DIABETES MEDICATIONS 101: NAVIGATING THROUGH ALGORITHMS, GUIDELINES, AND CASE STUDYS

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OBJECTIVES DIABETES MEDICATIONS 101: NAVIGATING THROUGH ALGORITHMS, GUIDELINES, AND CASE STUDYS Angela Thompson DNP (c ), FNP-C, BC-ADM, CDE Review statistics surrounding diabetes Discuss diabetes

1 OBJECTIVES DIABETES MEDICATIONS 101: NAVIGATING THROUGH ALGORITHMS, GUIDELINES, AND CASE STUDYS Angela Thompson DNP (c ), FNP-C, BC-ADM, CDE Review statistics surrounding diabetes Discuss diabetes medical management guidelines & algorithms Verbalize general action & a1c reduction of diabetes medication classes Recognize precautions & considerations in prescribing diabetes medications ADA= American Diabetes Association AACE= American Association of Clinical Endocrinologists ACE= American College of Endocrinology 2014 DIABETES SNAPSHOT 29.1 million people have diabetes or 9.3% of the population 7 th leading cause of death Total costs associated with diabetes $245 billion Direct medical costs $176 billion Indirect medical costs $69 billion DIABETES IN INDIANA 825,400 adults or 12.6% of the population 27 counties with 12-21% of population 1.6 million have prediabetes 86 million people have prediabetes 15-30% will convert to diabetes within 5 years CDC (2014). Diabetes Statistics Report. CDC (2014). Diabetes Statistics Report. STANDARDS OF CARE Utilize patient-centered approach/shared decision making Lifestyle modification- DSME, medical nutrition therapy, physical activity, and BGM Support behavior change Initiate appropriate & timely pharmacologic interventions STEP ONE: DETERMINE GLYCEMIC TARGETS Ongoing assessment & adjustment of glycemic targets and control Explore barriers DSME- Diabetes self-management education BGM- blood glucose monitoring 1

2/14/2016 2016 GLYCEMIC GOALS ADA AACE/ACE A1C 7% or less A1C 6.

2 2/14/ GLYCEMIC GOALS ADA AACE/ACE A1C 7% or less A1C 6.5% or less Preprandial mg/dl Preprandial <110 mg/dl Peak postprandial <180 mg/dl Peak postprandial <140 mg/dl *** Without significant hypoglycemia ***These goals are for non-pregnant adults with diabetes American Diabetes Association Dia Care 2014;37:S14-S80 CONTRIBUTIONS OF A1C TO PLASMA GLUCOSE A1C CORRELATION TO BGM A1C MEAN PLASMA GLUCOSE 6% 126 mg/dl 7% 154 mg/dl 8% 183 mg/dl 9% 212 mg/dl 10% 240 mg/dl 11% 269 mg/dl 12% 298 mg/dl Monnier, L. et al. Diabetes Care. 2003; 26: STEP TWO: DETERMINE OPTIONS 2

OMINOUS OCTET DIABETES MEDICATIONS Class Primary Mechanism of Action Agent(s) Available as -Glucosidase inhibitors Biguanide Delay carbohydrate absorption from intestine Decrease hepatic glucose

3 OMINOUS OCTET DIABETES MEDICATIONS Class Primary Mechanism of Action Agent(s) Available as -Glucosidase inhibitors Biguanide Delay carbohydrate absorption from intestine Decrease hepatic glucose production Increase glucose uptake in muscle Acarbose Miglitol Metformin Metformin XR Precose Glyset or generic acarbose Decrease hepatic glucose production? Bile acid sequestrant Colesevelam WelChol Increase incretin levels? DPP-4 inhibitors Increase glucose-dependent insulin secretion Decrease glucagon secretion Alogliptin Linagliptin Saxagliptin Sitagliptin Glucophage, Riomet, Fortamet, Glumetza or generic Metformin Nesina Tradjenta Onglyza Januvia Dopamine-2 agonist Activates dopaminergic receptors Bromocriptine Cycloset Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35: DIABETES MEDICATIONS Class Mechanism of Action Agent(s) Available as GLP-1 receptor agonists SGLT2 inhibitors Sulfonylureas/Glinid es Thiazolidinediones Increase glucose-dependent insulin Albiglutide secretion Dulaglutide Decrease glucagon secretion Exenatide Slow gastric emptying Exenatide XR Increase satiety Liraglutide Increase urinary excretion of glucose Increase insulin secretion Canagliflozin Dapagliflozin Empagliflozin Glimepiride Glipizide Glyburide Nateglinide-GLIN Repaglinide-GLIN Increase glucose uptake in muscle Pioglitazone and fat Rosiglitazone Decrease HGP Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35: Tanzeum Trulicity Byetta Bydureon Victoza Invokana Farxiga Jardiance Amaryl or generic Glucotrol or generic Dia eta, Glynase, Micronase, or generic Starlix Prandin Actos Avandia MEDICATION COMPARISON COMPLICATIONS COMORBIDITIES COVERAGE COST CLASS ADVANTAGE DISADVANTAGE COST A1C % MET Extensive experience No hypoglycemia Reduced CV events GI SE Vit. B def. Contraindications- CKD, hypoxia, acidosis SU/GLIN Extensive experience Hypoglycemia Weight Gain GLP-1 No hypoglycemia Weight loss Reduced CV events GI SE? Pancreatitis risk C-cell hyperplasia/mt tumors animals Injectable Low Low 1-2 High 1-2 DPP-4 No hypoglycemia Well tolerated Weight neutral? Pancreatitis? Heart Failure High

$Edema/heart failure Bone fractures GU & fungal infections Polyuria Hypotension/dizzy SE Low 1 1.5 High 0.7-1 BCR No hypoglycemia Lower CV events Dizzy/syncope SE Nausea/fatigue SE High 0.$

4 MEDICATION COMPARISON CLASS ADVANTAGE DISADVANTAGE COST A1C TZD Extensive experience No hypoglycemia Lower Trig, Increase HDL Reduced CV SGLT-2 No hypoglycemia Weight loss Lower BP Weight gain Edema/heart failure Bone fractures GU & fungal infections Polyuria Hypotension/dizzy SE Low High BCR No hypoglycemia Lower CV events Dizzy/syncope SE Nausea/fatigue SE High 0.7 COLSV No hypoglycemia Lower LDL AGI No hypoglycemia Nonsystemic Constipation Lower absorption of meds Higher Trig Frequent dosing GI SE Frequent dosing High 0.5 Moderate year-old married male with 10 year history of T2DM. Has four adult children. CASE STUDY 1 Works FT as engineer, sedentary lifestyle, no previous hx of DSME Health insurance through employer & Medicare Recent A1C 10.5 %, GFR 69, Crea 1.0 Medication regimen: metformin XR 2,000 QHS, atorvastatin 40mg QD, docusate sodium 100mg BID Medical hx: Hyperlipidemia, CKD stage II, Sleep Apnea with CPAP, constipation, vertigo Fatigue and intermittent blurry vision BMI 39, BP 140/80 Testing 1-2 times daily Does not want complex regimen r/t work BLOOD GLUCOSE LOG Fasting Prelunch Predinner Bedtime Sunday 150 Monday 212 Tuesday 305 Wednesday 291 Thursday 164 Friday Saturday 179 Sunday 363 Monday 237 Tuesday

CASE STUDY 1 Needs 2-3 agents Consider referral for DSME and initiation of lifestyle CASE STUDY 2 80 year old retired widow with 30 year hx of T2DM, Filipino descent, no children DSME at diagnosis

5 CASE STUDY 1 Needs 2-3 agents Consider referral for DSME and initiation of lifestyle CASE STUDY 2 80 year old retired widow with 30 year hx of T2DM, Filipino descent, no children DSME at diagnosis and in 2014 Attends water aerobics at YMCA 3 times a week Medicare & Medicaid Recent A1C 8.0%, GFR 32, Crea 1.6 Medication: metformin 500 mg BID, levothyroxine 88 mcg daily, bystolic 10 mg daily, losartan 50mg daily, asa 81mg daily, Crestor 20mg daily, MVI daily, furosemide 20mg daily, gabapentin 300mg TID Medical hx of CAD, CKD III, retinopathy, hypothyroidism, neuropathy, osteoporosis BMI 23, BP 120/70 Testing 1 time a day BLOOD GLUCOSE LOG Fasting Prelunch Predinner Bedtime Sunday 188 Monday 170 Tuesday 153 Wednesday 135 Thursday 155 Friday 178 Saturday 199 Sunday 196 Monday 140 Tuesday 187 Needs 1 agent CASE STUDY 2 5

35 year old Newly DX T2DM married Black American with 3 young kids CASE STUDY 3 Army Recruiter, Active lifestyle- runs >15 miles week Medical insurance through Army A1c 9%, GFR 110, Crea 0.

6 35 year old Newly DX T2DM married Black American with 3 young kids CASE STUDY 3 Army Recruiter, Active lifestyle- runs >15 miles week Medical insurance through Army A1c 9%, GFR 110, Crea 0.6 No previous Medical hx BMP 24, BP 155/95 Polyuria, polydipsia, and fatigue x 1 month CASE STUDY 3 Needs at least 2 agents Consider referral for DSME and initiation of lifestyle 63 year-old married female with 3-year history of T2DM. Controlled with lifestyle. CASE STUDY 4 Just recently lost job due to restructuring at work. Uninsured. Had diabetes education at diagnosis. Walks daily. Vegan. Recent A1C 8.5 %, GFR 90, Crea 0.7 Medication regimen: B12 supplement, MVI, Linzess 290 mcg daily, Medical hx: IBS, frequent UTI s BMI 26, BP 130/86 Not testing, no BGM 6

7 Needs 1-2 agents CASE STUDY 4 Consider referral for DSME for BGM Q U E S T I O N S? 7

Targeting the Kidney. Renal Glucose Transport 11/4/2015. Non insulin Agents Available IBITORS. Chao EC, et al. Nat Rev Drug Discovery. 2010;9:551 559.

Targeting the Kidney. Renal Glucose Transport 11/4/2015. Non insulin Agents Available IBITORS. Chao EC, et al. Nat Rev Drug Discovery. 2010;9:551 559. SGLT-2i and DPP-IVi in the Management of Diabetes Mellitus Type 2 Abel Alfonso, D.O., F.A.C.E. Endocrinologist November 5, 2015 DIABETES: CURRENT RATES AND PROJECTIONS CDC Press Release 2010: 1 in 3 adults