Treatment Approaches to Diabetes

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1 Treatment Approaches to Diabetes Dr. Sarah Swofford, MD, MSPH & Marilee Bomar, GCNS, CDE Quick Overview Lifestyle Oral meds Injectables not insulin Insulin Summary 1

2 Lifestyle & DM Getting to the point where change is desired Stages of Change, Motivational Interviewing Options for assistance you, your staff, referrals, community programs, online, apps Be Creative! Portion Mate 2

3 You Tube 23 ½ Hours: What is the single best thing we can do for our health? Dr. Mike Evans Monitoring 3

4 Sites Favorite Sites & Apps Calorie King American Diabetes Assoc Cooking Light My Fitness Pal also has an App Dlife Apps Fit Bit Metformin Oral Medications Potential GI issues, low dose, possible to use extended release Caution kidney function Caution diagnostics using contrast Low cost 4

5 Oral Medications Sulfonylureas Glipizide, Glimepiride, Glyburide Monitor for hypoglycemia Low cost Glipizide option for XL Oral Medications DPP-4 Inhibitors - Januvia, Onglyza Daily dosing Cannot be used with insulin Newer, more costly 5

6 Oral Medications Glinide Prandin Take up to 30 minutes before meal Skip meal, skip Prandin Depends on functioning beta cells TZDs Newest on market - Injectables not insulin Work with the incretin system GLP-1 receptor agonists Byetta,Victoza Stimulate pancreatic insulin secretion in glucose-dependent fashion Suppress pancreatic glucagon output Slow gastric emptying Decrease appetite 6

7 GLP-1 Agonists Main advantage is weight loss Limiting side effect is nausea and vomiting Black box warning about increased risk of pancreatitis No hypoglycemia Injectable BID, daily, weekly (Bydureon) Expensive Insulin Start early Titrate to goal Barriers to starting insulin 7

8 When to start insulin Already on two drugs and not at goal Adding a third non-insulin vs. starting insulin Diabetes is assoc with progressive beta-cell loss, most will eventually need to be transitioned to insulin Favor insulin where degree of hyperglycemia (A1C >8.5%) makes it unlikely a third drug will be successful When to start insulin Glucose toxicity decompensated type 2 diabetes with significant hyperglycemia and polydipsia, polyuria, weight loss Initiation of insulin promotes reversal of glucose toxicity and thought to rescue beta cells HbA1C 8% even with 2 or more drugs Not at goal after one year of treatment 8

9 Case for earlier insulin Intensive insulin can be an excellent first treatment for type 2 diabetes Immediate improvement in glucose control No ceiling effect Also has a lasting legacy effect UKPDS 10-year follow-up demonstrated relative benefit of intensive management group was maintained over a decade Barriers to starting insulin Patient fear Fear of injection Belief insulin will interfere with lifestyle Idea that use of insulin signifies impending complications or even death 9

10 Barriers to starting insulin Clinical inertia Physicians have been slow to intensify treatment for type 2 diabetes In a VA study, patients were out of control (HbA1C >8%) for an average of 4.6 years before insulin initiated Primary care physicians less likely to prescribe insulin than clinicians specializing in diabetes care Barriers to starting insulin Physician barriers Time required to train patients to use it correctly Lack of support, including access to diabetes educators Absence of clear guidelines on use of insulin 10

11 Getting started with basal insulin Single injection of basal insulin, units/kg/day u/kg/day if HbA1C is >8% Suppressing excessive hepatic glucose production, targeting fasting glucoses Glargine (Lantus), Detemir (Levemir) NPH duration hours, cheaper Getting started with basal insulin Commonly dosed at night. Can be given at any time convenient for patient (24 hour duration, no peak) Teach injection technique 11

12 Establish a titration schedule Pick a titration schedule and empower your patients Increase by 2 units every 3 days until fasting glucose <140 Or increase by 1-2 units twice weekly Or increase by 5 units once a week Track fasting glucose readings and titrate dose Establish a titration schedule Track fasting glucose readings and titrate dose Downward adjustment if any hypoglycemia During self-titration, frequent contact via telephone, may be necessary 12

13 Basal titration vs. mealtime coverage Fasting glucose is at target, but HbA1c remains above goal after 3-6 mo of basal insulin Time to look at post-prandial glucoses ( min after meal) Consider mealtime insulin coverage when postprandial glucoses >180 Avoid overbasalization Titrating basal insulin beyond its normal role of suppressing hepatic glucose production Large drops in glucose overnight or in between meals as basal insulin is increased 13

14 Pen vs. vial? Many patients prefer insulin pens, which are more convenient and easier to use than vial and syringe Pen vs. vial? Depends on dosage 3ml pen (100U/ml) = 300 units 10 ml vial (100U/ml) = 1000 units Max single dose of a pen is 80 units glargine (Lantus) and 60 units detemir (Levemir) 14

15 Tips & Techniques for Insulin Administration Teaching tools First injection in office when possible room temperature Site selection Technique Discuss why not to reuse needles Summary Many effective ways to counsel regarding lifestyle modifications Newer meds aren t necessarily better Starting insulin early along with adequate titration improves outcomes 15

16 16

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