Diabetes Update
Maximizing options to achieve optimal blood
glucose control
Carla Cox, PhD, RD, CDE
1. Be able to identify 3 lifestyle recommendations
that could change your patients life with
diabetes
2. Be able to list 3 classes of diabetes medications
and their target tissues and when to consider
using them
3. Understand the potential for technology to
enhance your patients ability to partner in the
management of their blood glucose
Objectives
American diabetes
Association
American Academy of
Clinical
Endocrinologists
FASTING 2 hour pp
< 130
< 180
mg/dl
mg/dl
FASTING
< 110
mg/dl
2 hour pp
< 140
mg/dl
What ARE those BG Goals?
ADA
< 7%
(with clinical judgment on comorbid conditions)
What ARE those BG Goals?
What ARE those BG Goals?
• 50% of Kaiser Permanente Northwest patients who
initiated metformin-sulfonylurea combination therapy
failed to maintain A1C levels below 8%....and it was 3
YEARS before insulin was added and at that time mean
A1C of 9% (Nichols et al, 2007)
• UK population using 2 agents had A1C of at least 8% for
6.9 YEARS before further intensification of therapy with
mean A1C of 9.1% (Khunti et al, 2013)
WE NEED TO DO BETTER THAN THIS!
What’s the data?
Lifestyle
Lifestyle:
Food
• It’s not just
about the carbs
anymore!
Food
Quality
Think and teach balance:
A fruit or vegetable with
every meal – and don’t
forget the whole grains!
Lifestyle:
Exercise
Minimum
• Aerobic Exercise 150 minutes per week
(3-5 days per week)
• Strength training 2-3 times per week
• Stretching 5 days of the week
Exercise – American College
of Sports Medicine
• Exercise most days of
the week
• Include strength and
aerobic exercise when
possible – think about
the order
Exercise – diabetes
specific
• Consider timing of the
meal with exercise and
present medication
regimen
• Follow minimum
standards of ACSM (no
evidence that stretching
per se is needed)
Exercise – diabetes specific
Benefits
• Helps to maintain/reach a healthy weight
• Treatment of osteoarthritis and rheumatoid
arthritis
• Greater emotional health and better sleep!
Benefits
• Reduced risk of developing:
• Diabetes
• Heart disease
• Stroke
• Cancers
• High blood pressure
Monitoring
Monitoring
DATE
Fasting
2 hour post
breakfast
Dinner
2 hour post
dinner
10/16
165
144
185
100
10/17
182
150
110
99
10/18
130
160
240
185
10/19
155
140
126
210
More data: 4 cookies for afternoon snack 10/16 ; ice cream
sundae 10/18
More data: Took a walk 10/17 afternoon and had 2 cookies
for afternoon snack
Using the data
DATE
Fasting
2 hour post
breakfast
Dinner
2 hour post
dinner
10/16
165
144
185
100
10/17
182
150
110
99
10/18
130
160
240
185
10/19
155
140
126
210
More data: 4 cookies for afternoon snack 10/16 ; ice cream
sundae 10/18
More data: Took a walk 10/17 afternoon and had 2 cookies
for afternoon snack
Using the data – what
should we change?
Medications
Remember – the goal is BG control, not necessarily
how we get there!
When lifestyle doesn’t do it (or doesn’t happen)
1921 – Insulin is
discovered (thank you
dogs!)
1923 – Insulin is
produced by Eli Lilly
1936 – first slower
insulin (NPH type)
Medications
• 1955 – Sulfonylureas
• 1983 – 2nd generation
of Sulfonylureas
• 1997 Thiazolidinediones
When lifestyle doesn’t do it (or doesn’t happen) - 2014
•
•
•
•
•
•
Biguanide
• Metformin/biguanide
Secretagogues
• Glucatrol/Glipizide
• Amaryl/glimiprimide
Meglitinides
• Prandin/repaglinide
• Starlix/nateglinide
TZD
• Actos/Pioglitazaone
Alpha-Glucosidase Inhibitors
• Precose/acarbose
• Glyset/miglitol
Medications
•
•
•
•
GLP-1 (incretins and incretin mimetics)
• Byetta/exenatide (BID)
• Victoza/liraglutide (1/day)
• Bydureon/exenatide (weekly)
• Tanzeum/albiglutide (weekly)
• Trulicity/dulaglutide (weekly) (11/18)
DPP-4
• Januvia/sitagliptin
• Onglyza/saxagliptin
• Tradjenta/linagliptin
• Nesina/alogliptin
SGLT-2 (sodium-glucose co-transporter)
• Invocana/Canagliflozin
• Farxiga/Dapagliflozin
• Jardiance/Empagliflozin
Combination drugs (such as Janumet)
Insulin
• Basal
• Bolus
• Premixed
GLP-1 receptor agonists
A1C 1-1.5
http://www.globalrph.com/DPP-4-inhibitors.htm
• Monitor with renal insufficiency (CrCl < 30 mL/min)
• Patients with history or risk of pancreatitis (insufficient
clinical evidence to support this)
• Patients with personal or family history of thyroid c-cell
tumors (not seen in humans)
• Individuals with stomach or intestinal issues may not be
candidates
Who should NOT use this
medication
DPP-4 inhibitors A1C .5-1
http://www.globalrph.com/DPP-4-inhibitors.htm
• Reduce dose in renal insufficiency (with the exception of
Trajenta)
Who should not use this
medication
SGLT-2 inhibitors
A1C .7-1
• Patients with hypovolemia
• Caution with the elderly – especially using diuretics
• Patients with GFR below 45 mL/min
(Farxiga/Dapagliflozin) – below 60 mL/min)
Who should not use this
medication
Phillips et al, We can change the natural history of type 2
diabetes, Diabetes Care 2014;37-2668-2676
Phillips et al, We can change the natural history of type 2
diabetes, Diabetes Care 2014;37-2668-2676
• Cefalu W, Del Prato S, LeRoith D et al. Beyond
Metformin: Safety Considerations in the DecisionMaking Process for Selecting a Second Medication for
Type 2 Diabetes Management: Reflections from a
Diabetes Care Editors Expert Forum. Diabetes Care
2014;37:267-2659.
Medication review
Using technology
Using technology –
reading the downloads
• Insulin delivery
• Pens - .5 – 1 unit
• Pumps (including V-Go)
• U-500 insulin option
• Blood glucose results
• Meters
• Sensors (additional layer)
Delivering insulin and
discovering results
Pens, pumps, sensors
14455-AW R2 03/11
1 a.m
7 a.m.
11 a.m.
1 pm.
3 p.m
6 pm.
9 p.m.
11 p.m.
130
300
169
116
139
136
116
264
180
241
118
201
201
191
142
335
362
346
192
100
145
162
110
339
322
186
115
96
132
144
102
229
214
152
Backcountry
management: 4 days
backpacking
3 Week CGMS
Sensor data
• There is a relationship between frequency of A1C testing
and better BG management results
• Those testing annually had a 1.5% increase
• Those testing every 3 months had a 3.8% decrease
• Those who tested more often did not improve beyond the
quarterly checks
Diabetes Care 2014;37:2731-2737
A1C testing
• Patient is 54 year old patient with A1C of 8.5%. He has
abdominal obesity and is sedentary. No significant joint
problems. He works 50 hours per week, and works
around the house on the week-ends. He is presently on
Metformin and Glipizide. Renal and liver function tests
are WNL. He denies symptoms such as frequent
urination, thirst, excessive fatigue
• What do you do?
Case #1
• Patient is 54 year old patient with A1C of 8.5%. He has
abdominal obesity and is sedentary. No significant joint
problems. He works 50 hours per week, and works around the
house on the week-ends. He is presently on Metformin and
Glipizide. Renal and liver function tests are WNL
• Consider referral to diabetes education – even a 2nd time
• Add a medication – which one?
• Make sure he is monitoring effectively (pre and post meal)
• Have him return for f/u or follow up with SOMEONE in 1-2
weeks
Case #1
• Patient returns 6 months later (having not returned as requested)
A1C of 11%. He did not see the educator, and continues to have
abdominal obesity and be sedentary. No significant joint problems.
He is presently on Metformin and Glipizide and takes the GLP-1 you
started him on. Renal and liver function tests remain WNL. He has
not been monitoring but now has tingling in his feet, blurry vision
and is exhausted all the time. He appears ready to make some
changes
• Referral to diabetes education – yet again
• Add a medication – which one?
• Make sure he is monitoring effectively (pre and post meal)
• Have him return for f/u or follow up with SOMEONE in 1-2 weeks.
Consider having an office person follow up with a phone call.
Case #1
• Patient is a 45 year old female. BMI 24. She reports
feeling tired and unable to think very well. Some
significant thirst. She is active playing hockey in the
winter and running and hiking all summer. She has no
family history of diabetes, but a finger stick in the office
reveals a BG of 376 mg/dl.
Case #2
• Patient is a 45 year old female. BMI 24. She reports
feeling tired and unable to think very well. Some
significant thirst. She is active playing hockey in the
winter and running and hiking all summer. She has no
family history of diabetes, but a finger stick in the office
reveals a BG of 376 mg/dl.
• What should you do?
• Refer to diabetes educator
• Start patient on what medication?
• Should you consider any specific tests for this patient?
Case #2
• Patient is a 45 year old female. BMI 24. She reports feeling
tired and unable to think very well. Some significant thirst.
She is active playing hockey in the winter and running and
hiking all summer. She eats reasonably, but has lost 20 pounds
recently without really trying. She has no family history of
diabetes, but a finger stick in the office reveals a BG of 376
mg/dl.
• You check an A1C and it is 10%
• You started her on Metformin and glipizide and nothing
happens
• What do you do now?
Case #2
• Patient is a 45 year old female. BMI 24. She reports feeling
tired and unable to think very well. Some significant thirst.
She is active playing hockey in the winter and running and
hiking all summer. She eats reasonably, but has lost 20 pounds
recently without really trying. She has no family history of
diabetes, but a finger stick in the office reveals a BG of 376
mg/dl.
• Back up –
• This patient may have LADA and require insulin!
• Look at the profile of the patient
• Consider referral to endocrinology
• THESE PATIENTS ARE FREQUENTLY MISSED!
Case #2
• Diabetes is a tedious but manageable disease – it takes
time and successful monitoring to find the way!
• Physical activity
• Eating healthfully and moderate, but high quality
carbohydrates
• Monitoring
• Medications
• Technology
• BG evaluation – trends and patterns
Conclusion
QUESTIONS?