Patient Case Discussion in Type 2 Diabetes

7/26/2019 Patient Case Discussion in Type 2 Diabetes

1/25

Patient Case Discussioin Type 2 Diabetes

What Intensifcation Plan is Best?


2/25

Outline

Introduction Diagnostic Criteria

Treatment Goals

Intensifcation Guidelines Changes in i!estyle and "#ercise$

Oral %gents$

Basal Insulin %nalogs$

Insulin Intensifcation

Case Presentations


3/25

Introduction

Type 2 Diabetes &ellitus 'De!n??(

Important to stay ) step aheado! T2D&$

Intensi!ying antihyperglycemictherapy re*uires+

Guideline recommendations '%D%

, %%C"($ -a!e and e.ecti/e plans based on

indi/idual cases$

Intensifcation in order to meetcertain goal$


4/25

Introduction

Diabetes is not a*uic1 f#$ egular !ollo34ups

needed$

Treatment adherence

is crucial$ Discuss goals o!treatment$

"ducate patients$


5/25

Diagnostic criteria

6asting Plasma Glucose$ Impaired 6asting Glucose$

Impaired Glucose Tolerance$

Plasma Glucose$

Glycated 7emoglobin$


6/25

Treatment Goals+ 9onpregnant %'Out Patient(

Parameter Treatment Goal

%)C ':(

Indi/iduali;e on the basis o! age$8 !or most Closer to normal !or healthy ess stringent !or @less healthyA

6PG 'mgd( ))

247our PPG 'mgd( )5

FPG = fasting plasma glucose; PPG = postprandial glucose.

Pro/ided target can be sa!ely achie/ed$


7/25

Treatment Goals+ Pregnant Wome'Out Patient(

Condition Treatment Goal

Gestational diabetes mellitus (GDM)

Preprandial glucose< mgd =E8

)47our PPG< mgd =)5

247our PPG< mgd =)2

Preexisting T1D or T2D

Premeal< bedtime< and o/ernight glucose4EE

Pea1 PPG< mgd )4)2E

%)C =>$:

FPG = fasting plasma glucose; PPG = postprandial glucose.



8/25

Treatment Goals+ 9onpregnant %'In Patient(

Hospital Unit Treatment Goal

Intensive!riti!al !are

Glucose range< mgd )54)

General medi!ine and surger"# non$ICU

Premeal glucose< mgd )5

andom glucose< mgd )

ICU = intensive care unit.



9/25

Intensifcation Guidelines

Is a principle 3hichemphasi;e patient should betreated based on+

%ge

Degree o! complication

Other co4morbid conditions Intensifcati

on Therapy

i!estyleChange

and"#ercise

%Oral %gents


10/25

Changes in i!estyle and "#ercis

i!estylemanagement is anintegral part o! T2D&management$

ealistic plan !or dietand physical acti/ityis necessary$

0

2

4

!

"0

"2

4.!

#.!

Intensive lifestyle

intervention*

(n=1079)

T2DMi

ncidence

per100person-years

Metfor"in

!#0 "$ %ID

(n=107&)

#!'

&1'

$Goal% #& reduction in 'aseline 'od( )eig*t t*roug* lo)+calorie, lo)+fat diet and -"0 min/)ee modera

PP, ia'etes Prevention Program; IG3, impaired glucose tolerance; 32, t(pe 2 dia'etes.

PP esearc* Group. N Engl J Med. 2002;54%565+405.


11/25

Oral %gents


12/25

Oral %gentsClass Primar" Me!%anism o& '!tion 'gent(s) 'vailable as

4Glucosidase

inhibitors

Delay carbohydrate

absorption !rom intestine

%carbose

&iglitol

Precose or gen

Glyset

%mylin analogue

Decrease glucagon secretion

-lo3 gastric emptying

Increase satiety

Pramlintide -ymlin

Biguanide

Decrease 7GP

Increase glucose upta1e in

muscle

&et!orminGlucophage orgeneric

Bile acidse*uestrant

Decrease 7GP?

Increase incretin le/els?Colese/elam WelChol

DPP45 inhibitors Increase glucose4dependent

insulin secretion

Decrease glucagon secretion

%logliptininagliptin-a#agliptin-itagliptin

9esinaTradHentaOngly;aanu/ia

Dopamine42agonist

%cti/ates dopaminergic

receptors

Bromocriptine

Cycloset

Glinides Increase insulin secretion9ateglinideepaglinide

-tarli# or generPrandin

"2

PP+4 = dipeptid(l peptidase; 7GP = *epatic glucose production.

Gar'er 89, et al. Endocr Pract. 20"5;"6:suppl 2%"+4!. In, et al. Diabetes Care. 20"2;5%"54+"5#6.


13/25

Oral %gentsClass Primar" Me!%anism o& '!tion 'gent(s) 'vailable as

GP4) receptoragonists

Increase glucose4dependent

insulin secretion Decrease glucagon secretion

-lo3 gastric emptying

Increase satiety

%lbiglutide

Dulaglutide"#enatide"#enatide Jiraglutide

Tan;eum

TrulicityByettaBydureonKicto;a

-GT2 inhibitors Increase urinary e#cretion o!

glucose

CanagliLo;inDapagliLo;in"mpagliLo;in

In/o1ana6ar#igaardiance

-ul!onylureas Increase insulin secretion

GlimepirideGlipi;ideGlyburide

%maryl or geneGlucotrol orgeneric

Diaeta< Glyna

&icronase< orgeneric

Thia;olidinediones

Increase glucose upta1e in

muscle and !at

Decrease 7GP

Pioglita;oneosiglita;one

%ctos%/andia

"5

G?P+" = glucagon+lie peptide; 7GP = *epatic glucose production; G?32 = sodium glucose cotransporter 2.

Gar'er 89, et al. Endocr Pract. 20"5;"6:suppl 2%"+4!. In, et al. Diabetes Care. 20"2;5%"54+"5#6.


14/25


15/25

Intensifcation Plan+ &ono< Dual< anTriple Therapy !or T2D&

"

8GI = +glucosidase in*i'itors; @C+A = 'romocriptine Buic release; Coles = colesevelam; PP4I = dipeptid(l peptidase 4 in*i'itors;G?P"8 = glucagon+lie peptide " receptor agonists; et = metformin; G?32I = sodium+glucose cotransporter 2 in*i'itors; U =sulfon(lureas; 3D = t*ia


16/25

Basal Insulin %nalogs

DoesnRt ha/e to be permanent$ -a!e and e.ecti/e$

But o/erly aggressi/e hypoglycemia$

7ypoglycemia Cogniti/e , psychological changes$

%ccidents , !alls$ CK ".ects$


17/25

Pharmaco1inetics o! Insulin'gent

+nset(%)

Pea, (%)Duration

(%)Considerations

-asal

9P7 245 54) )4)> Greater ris1 o! nocturnal hypoglyce

to insulin analogs

GlargineDetemir

S)45 9o pronouncedpea1

p to 25N ess nocturnal hypoglycemia comp

-asal$

Prandial

egular 48 =$8 S240 )2425 InHect 0 min be!ore a meal Indicated !or highly insulin res

indi/iduals se caution 3hen measuring d

inad/ertent o/erdose

Prandial

egular S$84) S240 p to &ust be inHected 0458 min be InHection 3ith or a!ter a meal c

ris1 !or hypoglycemia

%spartGlulisineisproInhaled insulin

$8 S$842$8 S048 Can be administered 4)8 min ess ris1 o! postprandial hypog

compared to regular insulin

$ >1*i'its a pea at *ig*er dosages.

E ose+dependent.

P7, eutral Protamine 7agedorn.og*issi > et al. Endocr Pract. 20"5;"6%2+5. 7umulin U+00 :concentrated insulin prescri'ing information. Indianapolis% ?ill( U8, ??C.


18/25


19/25


20/25


21/25

Case Discussion )


22/25

Case Discussion 2 54year old 7ispanic 3oman comes to her doctor

recommendations about her 3eight$ -he is married<

2 children in school and 3or1s !ull time as a boo11ee-he eats brea1!ast and dinner at home< and buys luat /arious locations$


23/25

Case Discussion 0ohn is a 88 year4old Caucasian man 3ith diabet

and asthma$ 7e teaches math at a local high schoin 9e3 or1 City$ 7e 3as diagnosed 3ith typediabetes on blood tests per!ormed 3hen he appli!or li!e insurance at age 8)$ %t the time< he 3obese< 3eighing 22 pounds at 8 !eet< ) inch

height 'B&I U 0)$>($ With 7b%)c le/el o! F$2:$


24/25

e!erences

Management of hyperglycemia in type 2 diabetepatient-centered approachV Diabetes care< /olum0854)0V -il/io "$In;ucchi

Patient case discussions in TD: what intensicatiis best?V&edscape educationV uingi 6$&eneghin


25/25

Documents

Patient Case Discussion in Type 2 Diabetes