Barriers to Diabetes ControlBarriers to Diabetes Control

Mark E. Molitch, MD

NHANES: Achieving ADA Recommendations, 2003-2006

• Individuals reaching glycemic control targets:• HbA1c <7% 57.1%

• Individuals achieving other ADA goals of therapy:• BP <130/80 mm Hg 45.5%• LDL <100 mg/dL 46.5%

• Only 12.2% of individuals met all 3 goals

Abbreviations: BP, blood pressure; HbA1c, glycosylated hemoglobin; LDL, low-density lipoprotein;

NHANES, National Health and Nutrition Examination Survey

Cheung BM, et al. Am J Med. 2009;122:443-453.2

Treatment Algorithm for Type 2 Diabetes

NOT glyburide, chlorpropamide NOT rosiglitazone

Intensive insulin

At diagnosis:

Lifestyle + MetforminSTEP 1

STEP 2

STEP 3

Add basal

insulin

Add

sulfonylurea

Add GLP-1

agonist

Add

pioglitazone

HbA1c >7.0%

Add DPP-4

inhibitor

Abbreviations: DPP-4, dipeptidyl peptidase-4; GLP-1, glucagon-like peptide

Nathan DM, et al. Diabetes Care. 2009;32:193-203.4

Combination Therapy in Type 2 Diabetes:Decision Considerations

HbA1c efficacy Reductions from baseline Reaching target

Synergy of mechanisms of action Side effects and toxicity profile Frequency and severity of hypoglycemia Effect on weight gain Avoiding polypharmacy and complex

regimens Compliance and convenience Cost

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Barriers to Diabetes Control

• Clinical inertia• Financial• Adverse effects of oral agents• Insulin

• Fear of injections• Fear of hypoglycemia• Complexity of management

• Targets of treatment• Need to adjust to individual patient

• Cultural

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Earlier and More Aggressive Intervention May Improve Treating to Target Compared With Conventional Therapy

Monotherapy

Uptitrate dose of monotherapy

Add 2nd and then 3rd drug

Add basal insulin then

multiple insulin injections per

day

Typical progression is to wait for HbA1c to reach 8–9%

before moving to next step

Moving more aggressively

to more potent treatment can

achieve goal of HbA1c

of < 7% more quickly

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Advantages & Disadvantages of Type 2 Diabetes MedicationsClass (examples) Potency Risk of hypoglycemia Weight Other

Sulfonylureas (glipizide, glyburide, glimepiride)

+++ +++ Greatest increase

Less likely to maintain control as monotherapy

Meglitinides (nateglinide, rapaglinide)

+ ++ Increase Short acting

Metformin +++ + Neutral GI intolerance, rare lactic acidosis

Thiazolidinediones (Rosiglitazone, Pioglitazone)

++ + Greatest increase

Fluid retention, worsen CHF, fractures. Risk of cardiac events.

α-Glucosidase inhibitors (acarbose, miglitol)

+ + Decrease Intestinal gas, poor tolerance

DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin)

+ + Neutral Headache, risk of infection

GLP-1 analogs (exenatide, liraglutide)

+ + Decrease Injection, GI effects

Insulin +++ +++ Greatest increase

Injection

AACE/ACE Diabetes Algorithm for Glycemic Control. Endrocr Pract. 2009;15:540-559.

Barriers to Insulin Therapy: Common Concerns

Insulin therapy might cause:

• Worsening insulin resistance

– But reduction of glucose toxicity improves resistance

• More cardiovascular risk

– But reduction in glucose improves cardiovascular risk

• Weight gain

– Yes, it does occur with improved metabolic efficiency

• Hypoglycemia

– Very rare with type 2 diabetes

– Common with type 1 diabetes as approaching optimum glycemic control

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• Rapidly growing populations• High rates of type 2 diabetes and its complications• Groups with unique culture, health beliefs, myths,

and food preferences• Diverse level of education and socio-economic status• Insufficient culturally oriented diabetes care, education,

and research programs • Health care system and health professional barriers

Cultural competency is key to approaching patients in a beneficial way

Challenges and Opportunities in Minority Populations

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Why We Cannot Always Extrapolate to Older Adults with Diabetes

• Heterogeneity• Comorbid conditions

– Functional limitations– Cognitive decline

• Polypharmacy• Life expectancy versus

– Time to incidence or progression of microvascular or macrovascular complications

– Time to expected benefit of intervention

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