, weighs 100kg
� History of CABG, tobacco
� A1c – 11.3%, BG 400-500 for past weeks
� What will inform you of how to proceed?
� Insurance coverage
� His willingness to stick to a complex regimen
� His ability to self-monitor
� His social support and connection to his medical team
Copyright Diabetes Education Services© 1998-2018 www.DiabetesEd.net Page 23
Critical Points� Individualize Glycemic targets & BG-lowering
� Metformin = optimal 1st-line drug.
� Diet, exercise, & education: foundation T2DM therapy
� After metformin, second med based on ASCVD Risk, kidney function, and Heart Failure status.
� Also consider cost, risk of hypo and weight gain.
� Most important, all treatment decisions should be made in conjunction with the person’s preferences, needs & values.
Thank You� Thanks for joining us!
� Please let us know if we
can be of more service to
you.
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