type 2 meds management - diabetes education · pdf filediabetes education services©...

DiabetesEducationServices19982015 Page1
2015Type2MedsManagement
www.DiabetesEd.net
BeverlyDyckThomassian,RN,MPH,BCADM,CDEPresident,DiabetesEducationServices
Diabetes Meds for Type 2: Objectives
1. Describe the main action of the different categories of type 2 diabetes medications. 2. Discuss using the AACE and ADA 2015 Guidelines to determine best therapeutic approach.3. Using the ADA Guidelines, describe strategies to initiate and adjust insulin therapy.
Copyright 1999-2015, Diabetes Educational Services, All Rights Reserved.

PathtoType2Diabetes
Patti Labelle"divabetic" --that's a mix of diabetic and
diva

NaturalProgressionofType2Diabetes
-20 -10 0 10 20 30Years of Diabetes
Relative -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.

ADA-EASD Position Statement: Management of Hyperglycemia in T2DM
...providingcarethatisrespectfulofandresponsivetoindividualpatientpreferences,needs,andvalues
ensuringthatpatientvaluesguideallclinicaldecisions.
Gaugepatientspreferredlevelofinvolvement.
Explore,wherepossible,therapeuticchoices.
Utilizedecisionaids.
Shared decisionmaking finaldecisionsre:lifestylechoicesultimatelyliewiththepatient.
Diabetes Care 2012;35:13641379Diabetologia 2012;55:15771596
PatientCenteredApproach
ADAStandardsofCare2015

OtherConsiderations Cost Hypoglycemia Age Weight Comorbidities Kidneydisease Heartdisease CHF,CAD Liverdysfunction
GlycemicTargets ADA AdultnonpregnantA1cgoals A1c

peripheralglucose uptake
hepatic glucose production
pancreatic insulinsecretion
pancreatic glucagonsecretion
gutcarbohydratedelivery &absorption
incretineffect
HYPERGLYCEMIAHYPERGLYCEMIA?
Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
Multiple,ComplexPathophysiologicalAbnormalitiesinT2DM
_
_
+renal glucose excretion

Antihyperglycemic Therapy 1st Step
LifestyleChanges Weightcontrol Healthyeating Activity

peripheralglucose uptake
hepatic glucose production
pancreatic insulinsecretion
pancreatic glucagonsecretion
gutcarbohydratedelivery &absorption
incretineffect
HYPERGLYCEMIAHYPERGLYCEMIA?
Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
Multiple,ComplexPathophysiologicalAbnormalitiesinT2DM
_
_
+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
LifeStudy 61yearoldoverweightwomanwithtype2diabetes3months.Hasbeentryingtocontroldiabeteswithdietandexercise.GFRin90s.Worriedaboutweightgain.
MostrecentA1c6.4% ADA AACE Cashpay

ADAStepWiseApproachtoHyperglycemia2015 Startwithlifestylecoaching WhenlifestylealoneisnotachievingA1cgoal Metforminshouldbeaddedat,orsoonafterdiagnosis(unlesscontraindicated).
Metforminhasalongstandingevidencebaseforefficacyandsafety,ischeapandmayreduceCVrisk.

Whengoalistoavoidweightgain Thesemedsareweightneutral Metformin DPPIVInhibitors:Januvia,Onglyza,Tradjenta,Nesina
Acarbose
Thesemedsassociatedwithwt loss GLP1agonists(Byetta,Bydureon,Victoza,Tanzeum,Trulicity)
SGLT2Inhibitors(Canagliflozin,Dapagliflozin,Empagliflozin)
Symlin (Pramlintide)
Whengoalistominimizecost Gogeneric. OralMedsMetforminandSulfonylureas Walmartoffers3mosupplyoffollowingmedsfor~$10
MetforminandMetforminXR Glipizide,Glyburide,Glimepiride
Insulins OldiesbutGoodies NPH,Regular,70/30mix $25avialatWalmart ReliOn Vialsandneedlescheaper

LifeStudy 54yearoldsmoker,creatinine1.2,BMI27.NotcheckingBG,eventhoughhehasglucosemeter.OnMetformin500mgBIDforpast4months.Hadbadexperiencewithhypoglycemiaonglyburide.
MostrecentA1c7.9% ADA AACE

WhengoalistoavoidHypoglycemia Avoidsulfonylureas Carefulinsulindosing Mayneedtoupadjustglucosegoals Monitorkidneyfunction ReinforceforpatientsoninsulintoTIE Test Inject Eat

LifeStudy 71yearoldwomanwithtype2diabetesforpastyear.BMI24.Hasbeentryingtocontroldiabetesbylimitingcarbsandexercise.Creat1.6.Goodsocialsupport.
MostrecentA1c8.6% Shehasgreatinsuranceor Sheiscashpay,hatesneedles

Reducedlifeexpectancy HigherCVDburden ReducedGFR Atriskforadverseeventsfrom
polypharmacy Morelikelytobecompromised
fromhypoglycemia
LessambitioustargetsA1c

Whatnext? 69yearoldmale,BMI31,onMetformin2000mgadayandGlipizide40mgaday.
A1c9.1%.Creat 1.2 Ptisobese,11yr historyofdiabetes Whatnext? Insurance Noinsurance

CaseStudy
70yr old,weighs100kg HistoryofCABG,tobacco A1c 11.3%,BG400500forpastweeks Insulin 100+unitsLantusaths (solostar) OralMeds:Metformin,Invokana PtcantaffordLantusinsulinpen whatotheroption?

CostPerVialinNorthernCA
CaseStudy
70yr old,weighs100kg HistoryofCABG A1c 11.3%,BG400500forpastweeks Insulin 100+unitsLantusaths (solostar). Metformin1000mgBID Whatismaxbasalinsulinshouldhebeon?

CaseStudy
70yr old,weighs100kg HistoryofCABG A1c 11.3%,BG400500forpastweeks Insulin 100+unitsLantusaths (solostar) Metformin1000mgBID Whatismaxbasalinsulinshouldhebeon? 100kgx0.5=50unitsaday
WhatcanwedonexttoimproveBG?

CaseStudy
Whatismaxbasalinsulinshouldhebeon? 100kgx0.5=50unitsaday
WhatcanwedonexttoimproveBG? AddGLP1(Exenatide,Victoza,Trulicity,Tanzeum) Addbolusinsulintolargestmeal Switchhimto70/30insulinacbreakfastanddinner
Totalpreviousbasaldose 100units 2/3inam 65unitsam(43NPHand22regular) 1/3predinner 35unitspm(23NPHand12regular)
CaseStudy
70yr old,weighs100kg HistoryofCABG,tobacco A1c 11.3%,BG400500forpastweeks Whatwillinformyouofhowtoproceed?

CriticalPoints IndividualizeGlycemictargets&BGlowering
Diet,exercise,&education:foundationT2DMtherapy
Metformin=optimal1stlinedrug.
Aftermetformin,datalimited.Combotherapyreasonable
Ultimately,manyT2patientswillrequireinsulintherapy
Alltreatmentdecisionsshouldbemadeinconjunctionwiththepatient(focusonpreferences,needs&values.)
CVriskreduction amajorfocusoftherapy.
ThankYou Havefuntonight Reps here tomorrow Nottoo late tosign upforAdv Assessment

type 2 meds management - diabetes education · pdf filediabetes education services©...

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