Clinical Update in Type 2 Diabetes

• A Case Discussion• Dr. Yancey R. Holmes, MD, FACE• Ohio Valley Endocrinology

Topics for Discussion

• Glycemic Targets• Therapeutic Agents• Case Discussion

Glycemic Targets

American Diabetes AssociationAmerican Association of Clinical Endocrinologists

HbA1cFasting glucosePost prandial glucoseHypoglycemia

Pharmacologic Agents

• Sulfonylureas and Meglitinides• Metformin• Alpha-glucosidase Inhibitors• Thiazolidinediones• Dipeptidyl Pepdidase-4 Inhibitors

Pharmacologic Agents

• Welchol• Incretin Mimetic• GLP-1 AgonistsGLP-1 Analogs• Amylin Analogs

Pharmacologic Agents

Human InsulinRegularNPH

Analog InsulinRapidBasalMix

Special Considerations

• Heart Disease• Renal Impairment• Liver Disease• Frailty• Weight Gain

Case Discussion

Case 1

• 56 year old man referred by cardiologist• Diabetes diagnosed during hospitalization

for acute MI associated with pulmonary edema

• BMI 32 NYHA Class III functional status

Case 1

• HbA1c 8.6%• Serum creatinine 1.3• Discloses that he “ain’t takin’ no damn

shots!”

Case 1 Discussion

• Drug naive patient with ischemic heart disease and systolic dysfunction

• Confrontational needle-phobe

Case 1

• Metformin: Will it get to goal?• Sulfonylurea: Hypoglycemia concerns?• TZD’s: Fluid retention?• DPP-4 Inhibitors?

Case 2a

• 42 year old woman referred by friend• Strong family history. Symptoms of post

prandial fatigue.• Currently at her highest body weight.• Exercise is infrequent

Case 2a

• BMI 36• HbA1c 7.8%• Expresses a good understanding of

recommended lifestyle changes.

Case 2a

• Metformin• Sulfonylurea• TZD• DPP-4• Injections???

Case 2b

• After successful adoption of healthy lifestyle changes and metformin she maintains HbA1c less than 6.5% over the next three years

• She presents for follow up to discuss options to address weight gain and diabetes

• BMI 32

Case 2b

9 months ago HbA1c 7.3%Metformin was titrated to 1000 mg bid

6 months ago HbA1c 6.4%Back on track with exercise and associated 6 pound weight loss

Case 2b

3 months ago HbA1c 7.1%Recent job change, stressed out. Feels certain she can get back on track without additional medicaiton

Now HbA1c 7.8%Weight is up 12 pounds from last visitVery frustrated with weight gain and constant hunger

Case 2b

• Metformin titration to 2500 mg?• Addition of Sulfonylurea?• Addition of TZD?• Addition of DPP-4 Inhibitor?• Addition of Basal Insulin• Addition of a GLP-1 Agent

Case 3a

• 40 year old man currently on Metformin and SU maximal dose

• FBG 160-180• PPG 160-200• HbA1c 8.2%• BMI 27

Case 3a

Addition of third oral agent?Addition of GLP-1/AmylinIntroduction of insulin?

Human vs. Analog?What kind of dosing regimen?

Case 3b

• Addition of basal insulin helped maintain good glycemic control over the next 18 months

• Now HbA1c 7.8%• FBG 100-140• PPG 180-220

Case 3b

• Oral agents?• Mealtime insulin• Mealtime amylin• Should anything be discontinued?

Case 4a

38 year old man presents for assessment after family member tests a blood sugar of 400He has already adopted many good dietary changes and saw the educator at the health departmentBlood sugars range from 180-250HbA1c 9.8%BMI 31

Case 4a

• Metformin with continued lifestyle modification?

• Combination agent?• Insulin?• GLP-1/Amylin?

Case 4b

• After 5 years of maintaining HbA1c <7% on combination Metformin+TZD blood sugars are elevated

• HbA1c 8.2%• 15 pound weight gain over past 3-6 months

Case 4b

• Third oral agent?• Insulin?• GLP-1/Amylin?

Case 560 year old woman with type 2 diabetes for 2 years treated with SUHbA1c has ranged from 8.2-6.8% over that time. Currently it is 7.5%Recent attempts to titrate SU have lead to frequent hypoglycemia, particularly with exerciseShe has been trying to exercise to stop her steady weight gain of 20 pounds over the past year

Case 5

• Metformin?• DPP-4?• TZD?• Insulin?• GLP-1/Amylin?

Case 6

• 36 year old woman recently relocated to your area presents for first visit

• Diabetes diagnosed last year.• Subacute onset of symptoms with passive

15 pound weight loss• Started on Metformin and titrated to 1000

mg twice daily with good response

Case 6

• Over past two months she has had recurrence of symptoms

• Blood sugars frequently in the 300+ range• No change in routine• Has experienced a 25 pound passive weight

loss• HbA1c now 10.5%

Case 6

• Additional oral therapy?• GLP-1/Amylin?• What is her diagnosis?

Thank you