DIABETES: New Insights into

Therapeutic Strategies

Lisa Ellard, MSN,CRNP, CDE

NEW, IMPROVED, ME TOO, &

NOT ALONE

u New: Sodium-glucose co-transporter 2 Inhibitors (SGLT 2)

u  Improved: Insulins – Delivery, Duration, and Dosing

u Me Too: More Dipeptidyl Peptidase 4 Inhibitors (DPP4) & More Glucagon-like peptide-1 Mimetics (GLP1)

u Not Alone: New Combinations of Oral Diabetic Medications

SGLT2 INHIBITOR MEDICATIONS:

A NEW CLASS OF DRUGS

SGLT2 INHIBITOR MECHANISM OF ACTION

SGLT2 INHIBITOR BENEFITS

u Decrease in A1c u Decrease in Blood Pressure

u Decrease in Weight

SGLT2 INHIBITOR CONTRAINDICATIONS

u  Severe Renal Impairment (eGFR <30ml) [Invokana & Jardiance (eGFR =/> 45ml)

Farxiga (eGFR =/>60)] u  End Stage Renal Disease

u  Dialysis u  Type 1 Diabetes

u  History of Diabetic Ketoacidosis u  Pregnancy and Nursing Mothers

u  Children < 18 years old

SGLT2 INHIBITOR WARNINGS AND PRECAUTIONS

u Hypotension

u Ketoacidosis

u  Impaired Renal Function

u Urosepsis & Pyelonephritis

u Hypoglycemia

u Genital Mycotic Infections

u Elevated LDL-C

u Bladder Cancer (Farxiga)

u Bone Fractures (Invokana)

SGLT2 INHIBITOR POSSIBLE SIDE EFFECTS

u  * Genital Mycotic Infections

u  * Urinary Tract Infections

u  * Increased Urination

u Ketoacidosis

u Hyperkalemia

u Elevated Creatinine

u Dehydration

u  Impaired Renal Function

u Elevated LDL-C

u Hypotension

u  Increased Risk of Bone Fractures (Invokana)

u  Increased Risk of Bladder Cancer (Farxiga)

INSULIN THERAPY: IMPROVEMENTS

New Delivery: Afrezza – Inhaled Insulin

Longer Duration: Toujeo & Tresiba New Doses: Humalog Kwik Pen

U200

NEW DELIVERY: INHALED INSULIN AFREZZA

u A rapid acting manmade inhaled insulin used to

control hyperglycemia in adults with diabetes

AFREZZA BENEFITS

u No injections required u Premeasured Cartridges

u Greater Bioavailability & Clearing u Easy Portability

AFREZZA CONTRAINDICATIONS

u COPD u Asthma u Smoking

u Pregnancy & Breastfeeding u Children (<18yo)

u DKA

AFREZZA WARNINGS AND PRECAUTIONS

u Acute Bronchospasms in patients with chronic

lung disease

u Changes in Insulin Regimen

u Hypoglycemia

u Decreased Pulmonary Function

u Hypokalemia

u Lung Cancer

u Diabetic Ketoacidosis

u Hypersensitivity

AFREZZA SIDE EFFECTS

u Hypoglycemia u Bronchospasms

u Cough

u Throat Irritation

INSULIN IMPROVEMENTS: LONGER DURATIONS

COMPARISONS OF LONGER DURATION INSULINS

Toujeo u  U300 concentration

u  450 units per pen

u  Available in boxes of 3 pens

u  Unrefrigerated shelf life is 6 weeks

u  Recommended to be given at same time of day

u  Duration of action is up to 36 hours

u  Transition to Toujeo from other long acting insulins is 1U:1U & 20%

reduction in Toujeo is recommended with transition from

BID NPH

Tresiba u  Both U100 and U200 concentrations

available

u  U100 – 300 units per pen (5/box)

u  U200 – 600 units per pen (3/box)

u  Unrefrigerated shelf life is 8 weeks opened or unopened

u  Recommended to be given same time of day once daily but may

delay by 16 hours if dose is missed

u  Duration of action is up to 42 hours

u  Transition to Tresiba from other long or immediate acting insulins is

1U:1U

NEW INSULIN DOSE: HUMALOG KWIK PEN U200

u Available in boxes of boxes of 2 pens/600 units per pen

DPP4-INHIBITORS & GLP-1 MIMETICS:

ME TOO MEDICATIONS

DPP-4 INHIBITORS

Januvia & Onglyza

+PLUS+

Nesina - Available in 6.25, 12.5, & 25mg tablets

Tradjenta - Available in 5mg tablets

GLP-1 MIMETICS Byetta and Victoza

+PLUS+

Trulicity – Available in .75 & 1.5mg Pens – sq weekly

Bydureon – Available in 2mgs Pens &

Syringes –sq weekly

Tanzeum – Available in 30 & 50mg Pens - sq weekly

COMBINATION ORAL DIABETES MEDICATIONS:

NOT ALONE

Janumet XR – Januvia+Metformin XR (100mg/1000mg, 50mg/500mg, & 50/1000mg) Jentadueto – Tradjenta+Metformin (2.5mg/500mg,

2.5mg/850mg, & 2.5/1000mg) Synjardy –Jardiance+Metformin (5mg/500mg, 5mg/1000mg 12.5/500mg, & 12.5/1000mg) Xigduo XR – Farxiga+Metformin XR (5mg/500mg, 5mg/1000mg 10mg/500mg, & 10mg/1000mg) Kazano – Nesina+Metformin (12.5mg/500mg, &

12.5mg/1000mg)

Duetact – Actos(TZD)+Amaryl(Sulfonylurea) (30mg/2mg & 30mg/4mg)

Oseni – Nesina+Actos (25mg/15mg, 25mg/30mg

25mg/45mg, 12.5mg/15mg, 12.5mg/30mg, & 12.5mg/45mg

Glyxambi – Jardiance+Tradjenta (10mg/5mg &

25mg/5mg)

IN SUMMARY

NEW CLASS OF DIABETES DRUGS – SGLT2 INHIBITORS (Invokana, Farxiga, & Jardiance)

IMPROVED DIABETES DRUGS – Insulins

(Afrezza, Toujeo, Tresiba, & Humalog U200 Pen)

ME TOO DIABETES DRUGS – DPP-4 Inhibitors (Nesina & Tradjenta)

GLP1 Mimetics (Trulicity, Bydureon, & Tanzeum)

NOT ALONE DIABETES DRUGS – Combinations with Metformin (Janumet XR, Jentadueto, Synjardy, Xigduo XR, &

Kazano) Combinations with Actos (Duetact & Oseni)

Other Combinations (Glyxambi)

THANK YOU