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Diabetic Care Pathway
Michael Shannon, MD
Endocrinologist and PSW Medical Director
Diabetes Pathway– 2019 PSW Key Goals
• Patients with diabetes need appropriate A1c goals
– Medicare/HEDIS quality target: A1c < 9%
– Clinical targets vary by patient:
• Most patients A1c < 7%
• Patients with limited life expectancy, significant comorbidities, or
hypoglycemia risk < 8%
• Young healthy low risk patients may aim for < 6.5%
• Statin adherence for diabetics
• Aspirin if ASCVD present (common in diabetics)
Diabetes Pathway– 2019 Changes
• Diabetic patients with CVD need drug with CV benefit, either
– SGLT-2 inhibitor – especially if patient has CHF or chronic renal
disease (ACC: Jardiance; ADA: Jardiance > Invokana)
– GLP-1 agonist (ACC: Victoza; ADA: Victoza > Ozempic > Bydureon)
• First injectable for most patients is GLP-1 agonist, not insulin
• ADA classifies other drugs based on secondary goals
Diabetes Pathway – 2019 Key Points
The Foundation
Diabetes Education • Nutrition Therapy • Weight Management
If Established CVD Add Either: If no known CVD Choose From:
1. GLP-1 Agonist (first line injectable
per ADA). Preferred for weight loss,
low hypoglycemia
2. SGLT-2 Inhibitor: Preferred for
weight loss, low hypoglycemia
3. Sulfonylurea: use glimepiride (NOT
glyburide), preferred for cost
4. Basal insulin: preferred for efficacy
(use if A1c > 11%, hyperglycemic
symptoms, suspect DM1)
Start with Metformin ER
(Extended Release)
• 500 mg tablets
• Increase weekly to
• Target dose of 2000 mg/day
Refer to Certified Diabetes
Educator at Diagnosis or
Refresher
1. SGLT Inhibitor with CV Outcomes:
a. ACC: Jardiance
b. ADA: Jardiance >
Invokana
2. GLP-1 Agonist with CV Outcomes:
a. ACC: Victoza
b. ADA: Victoza > Ozempic >
Bydureon
If patient has CVD with CHF or CKD,
SGLT-2 inhibitor is preferred (ADA).
Choose one even if patient at A1c
goal!
Place in therapyMedication
class
A1C
lowering
Established CVD:
Recommended by ACC or
ADA-EASDADA Recommendations
PSW Formularies
Tier 1: $
Tier 2: $$
Tier 3: $$$
Tier 4: $$$$
Cost/30 days
(AWP – 2016 Q1 prices)
1 Metformin 1-2% Trend to Benefit FIRST LINE Tier 1 <$10
1
If patient has established CVD
GLP-1 agonist 0.5-1.5%
ADA: Recommends Victoza >
Ozempic > Bydureon
ACC: Recommends Victoza
1. With established CVD
2. To reduce hypoglycemia
3. To reduce weight gain
Victoza: Tier 3*
Trulicity: Tier 3
Bydureon: Tier 4*
Ozempic: Humana
Tier 3; Premera
NF/Tier 3**
Once daily:
Victoza - $475-500
Once weekly:
Ozempic - $773
Bydureon - $515
Trulicity - $508-540
2
If no established CVD
Preferred 1st Injectable per ADA
1
If patient has established CVD SGLT-2
inhibitor 0.5-1.0%
ADA: Recommends
Jardiance > Invokana
ACC: Recommends Jardiance
Favor class if CVD with CHF or
Chronic Renal Disease
1. With established CVD (esp.
with renal disease and CHF)
2. To reduce hypoglycemia
3. To reduce weight gain
Jardiance: Tier 3*
Invokana: Humana
Tier 3; Premera
Tier 3/NF**
All around $435
*same price for different
doses of same med 2
If no established CVD
2
Sulfonylurea
(glimepiride
preferred)
1-2% --- If cost is major factor
Glimepiride: Tier 1
<$10
3 Basal Insulin unlimited ---
Recommend using after GLP-1
injectable unless A1c > 11%,
symptoms of hyperglycemia, or
suspect may be type 1 diabetic
Lantus & Levemir
(vials/pens): Tier 3
Toujeo pen: Tier 3
Basaglar: NF
Tresiba: Tier 3
NPH: Tier 3
Assuming average dose of
0.45 units/kg, 120 kg pt (54
units/day, 2 vials or 1 box
pens)
Glargine: $597
Detemir: $645
NPH: $304
4TZD
0.5-1.5% --- If cost is major factor
pioglitazone: Tier 1
piog+met: Tier 2
piog+glime: Tier 2
$40-$200
Depends on if insured and
pharmacy
4 DPP-4 inhibitor0.5-0.8% --- To reduce hypoglycemia
Januvia, Janumet,
Jentadueto:
Tier 3*
All around $390
How to Choose Diabetes Pharmacotherapy
Selection Color Key: 31 42 First Choice
Option
Second Choice
Option
Third Choice
Option
Fourth Choice
Option
*Premera requires trial of metformin before coverage; **2019 Ozempic and Invokana Premera coverage may vary
GLP-1 agonists are recommended as
first injectable (ADA 2018) but start
insulin first if:
a. A1c is > 11% OR
b.Hyperglycemia is severe OR
c. Presence of symptoms or
catabolic features (weight loss,
ketosis) OR
d.Unable to achieve A1c targets on
2 agents beyond metformin
How to initiate/titrate
1.Start with basal insulin 10 units
(or 0.1-0.2 units/kg) at bedtime
2.Adjust by 3 units every 3-4 days
until fasting blood sugar is 80-
110 mg/dL
• Bolus Insulin dosing: Start
with 4 units, adjust by 1-2
units every 3-4 days until
blood sugar 2 hours after
meal with which insulin is
administered is <180
mg/dL
• Consider addition of
GLP-1 agonist OR
prandial insulin before
largest meal
(basal-plus regimen).
• Consider Basal-GLP1
combination product
If blood sugar goals not obtained or repeated
A1c not progressing as expected, consider
additional therapy as below:
If you write for vials, write for syringes.
If you write for pens, write for tips
If you are giving insulin, please make sure the patient
has test strips.
How to Use Insulin
Diabetes Care Schedule Recommendations Measure Timing Metric Definition
MonitorHemoglobin A1c at Goal:
Shared decision making
Age < 65, default < 7%
Age > 65, default < 8%
Check A1c :
Every 3 months until at goal
Every 6 months once at
goal
At Goal:
Age 18-65: A1c obtained in the past 12 months and the most recent value is < 7.0%
Age > 65: A1c obtained in the past 12 months and the most recent value is < 8.0%
Blood Pressure
Controlled:
Goal < 140/90 mmHg
(Per ADA and JNC 8)
Measure every office visit Age 18-75 and most recent BP < 140/90
Per ADA: First-line pharmacologic therapy for HTN in patients with DM: ACEI or ARB.
NB: Per JNC-8: Initial HTN treatment in DM: CCB, thiazide diuretic, ACEI or ARB in nonblack population; thiazide or CCB
in general black population.
Lipid Screening At diagnosis and
“periodically” (ADA)
Per 2013 ACC/AHA guideline: All patients with DM should be a statin, baring contraindications, HEDIS/Quality Measures
target age 40-75.
Per ADA: Screening lipid profile is “reasonable” at diabetes diagnosis, at an initial medical evaluation and/or at age 40
years, and periodically (1-2 years) thereafter.
Nephropathy Screening: Yearly Age 18-75: Urine albumin to creatinine ratio or “medical attention for nephropathy” (visit for CKD) within the last 12
months. Patients prescribed ACE I or ARB excluded from metric.
Per ADA: Refer patients with “advanced kidney disease” to nephrology. Improved quality and decreased costs for CKD
IV. Yearly urine albumin/Cr still “reasonable” in patients on ACE/ARB.
Foot Exam Yearly All patients: Complete foot exam (change in 2015 HEDIS definition) in the past 12 months. Complete foot exam includes
3 components: visual inspection and palpation, sensation testing and vibratory testing.
Per ADA: Provide general foot self-care education to all patients.
Retinopathy screening Yearly
If normal exam: Every two
years “may be considered”
(ADA)
All patients: Retinal exam performed in the past 24 months
Per ADA: 1. If no retinopathy on exam, then q2 yrs “may be considered.”
2. Optimization of blood pressure and glycemic control slow the development of retinopathy.
Diabetes Care Schedule Recommendations Measure Timing Metric Definition
Diabetics with Known
Cardiovascular Disease –
Appropriate SGLT-2 or GLP-1
At each visit If patient has diabetes and cardiovascular disease, put them on either:
SGLT2: Jardiance (ACC recommendation), Jardiance > Invokana (ADA-EASD)
GLP-1: Victoza (ACC recommendation ), Victoza > Ozempic > Bydureon (ADA-EASD)
If diabetes and ASCVD with either CHF and/or renal disease, use SGLT-2
Depression Screening Yearly All patients: Patients with a documented PHQ2 or PHQ9 in the past 12 months.
Per ADA: Age > 65 a “high-priority” population.
Diabetes Tobacco Non-UseYearly
All patients: Patient has tobacco use status documented in the diabetes flow sheet within the past 12 months.
Per ADA: Advise all patients not to smoke or use tobacco products
Pneumococcal vaccines
PPSV < age 65
PPSV and PCV > age 65
Per ADA and ACIP/CDC: Age < 65: PPSV 23 vaccine
Age > 65: Both PPSV 23 and PCV 13, separated by 12 months
Influenza vaccine
yearly
All patients: Yearly influenza vaccine (ADA and ACIP/CDC)
Treat
Statin Therapy Always age 40 to 75 Per ACC/AHA guideline (and consistent with ADA):
Age 40-75: Moderate-Intensity statin recommended unless any one of three:
10-year ASCVD risk > 7.5, LDL > 190 or clinical ASCVD then high-intensity statin recommended.
Aspirin therapy Always, as appropriate Per ADA: If ASCVD: Daily aspirin (75-162 mg) or antiplatelet medication
Also if 10 year CV risk>10%. NB: Most men > age 50 and women > age 60 with one additional major risk factor
(family hx ASCVD, HTN, tobacco use, dyslipidemia, albuminuria)
Refer
Refer to Diabetes Education
and Nutrition TherapyAt diagnosis and yearly if A1c not at
goal, and then yearly.
Most insurance provider cover these services.
ADA-EASD 2018: Glucose-lowering medication in type 2 diabetes
Melanie J. Davies et al. Dia Care 2018;41:2669-2701
2018 ACC Expert Consensus Decision Pathway on Novel Therapies for CV Risk Reduction in
Patients With Type 2 Diabetes and ASCVD (Fig 2)
• Call to action
• Where to start to apply to practice
• What resources to use and who to contact
Next Steps