TREATMENT STRATEGIES FOR MANAGING TYPE 2 DIABETES MELLITUS. Friday, August 16, 13

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1 TREATMENT STRATEGIES FOR MANAGING TYPE 2 DIABETES MELLITUS 1

2 Heather Healy, FNP-BC Martha Shelver, CS, ACNP-BC Saint Alphonsus Regional Medical Center 2

3 OBJECTIVES 3

4 Review the current management algorithms Review the major classes of oral/injectable agents Brief overview of recently approved FDA antihyperglycemic agents Discuss cases studies of diabetic patients in the inpatient and outpatient settings 4

5 Major Classifications Of Medications 5

6 BIGUANIDES Causes the liver to decrease the amount of glucose released between meals and by increasing peripheral insulin sensitivity. METFORMIN: Fortamet, Glumetza, Riomet, Glucophage, Glucophage XR Powers A.C., D Alession D. (2011). Chapter 43. Endocrine Pancreas and Pharmacoltherapy of Diabetes Mellitus and Hypoglycemia. In L.L. Brunton, B.A.Chabner, B.C. Knollmann (Eds), Goodman & Gilman The Pharmacological Basis of Therapeutics, 12e. Retrieved July 10, 2013 from 6

7 SULFONAUREAS Prompt insulin production during and between meals Can cause HYPOGLYCEMIA GLIMEPIRIDE: Amaryl GLIPIZIDE: Glucotrol, Glucotrol XL Powers A.C., D Alession D. (2011). Chapter 43. Endocrine Pancreas and Pharmacoltherapy of Diabetes Mellitus and Hypoglycemia. In L.L. Brunton, B.A.Chabner, B.C. Knollmann (Eds), Goodman & Gilman The Pharmacological Basis of Therapeutics, 12e. Retrieved July 10, 2013 from 7

8 DPP-4 INHIBITORS Used for secretin defect Allows more insulin to be released by the cells SITAGLIPTIN: Januvia Powers A.C., D Alession D. (2011). Chapter 43. Endocrine Pancreas and Pharmacoltherapy of Diabetes Mellitus and Hypoglycemia. In L.L. Brunton, B.A.Chabner, B.C. Knollmann (Eds), Goodman & Gilman The Pharmacological Basis of Therapeutics, 12e. Retrieved July 10, 2013 from 8

9 THIAZOLIDINEDIONES (TZDS) Insulin sensitizer Increases insulin mediated glucose uptake by 50% Used for patients who are insulin resistant Pioglitazone: Actos Powers A.C., D Alession D. (2011). Chapter 43. Endocrine Pancreas and Pharmacoltherapy of Diabetes Mellitus and Hypoglycemia. In L.L. Brunton, B.A.Chabner, B.C. Knollmann (Eds), Goodman & Gilman The Pharmacological Basis of Therapeutics, 12e. Retrieved July 10, 2013 from 9

10 MEGLITINIDES Used to stimulate beta cells in the pancreas to produce insulin REPAGLINIDE: Prandin NATEGLINIDE: Starlix Powers A.C., D Alession D. (2011). Chapter 43. Endocrine Pancreas and Pharmacoltherapy of Diabetes Mellitus and Hypoglycemia. In L.L. Brunton, B.A.Chabner, B.C. Knollmann (Eds), Goodman & Gilman The Pharmacological Basis of Therapeutics, 12e. Retrieved July 10, 2013 from 10

11 ALPHA-GLUCOSIDASE INHIBITORS Decrease the amount of glucose in the intestines by delaying absorption Inhibits body from breaking down carbohydrates Take before first bite of food! ACARBOSE: Precose MIGLITOL: Glyset Powers A.C., D Alession D. (2011). Chapter 43. Endocrine Pancreas and Pharmacoltherapy of Diabetes Mellitus and Hypoglycemia. In L.L. Brunton, B.A.Chabner, B.C. Knollmann (Eds), Goodman & Gilman The Pharmacological Basis of Therapeutics, 12e. Retrieved July 10, 2013 from 11

12 GLP-1 AGONISTS Used for incretin deficits Exenatide: Byetta, Bydureon Liraglultide: Victoza Powers A.C., D Alession D. (2011). Chapter 43. Endocrine Pancreas and Pharmacoltherapy of Diabetes Mellitus and Hypoglycemia. In L.L. Brunton, B.A.Chabner, B.C. Knollmann (Eds), Goodman & Gilman The Pharmacological Basis of Therapeutics, 12e. Retrieved July 10, 2013 from aid=

13 INSULINS Long acting: Glargine: Lantus Detemir: Levemir Short acting: SQ: HumULIN R, HumULIN R U-500, NovOLIN R, Regular IV: Regular Intermediate acting: Isophane Insulin Suspension ( NovoLIN NPH, HumULIN N) Powers A.C., D Alession D. (2011). Chapter 43. Endocrine Pancreas and Pharmacoltherapy of Diabetes Mellitus and Hypoglycemia. In L.L. Brunton, B.A.Chabner, B.C. Knollmann (Eds), Goodman & Gilman The Pharmacological Basis of Therapeutics, 12e. Retrieved July 10, 2013 from 13

14 Rapid Acting: Glulisine: Apidra, Lispro: Aspart: HumALOG NovOLOG Combinations: Isophane Human Insulin (70%) & Regular Human Insulin (30%): HumULIN 70/30, NovOLIN 70/30, Insulin Lispro Protamine/ Insulin Lispro: HumALOG Mix 75/25 Insulin/Aspart Protamine/ Insulin Aspart: NovOLOG Mix 70/30 Powers A.C., D Alession D. (2011). Chapter 43. Endocrine Pancreas and Pharmacoltherapy of Diabetes Mellitus and Hypoglycemia. In L.L. Brunton, B.A.Chabner, B.C. Knollmann (Eds), Goodman & Gilman The Pharmacological Basis of Therapeutics, 12e. Retrieved July 10, 2013 from 14

15 NEW: SGLT-2 INHIBITOR SGLT-2 Inhibitor: SGLT-2 facilitates high glucose reabsorption in the kidneys. SGLT-2 Inhibitor inhibits blocks the renal reabsorption; thereby, increasing glucose excretion and decreasing blood glucose. Joffee D. (ed). SGLT2 Inhibitors: Diabtes in Control.: A new Class of Diabetes Medications. Retrieved July 17, 2013 from control.com/articles/91-how-glp-1-works/ sglt2-inhibitors-a-new-class-of-diabetes-medications 15

16 Canagliflozin: Invokana Use with DPP-4 or GLP-1 agonists Indicated as an adjunct to diet and exercise Dosage mg PO daily. Give before 1st meal. CrCl ml/min: 100 mg/daily; CrCl ml/min: avoid use; CrCl <30 ml/min; contraindicated Adverse events: > DPP-4; similar to GLP-1. Hypoglycemia > insulin, sulfonylureas or meglitinides. Joffee D. (ed). SGLT2 Inhibitors: Diabtes in Control.: A new Class of Diabetes Medications. Retrieved July 17, 2013 from control.com/articles/91-how-glp-1-works/ sglt2-inhibitors-a-new-class-of-diabetes-medications 16

17 NEW: DPP-4 INHIBITOR Alogliptin: Nesina Indicated as an adjunct to diet and exercise in T2DM. Dosage: 25 mg daily; taken with or without food Dosage with CrCl > 30 to < 60 ml/min: 12.5 mg daily Dosage < 30 ml/min or ESRD: 6.25 mg daily Hypoglycemia: 1.5% compared to 1.6% with placebo DailyMed FDA Approved Information on Prescription Drugs. Nesina. Web. 10 Aug

18 18

19 AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGIST AACE COMPREHENSIVE DIABETES MANAGEMENT ALGORITHM

20 Comprehensive plan for management of : Obesity Pre-diabetes Diabetes Cardiovascular health Garber A.J. (Task Force Chair), AACE Comprehensive Diabetes Management Algorithm 2013 Endocrine Practive Vol19 No.2 March/April 2013, pp

21

22 PRE-DIABETES Life style modifications CVD risk factors Dyslipidemia HTN Anti-Obesity therapies Garber A.J. (Task Force Chair), AACE Comprehensive Diabetes Management Algorithm 2013 Endocrine Practive Vol19 No.2 March/April 2013, pp

23

24 GLYCEMIC CONTROL GOALS A1c < to 6.5% For healthy patient w/o concurrent illness and at low hypoglycemic risk A1c > 6.5% Individual goals for patients with concurrent illness and at risk for hypoglycemia Garber A.J. (Task Force Chair), AACE Comprehensive Diabetes Management Algorithm 2013 Endocrine Practive Vol19 No.2 March/April 2013, pp

25 24

26 AMERICAN DIABETES ASSOCIATION ADA 2013 GUIDELINES 24

27 GLYCEMIC, BLOOD PRESSURE, LIPID CONTROL A1c: <7.0% B/P: < 140/<80 mm Hg Lipids: LDL-C: <100 mg/dl. Statin therapy for patients with MI history or aged >40 years with other risk factors American Diabetes Association. Diabetes Care. 2013;36(supp 1):S

28 26

29 CASE STUDIES 26

30 OUTPATIENT #1 51 y/o F. Wt kg. Ht. 160 cm Hx: T2DM, COPD, OSA, Depression, Rheumatic Heart Disease, PAT, MVR, TVR, ASD repair, HTN, Hyperlipidemia A1c 10.3% (avg. BS) 249 MEDS METFORMIN 1000 mg BID GLIPIZIDE 10 mg Daily LANTUS 15 Units BID 27

31 OUTPATIENT PLAN - Audience Feedback 28

32 OUTPATIENT PLAN #1 DC Glipizide - potential tolerance if patient has been on it a long time. Keep Metformin - Beta cell protection Slowly increase Lantus to in the evening and ( X ) am - depending on blood sugars and level of control Initiate Novolog with sliding scale and carb counting May take 3 months to find good control COPD patient - are they on frequent prednisone tapers or daily prednisone? We need to adjust for steroid use. Strict diet log - assess where hidden sugars/carbs are Depression - address patient s depression issues - determine if medications and/or counseling is necessary 29

33 INPATIENT #1 Chest Pain; N-STEMI Admit BG 244. Lantus 15 u BID; Correction mg/dl +2 units, mg/dl +3 units, then +3 units for q 50mg/dl > 200 mg/dl. I/C = 1/ cal consistent CHO 30

34 Follow the Blood Sugars Lantus 15 units BID Novolog correction mg/dl +2 units; mg/dl +3 units, then +3 units for q 50 mg/dl > 200 mg/dl; HS/0200 Correction: mg/dl +2 units, mg/dl +3 units, then add +3 units for q 50 mg/dl > 250 mg/dl. I/C = 1/12; 1800 cal consistent CHO diet Admit Lantus 25 BID Novolog Correction unchanged I/C = HD Lantus 32 units BID Novolog unchanged 1/C = 1/5 HD DISCHARGED LANTUS 32 Units BID Novolog 10 units with meals Novolog Correction with meals mg/dl +2 Units, mg/dl +3 units, then +3 units for q 50 mg/dl > 200 mg/dl. D/C all oral agents. 31

35 PATIENT NOW MOVES TO THE OUTPATIENT- WHAT NEXT? 32

36 OUR INPATIENT #1- IS NOW HOME New medications - LANTUS 32 Units BID Novolog 10 units with meals Novolog Correction with meals mg/dl +2 Units, mg/dl +3 units, then +3 units for q 50 mg/dl > 200 mg/dl. Hospital F/U - 7 days after discharge Make sure all other medications are clear and patient is set with blood sugar machine and test strips Confirm patient and family members have a plan for hypoglycemia episodes - travel pack is ready for emergencies Review blood work, if there was not an A1c - complete that along with CBC, CMP, Micro/Albumin creatin ratio (urine) - also Vitamin D levels, TSH/T4 free and Lipids - CMP will give you your liver function studies Consider outpatient diabetes education - classes and APRN management F/U in 6 weeks to review blood sugar logs, check weight, check edema and patients emotional status with new insulin start 33

37 OUTPATIENT #2 77 y/o F. Wt kg Ht cm HX: RA, A-Fib, T2DM, CHF, HTN, Dyslipidemia, CKD, PAD, Hypothyroidism A1c: 8.5% (avg. BS)

38 OUTPATIENT #2 MEDS: Prednisone 5 mg daily H.S. Vitorin 10 mg/20 mg daily H.S. Diltiazem ER 30 mg q 6 hrs Lisinopril 10 mg daily Actos 30 mg daily Glimepiride 1 mg daily Levothyroxine mg daily Warfarin per schedule 35

39 OUTPATIENT PLAN Audience Feedback 36

40 OUTPATIENT PLAN #2 Close to goal - as 77 yo - her A1c goal is between 7-8 and not 5-6. The risk of falls from hypoglycemia increase with age and we need to be careful to get her averaging blood sugar She is on prednisone, so we need to adjust for this. Is she a good candidate for some of the new agents? Strict diet log - assess where hidden sugars/carbs are Need to discuss weight loss - BMI = 36.6 Depression - address patient s depression issues - determine if medications and/or counseling is necessary 37

41 INPATIENT #2 Sepsis; Diastolic Heart Failure Admit BG 201 Lantus 10 units BID Novolog correction w/ meals. +3 units for every 50 mg/dl > 150 mg/dl Novolog correction HS/ units for every 50 mg/dl > 200 mg/ 1800 cal consistent CHO diet 38

42 Follow the Blood Sugars Lantus 10 units BID Novolog correction +3 units for every 50mg/dl > 150 mg/dl ADMIT HD HD HD ADD TO HD 7 NOVOLOG 5 UNITS TID w/ meals HD *

43 Follow the Blood Sugars Lantus 10 units BID; Novolog +3 units q 50 mg/dl > 150 mg/dl; Nov +5 TID meals HD Lantus 10 units HS CHANGED to 12 units HS HD HD D/C AM Lantus & Correction. Begin Glimepiride 1 mg daily HD D/C home HD

44 OUTPATIENT PLAN Audience Feedback 41

45 OUR INPATIENT #2- IS NOW HOME New medications - LANTUS 32 Units BID Novolog 10 units with meals Novolog Correction with meals mg/dl +2 Units, mg/dl +3 units, then +3 units for q 50 mg/dl > 200 mg/dl. Hospital F/U - 7 days after discharge Make sure all other medications are clear and patient is set with blood sugar machine and test strips Confirm patient and family members have a plan for hypoglycemia episodes - travel pack is ready for emergencies Review blood work, if there was not an A1c - complete that along with CBC, CMP, Micro/Albumin creatin ratio (urine) - also Vitamin D levels, TSH/T4 free and Lipids - CMP will give you your liver function studies Consider outpatient diabetes education - classes and APRN management F/U in 6 weeks to review blood sugar logs, check weight, check edema and patients emotional status with new insulin start 42

46 OUTPATIENT #3 49 y/o M. Wt. 111 kg Ht cm T2DM, HTN, Hyperlipidemia, PTSD, BiPolar Affective Disorder, Depression, Epilepsy, Leukemia AIc 16.1 % (avg. BS) 415 MEDS Metformin 500 mg BID Novolog ~ 15 units each meal 43

47 OUTPATIENT PLAN Audience Feedback 44

48 OUTPATIENT PLAN #3 Greatest challenge with this patient is their Bi-Polar and depression Metformin increase to 1000 mg BID Lantus/Levimer BID (titrate over 6-8 weeks to control) Continue with Novolog and sliding scale - High Set up social work services to determine if patient has resources for food, counseling, transportation Frequent visits - every 2 weeks while you are titrating insulin Consider referral to Endo 45

49 SAMPLE CORRECTION SCALES High Dose Short Acting < 150 No insulin units units units units > units Call your provider 46

50 SAMPLE CORRECTION SCALES Medium Dose Short Acting < 150 No insulin units units units units > units Call your provider 47

51 SAMPLE CORRECTION SCALES Low Dose Short Acting < 150 No insulin units units units units >349 5 units Call your provider 48

52 INPATIENT #3 N-STEMI Admit BG 0123: 371 Novolog 15 units 0327: 300 Regular insulin 10 units 0528 serum: cal consistent CHO diet 49

53 Follow the Blood Sugars Lantus 25 units BID I/C = 1/8 TID Meals Novolog w/ Meals: +3 units for q 50 mg/dl >150 mg/dl Novolog HS/0200: +3 units for q 50 mg/dl>200 mg/dl HD Lantus 30 units BID D/C I/C; Begin Novolog 15 units TID Meals Novolog w/ Meals: +3 units for q 50 mg/dl >150 mg/dl Novolog HS/0200: +3 units for q 50 mg/dl>200 mg/dl HD

54 Follow the Blood Sugars Lantus 30 units am Lantus 26 units hs D/C I/C; Begin Novolog 15 units TID Meals Novolog w/ Meals: +3 units for q 50 mg/dl >150 mg/dl Novolog HS/0200: +3 units for q 50 mg/dl>200 mg/dl HD Discharged. 51

55 OUTPATIENT PLAN Audience Feedback 52

56 OUR INPATIENT #3- IS NOW HOME New medications - Lantus 30 units am, Lantus 26 units hs Begin Novolog 15 units TID Meals Novolog w/ Meals: +3 units for q 50 mg/dl >150 mg/dl Novolog HS/0200: +3 units for q 50 mg/dl>200 mg/dl Hospital F/U - 7 days after discharge Make sure all other medications are clear and patient is set with blood sugar machine and test strips Confirm patient and family members have a plan for hypoglycemia episodes - travel pack is ready for emergencies Review blood work, if there was not an A1c - complete that along with CBC, CMP, Micro/Albumin creatin ratio (urine) - also Vitamin D levels, TSH/T4 free and Lipids - CMP will give you your liver function studies Consider outpatient diabetes education - classes and APRN management F/U in 6 weeks to review blood sugar logs, check weight, check edema and patients emotional status with new insulin start 53

57 INPATIENT #4 SEVERE 3 VESSEL DISEASE--> CABG A1c 10.7% (avg. BS) 260 BG: 204. Balloon pump. Insulin drip. 54

58 Follow the Blood Sugars Lantus 50 units BID Novolog 15 units TID meals Novolog correction w/meals: + 2 units mg/dl; +3 units mg/dl, then add +3 units for q 50 mg/dl >200 mg/dl. Novolog HS/0200 correction: +2 units mg/dl; + 3 units mg/dl, then add +3 units for q 50 mg/dl > 250 mg/dl. POD

59 Follow the Blood Sugars Lantus 40 units BID Novolog 10 units TID meals Novolog correction w/meals: + 2 units mg/dl; +3 units mg/dl, then add +3 units for q 50 mg/dl >200 mg/dl. Novolog HS/0200 correction: +2 units mg/dl; + 3 units mg/dl, then add +3 units for q 50 mg/dl > 250 mg/dl. POD

60 Follow the Blood Sugars Lantus 40 units BID Novolog 12 units TID meals Novolog correction w/meals: + 2 units mg/dl; +3 units mg/dl, then add +3 units for q 50 mg/dl >200 mg/dl. Novolog HS/0200 correction: +2 units mg/dl; + 3 units mg/dl, then add +3 units for q 50 mg/dl > 250 mg/dl. POD POD 7 94 D/C Home Lantus 38 Units BID Novolog 12 units TID Meals Novolog correction w/ Meals +3 units for q 50 mg/dl > 150 mg/dl 57

61 OUTPATIENT PLAN Audience Feedback 58

62 OUR INPATIENT #4- IS NOW HOME New medications - Lantus 38 Units BID Novolog 12 units TID Meals Novolog correction w/ Meals +3 units for q 50 mg/dl > 150 mg/dl Hospital F/U - 7 days after discharge Patient does not want to continue on insulin - what are next steps/ options? What is potential bridge to get patient on orals? 59

63 YOUR CASE STUDIES What are some of your stories? Share with the group your pearls of wisdom? 60

64 CONTACT INFO Martha Shelver - Heather Healy - 61

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