4/29/2019

1

Diana Emmick, MSN, ACNP-BC, CDE

St. Vincent Medical Group, Endocrinology

▪Describe diabetes treatment plans which are most appropriate in various settings

▪List new devices available and describe impact for diabetes management

TYPE 1

▪ Autoimmune

▪ Absolute insulin deficiency

▪ Increased insulin sensitivity

▪ Typically lean

▪ Must treat with INSULIN

TYPE 2

▪ Insulin Resistance

▪ May/may not be producing insulin

▪ Obese vs lean

▪ Many treatment options

4/29/2019

2

▪Treat with insulin

▪Testing: ▪ Anti-GAD antibody, islet cell antibody, zinc transporter antibody,

insulin antibody

▪ C-peptide

▪ Refer to endocrinology

INPATIENT

▪ Critically ill

▪ 140 – 180

▪ Non-Critically ill

▪ Pre meal: <140

▪ Post meals: <180

OUTPATIENT

▪ ADA

▪ Pre meal: 80 – 130

▪ 2 hour post meal: <180

▪ AACE

▪ Fasting < 110

▪ 2 hour post meal: <140

-http://inpatient.aace.com/strategies-for-

achieving-glycemic-control-management-of-

hyperglycemia-in-the-critical-care-setting

-http://inpatient.aace.com/management-of-

hyperglycemia-in-the-noncritical-care-

setting

4/29/2019

3

Metformin

DPP-4 inhibitors

SGLT2

Sulfonylurea

Glinides

TZDs

▪ Canagliflozin (Invokana)▪ 100 & 300 mg po daily

▪ Dapagliflozin (Farxiga)▪ 5 & 10 mg po once daily

▪ Empagliflozin (Jardiance)

▪ 10 & 25 mg po once daily

▪ Ertugliflozin (Steglatro)▪ 5 & 10 mg po once daily

A1C lowering: ~0.7 to 1% reduction

Caution: Renal function, yeast/UTI, hx amputations

4/29/2019

4

▪Use in type 1 diabetes →off label

▪ Increased DKA risk!▪ Lack of glucose

▪ Lack of insulin

Euglycemia DKA

→Starvation and alcoholic ketoacidosis

▪ Presenting symptoms▪ Nausea, vomiting, malaise, SOB

▪ Metabolic acidosis

▪ Check for serum ketones

▪ Start dextrose sooner than typical DKA

▪Alogliptin (Nesina)▪ 25 mg –renal dosing

▪Linagliptin (Tradjenta)▪ 5 mg – NO renal dosing

▪Saxagliptin (Onglyza)▪ 5 mg –renal dosing

▪Sitagliptin (Januvia)▪ 100 mg –renal dosing

A1C lowering: ~0.6 to 0.9 % reduction

Side effects: nasopharyngitis

Caution in: history of pancreatitis and CHF

▪ Dulaglutide (Trulicity)▪ 0.75 & 1.5 mg sc once weekly

▪ Exenatide (Byetta)▪ 5 & 10 mcg sc BID

▪ Exenatide (Bydureon)

▪ 2mg sc once weekly

▪ Liraglutide (Victoza)▪ 0.6, 1.2, 1.8 mg sc once daily

▪ Semaglutide (Ozempic)▪ 0.25, 0.5 & 1mg sc once weekly

* * *

BASAL + GLP-1

▪ Degludec/liraglutide (Xultophy)▪ 16 to 50 unit sc daily

▪Glargine/lixisenatide (Soliqua)▪ 15 to 60 unit sc daily

A1C lowering: ~1 % reduction (0.47 to 1.56 %)

Caution: pancreatitis, MTC. Common SE: nausea, weight loss

Albiglutide (Tanzeum) ~ discontinued

4/29/2019

5

CANVAS - Invokana

EMPAREG – Jardiance

LEADER – Victoza

REWIND – Trulicity

SUSTAIN6 - Ozempic

GLP-1

SGLT2

Basal Insulin

U100 insulins▪ Basaglar, Lantus, Levemir, Tresiba

U200 insulin▪ Tresiba U200

▪ Delivers in 2 units increments

U300 insulin▪ Toujeo Solostar – 1 unit increment

▪ Toujeo Max

▪ 2 units increments

4/29/2019

6

▪Longer duration of action (up to 36 & 42 hours)

▪ Injecting smaller volume

▪Larger dose all in one injection (160 units)

▪Longer shelf life

▪Aspart (Fiasp & Novolog)▪ Fiasp – onset ~2.5 minutes

▪Lispro (Admelog & Humalog)▪Humalog U200 – 2 units increments

▪Glulisine (Apidra)

$25 per Vial

4/29/2019

7

✓ More than 200 units/day

✓ BID to QID dosing

✓ Acts as basal & prandial

✓ Pen or Vial

*Actual vs measured units

Onset: 0.5 -1 hr

Peak: 2 - 4 hours

Duration: up to 24 hours

▪ Insulin is preferred treatment

▪Stop oral antihyperglycemic agents and injectables

▪Combination of basal & bolus insulin▪ 50 – 50% split

4/29/2019

8

▪Anticipate hyperglycemia

▪Diabetes status?

▪Bolus vs Continuous feeds

Treatment:

➢Correction insulin only

➢Basal + Correction

➢Basal + Rapid/Regular insulin + Correction

Watch out for Abrupt discontinuation

Intravenous ~ Oral ~ Intra-articular

▪Anticipate hyperglycemia

▪Steroids are counter regulatory hormone▪ Impair insulin action

→Increase insulin resistance

▪Appears to diminish insulin secretion

▪ Insulin = preferred treatment▪ Basal & Bolus insulin

▪ Increased prandial insulin needs

▪ Insulin infusion

▪Severe and persistent hyperglycemia

4/29/2019

9

Pre-procedure

▪Hold metformin 24 hours before and 48 hours after

▪Sulfonylurea/insulins – cut down▪Consume around same amount of carbs

▪Not all ‘sugar free’ items

▪Basal insulin ~ ½ usual dose night before

▪Bolus insulin▪Continue carb count during prep

▪ Sliding scale coverage

Intra-operative

▪ Insulin infusion if long procedure- open heart

Post surgery/procedure

▪ If taking diet, resume usual doses

▪NPO: basal insulin and correction doses

~Glycemic control is very important for healing process

4/29/2019

10

Newly diagnosed:

▪Metformin▪Must document why not taking it

▪ Intolerance

▪Contraindication

▪GFR <30

▪ Alcohol abuse

▪ Lactic acidosis

Metformin

DPP-4 inhibitors

SGLT2

Sulfonylurea

Glinides

TZDs

▪Oral agents

▪Injectables

▪Insulin ▪Basal + Oral/injectable

▪Basal and bolus

4/29/2019

11

▪Any uncontrolled patient

▪Already on multiple oral/injectable agents

▪Multiple intolerances

▪Pregnancy

▪Unsure of diabetes type

▪Must use INSULIN

▪Divided doses ▪50% basal

▪50% bolus

▪Diabetes education

▪Carbohydrate counting

4/29/2019

12

PROS

▪Variable insulin needs

▪Ease to bolus

CONS

▪DKA risk

▪Always connected

Small electronic device that delivers insulin based on pre-

programmed settings

▪ Pump terms:

Basal rates – individualized hour by hour

Bolus rates: Carbohydrate ratio

Correction/sensitivity factor

➢ ‘Sensors’

➢ Interstitial glucose

➢ Separate site

➢ Calibrations

➢ Integrated into

pump

4/29/2019

13

Freestyle

Libre

Medtronic

DexCom

How can Continuous Glucose Monitoring

impact diabetes management?

4/29/2019

14

Targets

▪Hypoglycemia < 3 %

▪Time in Range > 70 %

4/29/2019

15

▪Professionally inserted

▪90 day wear (up to 6 months)

▪Removable transmitter▪ Sensor not wasted

▪On body vibe

▪FDA approved for MRI

▪3 months accuracy 8.5 % MARD (40 -400 mg/dl)

4/29/2019

16

▪Glucose trends

▪Alert at/before glucose excursion

▪ Increase time in range

▪ Increased awareness

▪Do NOT rely only on A1C▪ Fingerstick/sensor readings very important

▪ ESRD, blood transfusion, etc

▪A1C lowering from >14 to 9% is relatively easy▪ Tougher zone A1C 8.5 to 6.5 %

▪Hypoglycemia risk increases with stricter diabetes control

4/29/2019

17

▪GLP-1 and DPP4

▪Sulfonylurea dosing▪ 50% of maximum dose or LESS

▪No basal sliding scale

Thank you