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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
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Thank you!
This presentation and any resources will be available online to CPhA members at
http://www.pharmacists.ca/pharmacy-practice-webinar-archive/
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