Meds Management ADA EASD 2018 - Diabetes Education …...ADA /EASD –Either SGLT2 or GLP1 ADA / EASD –Sulfonylurea? Insulin (NPH, Reg, 70/30)? Life Study 54 year old, smokes, hxof

Copyright Diabetes Education Services© 1998-2018 www.DiabetesEd.net Page 1

2018 Type 2 Meds Management ADA/EASD

www.DiabetesEd.net

Beverly Dyck Thomassian, RN, MPH, BC-ADM, CDEPresident, Diabetes Education Services

Please download PocketCards at DiabetesEd.net

PocketCards

Free on CDE® Coach AppConstantly updatedApp users receive priority notificationDownload on Website

DiabetesEd.net

Diabetes Meds Management for T2. Objectives

1. Describe the main action of the

different categories of type 2 diabetes

medications.

2. Discuss using the 2019 ADA & EASD

Guidelines to determine best

therapeutic approach.

3. Using the ADA and EASD

Guidelines, describe strategies to

initiate and adjust insulin therapy.


Please download and review

Poll Question 1

� Do you discuss medication adjustment with

your patients?

A. Yes – frequently

B. Yes – sometimes

C. Not usually

D. Not at all

Path to Type 2 Diabetes


Patti Labelle

"divabetic”

“I have diabetes, it

doesn’t have me”

BMI Categories


Natural Progression of Type 2 Diabetes

-20 -10 0 10 20 30

Years of Diabetes

Relative β-Cell

Function

PlasmaGlucose

Insulin resistance

Insulin secretion

126 mg/dLFasting glucose

Postprandial glucose

Prior to diagnosis After diagnosis

Adapted from Bergenstal et al. 2000; International Diabetes Center.

Poll Question 2

� Which of the following match ADA's and EASD

philosophy regarding hyperglycemia

management?

A. Encourage compliance

B. Start with metformin and lifestyle

C. Maintain A1c less then 6.5%

D. Avoid SGLT-2 Inhibitors if GFR is less than 60

Antihyperglycemic Therapy – 1st Step

� Metformin plus

� Lifestyle Changes� Weight control

� Healthy eating

� Activity


Medication Taking Behaviors� 23% of time, if A1c, B/P, lipids

above target - due to med taking behavior

� Adequate medication taking is defined as 80%

� If pt taking meds 80% of time and treatment goals not met, intensification should be considered.

� Barriers to taking meds include:� Forgetting to fill Rx, fear, depression, health

beliefs, medication complexity, cost, system factors, etc

� Work on targeted approach for specific barrier

Diabetes Agents Considerations

� Diabetes medications can be

used as monotherapy, in combo

or with insulin

� Meds reduce A1c 0.5 – 2.0%

� Each new added class drops A1c

an additional 0.7- 1.0%

� Not to be used during

preconception, pregnancy or

when breastfeeding


Clinical Inertia Happens

� Reassess every 3-6

months

peripheralglucose uptake

hepatic glucose production

pancreatic insulinsecretion

pancreatic glucagonsecretion

gutcarbohydratedelivery &absorption

incretineffect

HYPERGLYCEMIA

?

Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011

Multiple, Complex Pathophysiological Abnormalities in T2DM

_

_

+renal glucose excretion

Biguanide derived from:Goat’s Rue Galega officinalis,French Lilac


Approved for CV Disease


peripheralglucose uptake

hepatic glucose production

pancreatic insulinsecretion

pancreatic glucagonsecretion

gutcarbohydratedelivery &absorption

incretineffect

HYPERGLYCEMIA

?

Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011

Multiple, Complex Pathophysiological Abnormalities in T2DM

_

_

+renal glucose excretion

Dopamine R agonists

T Z D sMetformin

S U sGlinides

DPP-4 inhibitors

GLP-1Ragonists

A G I s

Amylinmimetics

Insulin

SGLT2 Inhibitors

Glycemic Targets - ADA

� Adult non pregnant A1c goals

� A1c < 7% - a reasonable goal for

adults.

� A1c < 6.5% - may be appropriate for

those without significant risk of

hypoglycemia or other adverse effects

of treatment.

� A1c < 8% - may be appropriate for

patients with history of hypoglycemia,

limited life expectancy, or those with

longstanding diabetes and vascular

complications.


American Association of Clinical

Endocrinology (AACE) Glycemic Goals

� Before meals� Less than 110

� After meals� Less than 140

Step Wise Approach to Hyperglycemia

ADA 2018� Step 1 – Metformin + Lifestyle

� Step 2 - If A1c target not achieved after 3 months, Metformin + another med� If CV Disease, consider adding a second agent with CV risk

reduction (based on drug effects and patient factors).

� SGLT-2 Inhibitors – empagliflozin (Jardiance) and canagliflozin (Invokana)

� GLP-1 Receptor Agonist – liraglutide (Victoza)

� Step 3 - If A1c target still not achieved after 3 months, combine metformin plus two other (3 drugs)

� Step 4 - If A1c target is still not achieved after 3 months, add combo injectable therapy to 3 drug combination.

Treating Hyperglycemia with Meds

� For all of the following case

studies, we assume we are

providing ongoing education on

lifestyle – including referral to a

RD and diabetes educator.

� In describing what meds match

the patient best, I am speaking

as an advocate for patients and

a consultants to providers.


Poll Question 3

� What factors do you consider when deciding

what is the best medications for patients?

(multiple answers)

A. cost

B. risk of hypoglycemia

C. impact on body weight

D. kidney function

E. person’s willingness to take med

Cardiovascular Disease is the

Leading Cause of Death in

Diabetes


Heart Disease & DM = 3-5xs Risk� CHF

� 7.9 % w/ diabetes vs.

� 1.1 % no diabetes

� Heart attack � 9.8 % w/ diabetes vs.


� Coronary heart disease � 9.1 % w/ diabetes vs.


� Stroke � 6.6 % w/ diabetes vs.

� 1.8 % no diabetes� 2007 AACE

To determine next med step, Assess for CVD

� 15-25% of people with diabetes

have ASCVD (Atherosclerotic Cardiovascular Disease)

� When adding meds, consider presence or absence of established� ASCVD

� HF (Heart Failure) and

� CKD (Chronic Kidney Disease)

� Recent trials demo that SGLT2 and GLP-1s improve CV outcomes� Also decrease heart failure and improve

kidney function.

ASCVD Defined in Outcomes Trials

� Established CVD

� Previous event - Heart attack, Stroke,

or required revascularization procedure

� Clinically significant

atherosclerosis

� Transient ischemic attack, hospitalized

for unstable angina, amputation,

congestive heart failure, >50% stenosis

of any artery, coronary artery disease

� CKD with GFR < 60


Bottom Line – Diabetes and CVD

� If not meeting A1c target

on metformin

� Add SGLT2 or GLP-1 RA to

treatment regimen

� There is no evidence to

date of CV protective

benefit of using these meds

in people with A1c <7 and

no history of ASCVD.


People with ASCVD + Heart Failure

� Use SGLT2 Inhibitors

� People with diabetes are at risk

of HF

� Use of SGLT2 decreases

hospitalization for HF

� 5.5 vs 8.7 event per 1000 pt years

(EMPA-REG Trial and CANVAS

Program)

Diabetes + CKD – Consider SGLT2

� Diabetes + CKD = increase

CVD Risk

� In several studies, participants on

SGLT2 with GFRs of 30-60 (stage

3) reduced ASCVD risk

� In addition to reducing ASCVD

risk, those on SGLT2 and GLP-1s

had improved renal function

� Slowed kidney disease or death

� Most consistent improvement with

SGLT2s


Poll question 4

� For someone trying NOT to gain weight, which

medication(s) would you consider?

A. Sulfonylureas

B. Metformin

C. GLP-1 Receptor Agonists

D. SGLT-2 Inhibitors

E. DPP-IV Inhibitors

When goal is to avoid weight gain

� These meds are weight neutral� Metformin

� DPP-IV Inhibitors: sitagliptin, saxgliptin, linagliptin, alogliptin

� Acarbose

� These meds associated with wt loss� GLP-1 agonists (exenatide, liraglutide,

dulaglutide, semaglutide)

� SGLT-2 Inhibitors (Canagliflozin, Dapagliflozin, Empagliflozin, Ertugliflozin)

� Symlin (Pramlintide)

When goal is to avoid Hypoglycemia

� Avoid sulfonylureas

� Careful insulin dosing

� May need to up adjust glucose goals

� Monitor kidney function

� Reinforce for patients on insulin to “PIE”

� Poke

� Inject

� Eat


Poll Question 5

� Which are your meds of choice for

someone who is cash pay?

(multiple)

A. Januvia

B. Glipizide

C. Lantus

D. NPH

E. Metformin

Metformin / Sulfonylureas generic3 month supply for about $10Walmart, Target, others

NPH, Reg and 70/30 ReliOn Insulin $25 a vial (1000 units) at Walmart


When goal is to minimize cost

� Go generic.

� Oral Meds -Metformin and Sulfonylureas� Walmart, Target and others

� 3 mo supply of following meds for ~ $10

� Metformin and Metformin XR

� Glipizide, Glyburide, Glimepiride

� Insulins – Oldies but Goodies � NPH, Regular, 70/30 mix

� $25 a vial at Walmart – ReliOn

� Also have ReliOn� Syringes, meters, strips

Life Study

� 61 year old overweight woman with type 2

diabetes 3 months. Has been trying to control

diabetes with diet and exercise. GFR in 90s.

Worried about weight gain.

� Most recent A1c 7.2%

� ADA /EASD

� AACE

� Cash pay


Life Study - Answer

� 61 year old overweight woman with type 2

diabetes 3 months. Has been trying to control

diabetes with diet and exercise. GFR in 90s.

Worried about weight gain.


� ADA / EASD - Metformin

� AACE - Metformin

� Cash pay - Metformin

Life Study

� 67 year old overweight man with type 2 on

metformin 2000mg daily for past 6 months.

Had revascularization surgery last year.

GFR >60. Most recent A1c 8.1%.

� What is next step?

� ADA /EASD – has good insurance

� ADA / EASD – big copay


Life Study

� 67 year old overweight man with type 2 on

metformin 2000mg daily for past 6 months.

Had revascularization surgery last year.

GFR >60. Most recent A1c 8.1%.

� What is next step?

� ADA /EASD – Either SGLT2 or GLP1

� ADA / EASD – Sulfonylurea?

Insulin (NPH, Reg, 70/30)?

Life Study� 54 year old, smokes, hx of

stroke.

� GFR in 60s.

� Not checking BG, even though he has glucose meter.

� On Metformin 500mg BID for past 4 months.

� Had bad experience with hypoglycemia on glyburide.

� Most recent A1c 8.9%� ADA / EASD

� Big deductible


Life Study� 54 year old, smokes, hx of

stroke.

� GFR in 60s.

� Not checking BG, even though he has glucose meter.

� On Metformin 500mg BID for past 4 months, GI upset

� Had bad experience with hypoglycemia on glyburide.

� Most recent A1c 8.9%� ADA / EASD

� Big deductible

Solution:• Change to Metformin XR and double

doseIf that still doesn’t work

• Add SGLT-2 or • Add GLP-1 • If $ an issue, consider adding

SU or insulin

Life Study

� 71 year old woman with type 2 diabetes for

past year. BMI 27. Has been trying to control

diabetes by limiting carbs and exercise.

Creat 1.6, GFR high 40s, with CHF. Good social

support.


� She has great insurance or

� She is cash pay

� Other referrals


• Reduced life expectancy

• Higher CVD burden

• Reduced GFR

• At risk for adverse events from

polypharmacy

• More likely to be compromised

from hypoglycemia

Less ambitious targets

A1c <7.5–8.0%

Focus on drug safety

Diabetes Care 2012;35:1364–1379

Diabetologia

2012;55:1577–1596

Older Adults - Considerations

Life Study

� 71 year old woman with type 2 diabetes for

past year. BMI 27. Has been trying to control

diabetes by limiting carbs and exercise.

Creat 1.6, GFR high 40s with CHF. Good social

support.


� Great insurance – SGLT2

� Cash pay – Sulfonylurea

� Other referrals?


What next?

� 69 year old male, BMI 28, on Metformin 2000mg a day, Glipizide 40mg a day and Empagliflozin 25mg a day.

� A1c 10.1%. GFR 50s.

� Pt c/of foot pain, polyuria, 11 yr diabetes� ADA / EASD What next?

� Insurance

� No insurance

PocketCard – Great Study Tool


What next?� 69 year old male, BMI 28, on

Metformin 2000mg a day, Glipizide 40mg a day and Empagliflozin 25mg a day.

� A1c 10.1%. GFR 50s.

� Solutions� Insurance – Add Basal + GLP-1 combo or

� Start basal insulin, then add GLP-1, then bolus insulin (stop glipizide)

� No insurance – Stop Glipizide?, keep metformin add 70/30 insulin � Add 70/30 insulin 1-2 times a day

� 100kg x 0.5 = 50 units daily (30units am/ 20units dinner)

Case Study

� 70 yr old, weighs 100kg

� History of CABG, tobacco

� A1c – 11.3%, BG 400-500 for past weeks

� What will inform you of how to proceed?

� Insurance coverage

� His willingness to stick to a complex regimen

� His ability to self-monitor

� His social support and connection to his medical team


Critical Points� Individualize Glycemic targets & BG-lowering

� Metformin = optimal 1st-line drug.

� Diet, exercise, & education: foundation T2DM therapy

� After metformin, second med based on ASCVD Risk, kidney function, and Heart Failure status.

� Also consider cost, risk of hypo and weight gain.

� Most important, all treatment decisions should be made in conjunction with the person’s preferences, needs & values.

Thank You� Thanks for joining us!

� Please let us know if we

can be of more service to

you.

� www.DiabetesEdUniversity.net

Documents

Meds Management ADA EASD 2018 - Diabetes Education …...ADA /EASD –Either SGLT2 or GLP1 ADA / EASD –Sulfonylurea? Insulin (NPH, Reg, 70/30)? Life Study 54 year old, smokes, hxof