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January 2013 Webinar: “Practical Ways to Help Get Our Diabetes Patients to Goal”. Controlling the ABC’s Cases. Evidence Based Interventions that Reduce Morbidity and Mortality. HbA1C < 7 BP < 140/90 LDL cholesterol < 100 (or 50 men, 60 women with 1 risk factor - PowerPoint PPT Presentation
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January 2013 Webinar:“Practical Ways to Help Get Our Diabetes Patients to Goal”
• Controlling the ABC’s• Cases
Evidence Based Interventions that Reduce Morbidity and Mortality• HbA1C < 7• BP < 140/90• LDL cholesterol < 100 (or <70 if CAD) • Aspirin age > 50 men, 60 women with 1 risk
factor• ACE - age >55• Statin use - age >40• Yearly screen for nephropathy, feet, and eye
exams
The ‘ABCs’
•A1C
•BP < 140/90
•Cholesterol (LDL<100, if CAD <70)
Improving Glucose Control
“But I Thought It Was Bad to Lower A1C Too Much..”• All recent studies aimed at A1C = 6.5 or lower• No evidence that A1C = 7 is bad• Data says to reduce CVD
• It is not so much about glucose• It’s the Blood Pressure and Cholesterol!
Really, Really Important Points:1. Aggressive control early prevents complications2. Because of the log-linear relationship between
control and complications, absolute benefits are greatest at high HbA1c values (i.e. target A1C >9)
3. Pushing patients with advanced disease (particularly macrovascular complications) to ‘tight’ control that they cannot achieve probably increases mortality
-Attention to hypoglycemia and particularly nocturnal hypoglycemia
Managing Glucose
• Goal A1C <7• Consider higher (8) if CAD, elderly, or
hypoglycemia unawareness• Focus on those at highest risk (i.e. A1C >9)
Sites of Drug ActionCarbohydrate
DIGESTIVE ENZYMES
Glucose
Defectiveb-cell secretion
Excessglucoseproduction
Resistance to the action of insulin
Reduced glucoseuptake
Excessivelipolysis
Dinneen SF. Diabet Med. 1997; 14 (Suppl 3): S19-24.
Sulfonlyureas MeglitinidesIncretinsInsulin
Alpha-glucosidaseInhibitors, Incretins
MetforminTZDIncretins TZD, Metformin
Points to Remember
• Each agent, except insulin, lowers A1C 1-2• If A1C >9, start two agents• Follow SMBG, A1C, and Titrate!!!!!
Case
• 58 yo with Type 2 x 5 yrs• A1C = 9.5• On metformin 1000 mg bid• Glimepiride 4 mg qd
• What next?
20 10 0 10 20 30
Natural History of Type 2 Diabetes
Adapted from International Diabetes Center (IDC). Minneapolis, Minnesota.
Years of Diabetes
Relative b-Cell Function
PlasmaGlucose
Insulin resistance
Insulin secretion
126 mg/dL Fasting glucose
Postmeal glucose
Type 2 Diabetes… A Progressive Disease
Over time, most patients will need
insulin to control glucose.
Reducing Clinical Inertia
• Eternal hope on lifestyle working• Negotiate a deadline
• Escalating therapy more quickly• Oral agents can be monthly• Insulin can be weekly
Barriers to Starting Insulin
• Patient Barriers• Guilt, failure• Injection?
• Provider Barriers• Who teaches?• Consider pens
• Team Based Care to the rescue!• Diabetes Educators?
Talking About Insulin
• “It seems like you have some concerns about insulin?”
• “What do you know about using insulin in DM?”• Inevitable • Simple• Pens• Can be daily at first• No one needs to know • Correct misconceptions
What To Do With Oral Agents
• Negotiate• For weight- keep metformin• For reducing need for second injection - insulin
secretagouge• For cost- stop orals
Correcting Fasting Hyperglycemia…
100
200
300
Normal A1C 5%–6%
PG (
mg/
dL)
0800 1200 1800 0800Time of Day
Uncontrolled A1C ~9%
A1C ~6%
Is Usually the First Task!!
…then, Tackle Postprandial Hyperglycemia if A1C still >7%!
“Controlled” A1C <7%
Titrating Glargine or Detemir
• Start 10 units• 2 units q 3 days until FPG < 100• It’s that easy and it works!
50
4:00
25
75
8:00 12:00 16:00 20:00 24:00 4:00
Breakfast Lunch Dinner
PlasmaInsulin ( µU/mL)
Time8:00
Physiologic Serum Insulin Secretion Profile
How do you know they need another
injection?FPG good but A1C not
22
Case
• Type 2 DM x 6 y• Glargine 60 units qhs• FPG 90-110• A1C=8.5• Pt can measure qhs BG?
• Start 10 units rapid insulin pre-dinner• If regular meals- 70/30 insulin
• 40 q Am, 30 q PM
Who Are Your High A1C Patients?
• Orals and need second oral?• Need insulin?• On insulin?• There can be inertia at each level• DEPRESSION?• Adherence?
• Open-ended ended question:• “Some people find it hard taking their insulin
every day, how’s it going for you?”
BP CONTROL
BP Management
• <140/90• Multiple meds • Don’t miss an opportunity to titrate• Standing orders?
Medication Treatment Algorithm?
• Start with ACE or ARB and/or HCTZ• Either one
• Best might be early combo since all will likely need it
• Third agent based on co-morbidity• Beta blocker and/or Ca channel
• Add the 4th and hopefully you’ve reached goal - if not call an expert +/- alpha blocker?
Tashko and Gabbay, Integrated Blood Pressure Control (2010)
Cholesterol LDL control <100If CVD <70
Getting to Goal on LDL
• Most myalgia not from statins!• Stop and observe• Switch to another statin• Mention stroke risk• TITRATE
Evidence Based Interventions That Reduce Morbidity and Mortality• HbA1C < 7• BP < 130/80• LDL cholesterol < 100 (or <70 if CAD) • Aspirin age > 50 men, 60 women with 1 risk
factor• ACE -age >55• Statin use- age >40• Yearly screen for nephropathy, feet, and eye
exams
QUESTIONS?
Any Cases?
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