A Personalized Approach for A1C Goals
|
|
- Cuthbert Bryant
- 7 years ago
- Views:
Transcription
1 PL Detail-Document # This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER July 2012 A Personalized Approach for A1C Goals Introduction The American Diabetes Association (ADA) standards of care recommend a personalized approach to A1C goals. The benefit of intensive glucose lowering for reducing microvascular complications is established. However, newer studies haven t shown a significant reduction in cardiovascular outcomes. The ADA recommendations reflect these findings and suggest individualizing A1C goals based on patient factors such as duration of diabetes, comorbidities, history of hypoglycemia, etc. This document reviews the evidence that supports a more personalized approach for glycemic control. Evidence Microvascular disease. Good glycemic control was first shown to reduce the risk of microvascular disease (e.g., nephropathy, neuropathy, retinopathy) in the Diabetes Control and Complications Trial (DCCT) in patients with type 1 diabetes. Later, in the United Kingdom Prospective Diabetes Study (UKPDS), good glycemic control was shown to reduce the risk of microvascular complications in patients with type 2 diabetes. 1 Subjects in both of these studies had short duration of disease. The benefit of early intensive glycemic control on microvascular complications persisted over time, even when intensive control was not maintained. 1 More recently, the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial showed a significant reduction in the risk of nephropathy with A1C levels of 6.4% compared to 7%. 2 An analysis of data from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial suggested that the onset and progression of microvascular complications are slowed with intensive glycemic control (i.e., A1C target <6%; 6.4% vs 7.5% achieved). 1,3 Macrovascular disease. Data from randomized, controlled trials like ADVANCE, ACCORD (Action to Control Cardiovascular Risk in Diabetes), and VADT (Veterans Affairs Diabetes Trial) have generally not shown a benefit of reducing A1C to less than 7% on cardiovascular outcomes in patients with type 2 diabetes. In the ACCORD study, despite the fact that the group who received intensive therapy to target A1C less than 6% for 3.7 years had a reduction in nonfatal heart attacks at five years, there was an increase in mortality compared with the group that received standard therapy. 4 Note that these studies enrolled older subjects, at high cardiovascular risk, with around a ten-year history of diabetes. 1,2,5,6 The UKPDS and DCCT trials also did not show improved cardiovascular outcomes during the periods of the trials. However, long-term follow-up data from both studies suggest that A1C targets below or around 7% in the years soon after diagnosis of diabetes is associated with long-term reduction in the risk of cardiovascular disease. As with microvascular complications, benefits are seen even if intensive glycemic control is not maintained. The A1C values increased over time to around 8%, and some patients were followed for up to 30 years. 7,8 Both UKPDS and DCCT enrolled healthier and younger subjects than ADVANCE, ACCORD, or VADT. The Latest Recommendations Per the ADA, the general A1C target for nonpregnant adults with type 1 or type 2 diabetes continues to be less than 7% (estimated average glucose [eag] less than 154 mg/dl). 1,9 Likewise, the Canadian Diabetes Association (CDA), recommends an A1C of 7% or lower for most adult patients with type 1 or type 2 diabetes. 10 But based on the findings of both newer and older studies, certain patients may benefit from lower or higher A1C goals. 1 Higher A1C goals (e.g., 7.5% to 8%, or slightly higher). Less stringent goals might be appropriate for patients with a recent history of
2 severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid complications, and those with longstanding diabetes in whom a target A1C of less than 7% is difficult to achieve. 1,3,9 One of the criticisms of the newer intensive glycemic control trials is that therapy changes were made very fast and aggressively. 2,5 Some experts suggest that a good approach to therapy in patients similar to subjects in these newer trials (e.g., older, cardiovascular risk factors, longstanding diabetes) is to make treatment changes slowly and in small increments. Some of these patients may not be able to reach the general goal of less than 7%. In these cases it may not be necessary to make drug therapy changes even when A1C is in the high 7% range. 1 However, others will be able to make the general goal of less than 7%. Clinicians say it s not necessary to back off on therapy if patients are doing well. Even though the ADVANCE, ACCORD, and VADT studies did not show a benefit of intensive glycemic control on cardiovascular events in highrisk patients, it s important to note that the range of A1C values in these studies is one where the reduction in cardiovascular risk isn t expected to be drastic. 1,2,5,6 As such, the ADA recommendations stress that the results of these studies should not be interpreted to underestimate the importance of reducing A1C values in poorly controlled patients (e.g., A1C >9%). 1 Lower A1C goals (e.g., 6% to 6.5%). As mentioned, results of the ADVANCE study suggest that targeting an A1C closer to 6% reduces the risk of albuminuria and data from the ACCORD study suggest that the onset and progression of microvascular complications (i.e., retinopathy, neuropathy, albuminuria) is slowed with A1C target values of less than 6%. 3,5 However, the risk reduction for microvascular complications becomes smaller as A1C approaches 6%. And there is no proof that these lower goals prevent significant vision loss or development of nephropathy. 3 Plus, lower goals are associated with a higher risk of hypoglycemia. The risk of hypoglycemia can at least double or triple. 1,3,5 So targeting A1C of around 6% is not appropriate for all patients, including those with a recent history of significant hypoglycemia. 1,3 Patients who might benefit from an A1C approaching a normal value of 6% include those (PL Detail-Document #280708: Page 2 of 3) with a shorter duration of diabetes, a long life expectancy, and no significant cardiovascular disease. 1,3,9 In these patients it may be appropriate to make therapy changes to further lower A1C even when A1C is in the low 7% range. The CDA suggests that a target A1C of 6.5% or lower may be considered in some patients with type 2 diabetes to further reduce the risk of nephropathy. Of course this should be balanced against the risk of hypoglycemia and possible increased risk of mortality in patients at high cardiovascular risk. 10 Although there s no bottom number for lowering A1C, it s generally accepted to not push the A1C much below 6%. This is because there s not much evidence that lowering A1C to the normal range improves outcomes. Conclusion Treatment recommendations suggest personalizing A1C targets for patients based on duration of diabetes, age, life expectancy, comorbid conditions, history of cardiovascular disease, and predisposition to hypoglycemia [Evidence level C; consensus]. 1 Older patients with a longer duration of disease and comorbidities may sometimes be better off with a less aggressive goal than the general recommendations. 2,3,5,11 Other patients who can tolerate lower goals might benefit from A1C values closer to 6% for reduction of microvascular complications. 1-3,10 Interventions proven to reduce cardiovascular risk, like reaching blood pressure and lipid goals, and low-dose daily aspirin in patients with heart disease, are important for diabetes patients. 1,9,10 Remember that although diabetes does increase the risk of coronary heart disease, it is no longer considered to be a cardiovascular risk equivalent in all patients. 12 Continue to encourage all patients with diabetes to make healthy lifestyle changes, like stopping smoking, eating healthy, and exercising. Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and internet links in this article were current as of the date of publication.
3 (PL Detail-Document #280708: Page 3 of 3) Levels of Evidence In accordance with the trend towards Evidence-Based Medicine, we are citing the LEVEL OF EVIDENCE for the statements we publish. Level Definition A High-quality randomized controlled trial (RCT) High-quality meta-analysis (quantitative systematic review) B Nonrandomized clinical trial Nonquantitative systematic review Lower quality RCT Clinical cohort study Case-control study Historical control Epidemiologic study C Consensus Expert opinion D Anecdotal evidence In vitro or animal study Adapted from Siwek J, et al. How to write an evidence-based clinical review article. Am Fam Physician 2002;65: Project Leader in preparation of this PL Detail- Document: Stacy A. Hester, R.Ph., BCPS, Assistant Editor References 1. American Diabetes Association. Standards of medical care in diabetes Diabetes Care 2012;35(Suppl 1):S The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358: Ismail-Beigi F, Moghissi E, Tiktin M, et al. Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials. Ann Intern Med 2011;154: The ACCORD Study Group. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med 2011;364: The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008;358: Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009;360: Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359: DCCT/EDIC Study Research Group. Intensive diabetes treatment and cardiovascular diseases in patients with type 1 diabetes. N Engl J Med 2005;353: Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach. Diabetes Care 2012;35: Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2008;32:S1-S Dluhy RG, McMahon GT. Intensive glycemic control in the ACCORD and ADVANCE trials. N Engl J Med 2008;358: PL Detail-Document, Cardiovascular Risk in Patients with Diabetes. Pharmacist s Letter/Prescriber s Letter. May Cite this document as follows: PL Detail-Document, A Personalized Approach for A1C Goals. Pharmacist s Letter/Prescriber s Letter. July Evidence and Recommendations You Can Trust 3120 West March Lane, P.O. Box 8190, Stockton, CA ~ TEL (209) ~ FAX (209) Subscribers to the Letter can get PL Detail-Documents, like this one, on any topic covered in any issue by going to or
4 PL Detail-Document # This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER June 2012 Stepwise Approach to Selecting Treatments for Type 2 Diabetes (ADA) (2012 American Diabetes Association and European Association for the Study of Diabetes) Diagnosis of type 2 diabetes in nonpregnant adults 1,a,b Counsel patients regarding lifestyle modification such as healthy diet, weight loss, exercise At or soon after diagnosis, add metformin c monotherapy ( A1C 1%-1.5%) unless contraindicated If target A1C not achieved after approximately 3 months, consider ADDING a second agent (based on patient and drug characteristics) Sulfonylurea d TZD f DPP-4 inhibitor GLP-1 agonist insulin (usually basal) e ( A1C 1%-1.5%) ( A1C 1%-1.5%) ( A1C 0.5%-1%) ( A1C 1%-1.5%) ( A1C 1.5%-3.5%) 2 (2nd generation) -pioglitazone (Actos) -sitagliptin (Januvia) -exenatide (Byetta) -glyburide (not preferred) -saxagliptin (Onglyza) -exenatide extended-release (Bydureon) -glipizide (Glucotrol) -linagliptin (Tradjenta) -liraglutide (Victoza) -glimepiride (Amaryl) If target A1C not achieved after approximately 3 months, consider ADDING a third agent TZD f or SU d or SU d or SU d or TZD f or DPP-4 inhibitor or DPP-4 inhibitor or TZD f or TZD f or DPP-4 inhibitor or GLP-1 agonist or GLP agonist or insulin (usually basal) e insulin (usually basal) e GLP-1 agonist insulin (usually basal) e insulin (usually basal) e If a 3-drug combination (including basal insulin) does not achieve target A1C after 3 to 6 months, move to more complex insulin regimen (multiple daily doses), with 1 or 2 non-insulin agents. Sulfonylureas and meglitinides are generally avoided in patients who require more complex insulin regimens including prandial insulins. 1 See our PL Chart, Drug Classes for Type 2 Diabetes, for more information about the pros and cons of the drugs used for type 2 diabetes. Abbreviations: DPP-4 = dipeptidyl peptidase-4; GLP-1 = glucagon-like peptide-1; SU = sulfonylurea; TZD = thiazolidinedione.
5 (PL Detail-Document #280601: Page 2 of 3) The above algorithm does not include pramlintide (Symlin), alpha-glucosidase inhibitors (acarbose [Precose], miglitol [Glyset]), bile acid sequestrant (colesevelam [Welchol]), or dopamine agonists (bromocriptine [Cycloset]), because of modest efficacy and/or intolerable side effects. However, these may be used in selected patients. Insulin is likely to be more effective than other third-line agents, especially in patients with high A1C (e.g., 9% or greater). In patients with severe hyperglycemia (e.g., A1C 10% or greater), a more rapid progression from a two-drug combination directly to a regimen of multiple daily insulin doses is indicated. a. This algorithm provides a summary of the 2012 position statement of the American Diabetes Association and European Association for the Study of Diabetes created for the treatment of adult, nonpregnant patients with type 2 diabetes. Of note, it is based on evidence, where it exists, but also relies on the opinions of experts. The recommendations should be considered within the context of the needs, preferences, and tolerance of the individual patient. b. While the American Diabetes Association Standards of Medical Care in Diabetes recommends lowering the A1C to less than 7% in most patients, some patients may benefit from less stringent A1C goals. For example, an A1C goal of 7.5% to 8.0% or slightly higher may be acceptable in patients with a history of severe hypoglycemia, those with a limited life expectancy, those with advanced complications such as moderate to severe renal dysfunction, or those with extensive comorbid conditions. Conversely, some patients may benefit from more stringent goals (e.g., A1C 6.0% to 6.5%) such as those with a short duration of disease, long life expectancy, and no significant cardiovascular disease. c. Metformin is contraindicated in patients at risk of lactic acidosis such as those with significant renal dysfunction (e.g., serum creatinine values >1.5 mg/dl [males] and >1.4 mg/dl [females]) or alcoholism. For more information about contraindications for metformin, see our PL Detail- Document, Clinical Use of Metformin in Special Populations - Chronic Renal Insufficiency, Heart Failure, and Hepatic Dysfunction. d. Consider rapid-acting secretagogues or the meglitinides (repaglinide [Prandin], nateglinide [Starlix]) in place of sulfonylurea agents in certain patients. For example, meglitinides may be safer in patients with irregular meal schedules or in those who develop late postprandial hypoglycemia while on sulfonylurea agents. e. Basal insulin: insulin glargine (Lantus), insulin detemir (Levemir), or NPH insulin. f. Rosiglitazone use is restricted. It is only available by mail order from specially certified pharmacies. Health care providers and patients must enroll in the Avandia-Rosiglitazone Medicines Access Program. Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and internet links in this article were current as of the date of publication.
6 (PL Detail-Document #280601: Page 3 of 3) Project Leader in preparation of this PL Detail- Document: Neeta Bahal O Mara, Pharm.D., Drug Information Consultant References 1. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach. Diabetes Care Published on-line ahead of print, April 19, 2012; doi: /dc Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009;32: Cite this document as follows: PL Detail-Document, Stepwise Approach to Selecting Treatments for Type 2 Diabetes. Pharmacist s Letter/Prescriber s Letter. June Evidence and Recommendations You Can Trust 3120 West March Lane, P.O. Box 8190, Stockton, CA ~ TEL (209) ~ FAX (209) Subscribers to the Letter can get PL Detail-Documents, like this one, on any topic covered in any issue by going to or
Acarbose INITIAL: 25 mg PO TID ($45) Miglitol INITIAL: 25 mg PO TID ($145)
PL Detail-Document #310601 This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER June 2015 Drugs for Type 2
More informationComparing Medications for Adults With Type 2 Diabetes Focus of Research for Clinicians
Clinician Research Summary Diabetes Type 2 Diabetes Comparing Medications for Adults With Type 2 Diabetes Focus of Research for Clinicians A systematic review of 166 clinical studies published between
More informationVolume 01, No. 08 November 2013
State of New Jersey Department of Human Services Division of Medical Assistance & Health Services New Jersey Drug Utilization Review Board Volume 01, No. 08 November 2013 TO: SUBJECT: PURPOSE: Physicians,
More informationTreatment of Type 2 Diabetes
Improving Patient Care through Evidence Treatment of Type 2 Diabetes This information is based on a comprehensive review of the evidence for best practices in the treatment of type 2 diabetes and is sponsored
More informationType 2 Diabetes Medicines: What You Need to Know
Type 2 Diabetes Medicines: What You Need to Know Managing diabetes is complex because many hormones and body processes are at work controlling blood sugar (glucose). Medicines for diabetes include oral
More informationInitiation and Adjustment of Insulin Regimens for Type 2 Diabetes
PL Detail-Document #300128 This Detail-Document accompanies the related article published in PHARMACIST S LETTER / PRESCRIBER S LETTER January 2014 Initiation and Adjustment of Insulin Regimens for Type
More informationAdd: 2 nd generation sulfonylurea or glinide or Add DPP-4 inhibitor Start or intensify insulin therapy if HbA1c goals not achieved with the above
Guidelines for Type Diabetes - Diagnosis Fasting Plasma Glucose (confirm results if borderline) HbAIC Normal FPG < 00 < 5.5 Impaired Fasting Glucose (IFG) 00 to < 5.7%-.5% Diabetes Mellitus (or random
More informationNoninsulin Diabetes Medications Summary Chart Medications marked with an asterisk (*) can cause hypoglycemia MED GROUP DESCRIPTOR
Noninsulin Diabetes Medications Summary Chart Medications marked with an asterisk (*) can cause MED GROUP DESCRIPTOR INSULIN SECRETAGOGUES Sulfonylureas* GLYBURIDE* (Diabeta) (Micronase) MICRONIZED GLYBURIDE*
More informationBritni Hebert, MD PGY-1
Britni Hebert, MD PGY-1 Importance of Diabetes treatment Types of treatment Comparison of treatment/article Review Summary Example cases 1 out of 13 Americans have diabetes Complications include blindness,
More information10/30/2012. Anita King, DNP, RN, FNP, CDE, FAADE Clinical Associate Professor University of South Alabama Mobile, Alabama
Faculty Medications for Diabetes Satellite Conference and Live Webcast Wednesday, November 7, 2012 2:00 4:00 p.m. Central Time Anita King, DNP, RN, FNP, CDE, FAADE Clinical Associate Professor University
More informationSecond- and Third-Line Approaches for Type 2 Diabetes Workgroup: Topic Brief
Second- and Third-Line Approaches for Type 2 Diabetes Workgroup: Topic Brief March 7, 2016 Session Objective: The objective of this workshop is to assess the value of undertaking comparative effectiveness
More informationMedicines for Type 2 Diabetes A Review of the Research for Adults
Medicines for Type 2 Diabetes A Review of the Research for Adults Is This Information Right for Me? Yes, if: Your doctor or health care provider has told you that you have type 2 diabetes and have high
More informationHow To Treat Diabetes
Overview of Diabetes Medications Marie Frazzitta DNP, FNP c, CDE, MBA Senior Director of Disease Management North Shore LIJ Health Systems Normal Glucose Metabolism Insulin is produced by beta cells in
More informationCASE A1 Hypoglycemia in an Elderly T2DM Patient with Heart Failure
Hypoglycemia in an Elderly T2DM Patient with Heart Failure 1 I would like to introduce you to Sophie, an elderly patient with long-standing type 2 diabetes, who has a history of heart failure, a common
More informationSHORT CLINICAL GUIDELINE SCOPE
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SHORT CLINICAL GUIDELINE SCOPE 1 Guideline title Type 2 diabetes: newer agents for blood glucose control in type 2 diabetes 1.1 Short title Type 2
More informationThe prevalence of diabetes in the United States in
Medical Management of Type 2 Diabetes Celia Levesque, CNS-BC ABSTRACT More than 20 million Americans have type 2 diabetes. Managing blood glucose is an important component in delaying, slowing, or preventing
More informationTargeting 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
More informationAntihyperglycemic Agents Comparison Chart
Parameter Metformin Sulfonylureas Meglitinides Glitazones (TZD s) Mechanism of Action Efficacy (A1c Reduction) Hepatic glucose output Peripheral glucose uptake by enhancing insulin action insulin secretion
More informationAntidiabetic Drugs. Mosby items and derived items 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Antidiabetic Drugs Mosby items and derived items 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Diabetes Mellitus Two types Type 1 Type 2 Type 1 Diabetes Mellitus Lack of insulin production
More informationMary Bruskewitz APN, MS, RN, BC-ADM Clinical Nurse Specialist Diabetes
Mary Bruskewitz APN, MS, RN, BC-ADM Clinical Nurse Specialist Diabetes Objectives Pathophysiology of Diabetes Acute & Chronic Complications Managing acute emergencies Case examples 11/24/2014 UWHealth
More informationCASE B1. Newly Diagnosed T2DM in Patient with Prior MI
Newly Diagnosed T2DM in Patient with Prior MI 1 Our case involves a gentleman with acute myocardial infarction who is newly discovered to have type 2 diabetes. 2 One question is whether anti-hyperglycemic
More informationPills for Type 2 Diabetes. A Guide for Adults
Pills for Type 2 Diabetes A Guide for Adults December 2007 Fast Facts on Diabetes Pills n Different kinds of diabetes pills work in different ways to control blood sugar (blood glucose). n All the diabetes
More informationPharmaceutical Management of Diabetes Mellitus
1 Pharmaceutical Management of Diabetes Mellitus Diabetes Mellitus (cont d) Signs and symptoms 2 Elevated fasting blood glucose (higher than 126 mg/dl) or a hemoglobin A1C (A1C) level greater than or equal
More informationDiabetes Medications. Minal Patel, PharmD, BCPS
Diabetes Medications Minal Patel, PharmD, BCPS Objectives Examine advantages and disadvantages of oral anti-hyperglycemic medications Describe the differences between different classes of insulin Explore
More informationManagement of Diabetes: A Primary Care Perspective. Presentation Outline
Management of Diabetes: A Primary Care Perspective Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Declaration of full disclosure: No conflict of interest Presentation Outline
More informationUpdate on the management of Type 2 Diabetes
Update on the management of Type 2 Diabetes Mona Nasrallah M.D Assistant Professor, Endocrinology American University of Beirut 10 th Annual Family Medicine Conference October 14,2011 Global Prevalence
More informationMaking Clinical Sense of Diabetes Medications. Types of Diabetes. Pathophysiology. Beta Cell Function & Glucagon
Making Clinical Sense of Diabetes Medications Kathy Reily, RD, CDE Prince William Hospital Diabetes Program Coordinator Virginia Dietetic Association April 4, 2011 Types of Diabetes Type 1 DM = Beta Cell
More informationApproximate Cost Reference List i for Antihyperglycemic Agents
Alpha Glucosidase Inhibitor Acarbose (Glucobay ) Biguanides Metformin (Glucophage, generic) Metformin ER (Glumetza ) Approximate Cost Reference List i for Antihyperglycemic Agents Incretin Agents - DPP-4
More informationGuidelines for Type 2 Diabetes Diagnosis
Guidelines for Type 2 Diabetes Diagnosis Fasting Plasma Glucose (in asymptomatic individuals, repeat measurement to confirm the test) Normal FPG < 100 2-hr OGTT < 140 HbA1C < 5.5% Impaired Fasting Glucose
More informationMedications for Type 2 Diabetes
Main Page Risk Factors Symptoms Diagnosis Treatment Screening Complications Reducing Your Risk Talking to Your Doctor Living With Type 2 Diabetes Resource Guide Medications for Type 2 Diabetes by Karen
More informationDiabetes: Medications
Diabetes: Medications Presented by: APS Healthcare Southwestern PA Health Care Quality Unit (APS HCQU) May 2008 sh Disclaimer Information or education provided by the HCQU is not intended to replace medical
More informationNewer Anticoagulants and Newer Diabetic Drug Classes. Nicole N. Nguyen, PharmD Senior Clinical Pharmacist Health Care Services August 21, 2013
Newer Anticoagulants and Newer Diabetic Drug Classes Nicole N. Nguyen, PharmD Senior Clinical Pharmacist Health Care Services August 21, 2013 Apixaban Newer Anticoagulants Dabigatran etexilate Rivaroxaban
More informationTreatment of Hypertension: JNC 8 and More
PL Detail-Document #300201 This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER February 2014 Treatment of
More informationPrimary Care Type 2 Diabetes Update
Primary Care Type 2 Diabetes Update May 16, 2014 Presented by: Barb Risnes APRN, BC-ADM, CDE Objectives: Discuss strategies to address common type 2 diabetes patient management challenges Review new pharmacological
More information25 mg QD-TID @ meals w/1st bite of. food, titrate Q 4 8 weeks; adjust based on 1 postprandial glucose; 100 mg TID max
Table Selected Non-Insulin Antihyperglycemic Agents Class Drug (Brand) Dosing Comments -Glucosidase inhibitors Acarbose a (Precose) 25 mg QD-TID @ meals w/1st bite of MOA: Enzyme inhibitor, delays hydrolysis
More informationFYI: (Acceptable range for blood glucose usually 70-110 mg/dl. know your institutions policy.)
How Insulin Works: Each type of insulin has an onset, a peak, and a duration time. Onset is the length of time before insulin reaches the bloodstream and begins lowering blood Peak is the time during which
More informationTreatment Approaches to Diabetes
Treatment Approaches to Diabetes Dr. Sarah Swofford, MD, MSPH & Marilee Bomar, GCNS, CDE Quick Overview Lifestyle Oral meds Injectables not insulin Insulin Summary 1 Lifestyle & DM Getting to the point
More informationDiabetes Mellitus 1. Chapter 43. Diabetes Mellitus, Self-Assessment Questions
Diabetes Mellitus 1 Chapter 43. Diabetes Mellitus, Self-Assessment Questions 1. A 46-year-old man presents for his annual physical. He states that he has been going to the bathroom more frequently than
More informationHarmony Clinical Trial Medical Media Factsheet
Overview Harmony is the global Phase III clinical trial program for Tanzeum (albiglutide), a product developed by GSK for the treatment of type 2 diabetes. The comprehensive program comprised eight individual
More informationCADTH Optimal Use Report
Canadian Agency for Drugs and Technologies in Health Agence canadienne des médicaments et des technologies de la santé CADTH Optimal Use Report Volume 3, Issue 1A July 2013 Second-Line Pharmacotherapy
More informationMedicines Used to Treat Type 2 Diabetes
Goodman Diabetes Service Medicines Used to Treat Type 2 Diabetes People who have type 2 diabetes may need to take medicine to help lower their blood glucose, in addition to being active & choosing healthy
More informationDiabetes Fundamentals
Diabetes Fundamentals Prevalence of Diabetes in the U.S. Undiagnosed 10.7% of all people 20+ 23.1% of all people 60+ (12.2 million) Slide provided by Roche Diagnostics Sources: ADA, WHO statistics Prevalence
More informationTrends in Prescribing of Drugs for Type 2 Diabetes in General Practice in England (Chart 1) Other intermediate and long-acting insulins
Type 2 Diabetes Type 2 diabetes is the most common form of diabetes, accounting for 90 95% of cases. 1 Charts 1 and 2 reflect the effect of increasing prevalence on prescribing and costs of products used
More informationManagement of Diabetes in the Elderly. Sylvia Shamanna Internal Medicine (R1)
Management of Diabetes in the Elderly Sylvia Shamanna Internal Medicine (R1) Case 74 year old female with frontal temporal lobe dementia admitted for prolonged delirium and frequent falls (usually in the
More informationTake a moment Confer with your neighbour And try to solve the following word picture puzzle slides.
Take a moment Confer with your neighbour And try to solve the following word picture puzzle slides. Example: = Head Over Heels Take a moment Confer with your neighbour And try to solve the following word
More informationOral Therapy for Type 2 Diabetes
Oral Therapy for Type 2 Diabetes Diabetes pills can help to manage your blood sugar. These pills are not insulin. They work to manage your blood sugar in several ways. You may be given a combination of
More informationManagement of Type 2 Diabetes Mellitus in the Elderly
Management of Type 2 Diabetes Mellitus in the Elderly ANDREA FERENCZI, M.D. BANNER ARIZONA MEDICAL CLINIC DEPARTMENT OF ENDOCRINOLOGY Incidence and Prevalence of Diabetes in the United States County-level
More informationManagement of Clients with Diabetes Mellitus
Management of Clients with Diabetes Mellitus Black, J.M. & Hawks, J.H. (2005) Chapters 47, (pp 1243-1288) 1288) Baptist Health School of Nursing NSG 4037: Adult Nursing III Carole Mackey, MNSc,, RN, PNP
More informationMEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES
MEDICAL ASSISTANCE HBOOK I. Requirements for Prior Authorization of Incretin Mimetic/Enhancer Hypoglycemics (formerly referred to as Other Hypoglycemics) A. Thresholds for Prior Authorization All prescriptions
More informationDIABETES MEDICATION-ORAL AGENTS AND OTHER HYPOGLYCEMIC AGENTS
Section Two DIABETES MEDICATION-ORAL AGENTS AND OTHER HYPOGLYCEMIC AGENTS This section will: Describe oral agents (pills) are specific for treating type 2 diabetes. Describe other hypoglycemic agents used
More informationThere seem to be inconsistencies regarding diabetic management in
Society of Ambulatory Anesthesia (SAMBA) Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery Review of the consensus statement and additional
More informationMeasure #1 (NQF 0059): Diabetes: Hemoglobin A1c Poor Control National Quality Strategy Domain: Effective Clinical Care
Measure #1 (NQF 0059): Diabetes: Hemoglobin A1c Poor Control National Quality Strategy Domain: Effective Clinical Care 2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY DESCRIPTION: Percentage
More informationwe have to keep up. Timothy S. Reid, M.D. Mercy Diabetes Center Janesville, WI Entity Activity Financial Consideration Comments
Timothy S. Reid, M.D. Mercy Diabetes Center Janesville, WI Entity Activity Financial Consideration Comments Novo Nordisk Speaker/Consultant Speaker Fees/Honoraria Sanofi-Aventis Speaker/Consultant Speaker
More informationMedical Policy An independent licensee of the Blue Cross Blue Shield Association
Afrezza Page 1 of 6 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Afrezza (human insulin) Prime Therapeutics will review Prior Authorization requests Prior Authorization
More informationINSULIN TREATMENT FOR TYPE 2 DIABETES MANAGEMENT
INSULIN TREATMENT FOR TYPE 2 DIABETES MANAGEMENT APIRADEE SRIWIJITKAMOL DIVISION OF ENDOCRINOLOGY AND METABOLISM DEPARTMENT OF MEDICINE FACULTY OF MEDICINE SIRIRAJ HOSPITOL QUESTION 1 1. ท านเคยเป นแพทย
More informationMICHIGAN TYPE 2 DIABETES REPORT 2014
MICHIGAN TYPE 2 DIABETES REPORT 2014 CONTENTS Patient Demographics...3 Cases/ALOS/Hospital Charges...4 Professional Charges...5 Use of Services...6 Pharmacotherapy...6 7 Persistency...8 ADA/EASD Position
More informationFundamentals of Diabetes Care Module 5, Lesson 1
Module 5, Lesson 1 Fundamentals of Diabetes Care Module 5: Taking Medications Healthy Eating Being Active Monitoring Taking Medication Problem Solving Healthy Coping Reducing Risks Foundations For Control
More informationComparative Review of Oral Hypoglycemic Agents in Adults
SECTION 18.5 Comparative Review of Oral Hypoglycemic Agents in Adults Harinder Chahal For WHO Secretariat Table of Contents Acronyms:... 3 I. Background and Rationale for the review:... 4 II. Medications
More informationDr. John Bucheit, Pharm.D., BCACP, CDE Clinical Assistant Professor Mercer University College of Pharmacy
Dr. John Bucheit, Pharm.D., BCACP, CDE Clinical Assistant Professor Mercer University College of Pharmacy Disclosures to Participants Requirements for Successful Completion: For successful completion,
More informationClass Update: Diabetes Medications. Month/Year of Review: September 2014 End date of literature search: August 2014
Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35, Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119
More informationDiabetes Update Lanita S. Shaverd, Pharm.D. Director, UAMS 12 th Street Health and Wellness Center Assistant Professor, UAMS College of Pharmacy
Objectives Review oral medications used for the treatment of diabetes Explain how to effectively combine oral diabetes medications for optimal results Discuss insulins and non-insulin injectable diabetes
More informationCardiovascular Disease in Diabetes
Cardiovascular Disease in Diabetes Where Do We Stand in 2012? David M. Kendall, MD Distinguished Medical Fellow Lilly Diabetes Associate Professor of Medicine University of MInnesota Disclosure - Duality
More informationDiabetes Mellitus Pharmacology Review
Diabetes Mellitus Pharmacology Review Hien T. Nguyen, Pharm.D., BCPS Clinical Pharmacist Specialist AtlantiCare Regional Medical Center E-Mail: HienT.Nguyen@atlanticare.org Objectives 1. Review the epidemiology
More informationCME Test for AMDA Clinical Practice Guideline. Diabetes Mellitus
CME Test for AMDA Clinical Practice Guideline Diabetes Mellitus Part I: 1. Which one of the following statements about type 2 diabetes is not accurate? a. Diabetics are at increased risk of experiencing
More informationdiabetes and I think things are pretty much what they were but there have been some confusion that
MARY T. KORYTKOWSKI,, M.D. 1 Good morning. Thank you very much for inviting me to speak at this year s conference, update in internal medicine. And as was said, I will talk to you about what may not be
More informationMANAGEMENT OF TYPE 2 DIABETES: REVIEW OF DRUG THERAPY
MANAGEMENT OF TYPE 2 DIABETES: REVIEW OF DRUG THERAPY AND THE ROLE OF THE PHARMACIST NINA BEMBEN, PHARMD MARY LYNN MCPHERSON, PAHRMD, MA, BCPS, CDE ZEMEN HABTEMARIAM, STUDENT PHARMACIST MANAGEMENT OF TYPE
More informationINSULIN INTENSIFICATION: Taking Care to the Next Level
INSULIN INTENSIFICATION: Taking Care to the Next Level By J. Robin Conway M.D., Diabetes Clinic, Smiths Falls, ON www.diabetesclinic.ca Type 2 Diabetes is an increasing problem in our society, due largely
More informationALL IN THE FAMILY 75 YEARS OF DIABETES TREATMENT OPTIONS FROM GLASS SYRINGES TO SGLT2 INHIBITORS PETER A. KRECKEL, R.PH.
ALL IN THE FAMILY 75 YEARS OF DIABETES TREATMENT OPTIONS FROM GLASS SYRINGES TO SGLT2 INHIBITORS PETER A. KRECKEL, R.PH. ALL IN THE FAMILY 75 YEARS OF DIABETES TREATMENT OPTIONS FROM GLASS SYRINGES TO
More informationtrends in the treatment of Diabetes type 2 - New classes of antidiabetic drugs. IAIM, 2015; 2(4): 223-
Review Article Pharmacological trends in the treatment of Diabetes type 2 - New classes of antidiabetic Silvia Mihailova 1*, Antoaneta Tsvetkova 1, Anna Todorova 2 1 Assistant Pharmacist, Education and
More informationIt is estimated that 25.8 million people or 8.3% of the US
1.0 CPEUs and 2.0 ANCC Contact Hours An Overview of Glycemic Goals and Medications Used to Manage Type 2 Diabetes Mary-Kathleen Grams, PharmD Suzanne Dinsmore, PharmD, CGP Jennifer Goldman-Levine, PharmD,
More informationHow to Switch Between Insulin Products
Detail-Document #251005 This Detail-Document accompanies the related article published in PHARMACIST S LETTER / PRESCRIBER S LETTER October 2009 ~ Volume 25 ~ Number 251005 How to Switch Between Insulin
More informationDiabetes, Type 2. RelayClinical Patient Education Sample Topic Diabetes, Type 2. What is type 2 diabetes? How does it occur?
What is type 2 diabetes? Type 2 diabetes is a disorder that happens when your body does not make enough insulin or is unable to use its own insulin properly. The inability to use insulin is called insulin
More informationINSULIN AND INCRETIN THERAPIES: WHAT COMBINATIONS ARE RIGHT FOR YOUR PATIENT?
INSULIN AND INCRETIN THERAPIES: WHAT COMBINATIONS ARE RIGHT FOR YOUR PATIENT? MARTHA M. BRINSKO, MSN, ANP-BC CHARLOTTE COMMUNITY HEALTH CLINIC CHARLOTTE, NC Diagnosed and undiagnosed diabetes in the United
More informationDM Management in Elderly- What are the glucose targets?
DM Management in Elderly- What are the glucose targets? AFSHAN ZAHEDI, BASC, MD, FRCP(C) ENDOCRINOLOGY WOMEN S COLLEGE HOSPITAL ASSISTANT PROFESSOR OF MEDICINE UNIVERSITY OF TORONTO NOVEMBER 2, 2011 Disclosures
More informationDiabetes Medications at the End of Life. Goals and Objectives. Diabetes. Type 2 Diabetes Mellitus. Types of Diabetes
Diabetes Medications at the End of Life Paul J. Schmidt Jr., R.Ph., M.S. Clinical Supervisor HospiScript Services pschmidt@hospiscript.com Goals and Objectives Describe the Current Impact of Diabetes Mellitus
More informationInsulin myths and facts
london medicines evaluation network Insulin myths and facts Statement 1 Insulin is the last resort for patients with Type 2 diabetes After initial metformin and sulfonylurea therapy, NICE and SIGN suggest
More informationDiabetes Mellitus Type 2
Diabetes Mellitus Type 2 What is it? Diabetes is a common health problem in the U.S. and the world. In diabetes, the body does not use the food it digests well. It is hard for the body to use carbohydrates
More informationType 2 diabetes Definition
Type 2 diabetes Definition Type 2 diabetes is a lifelong (chronic) disease in which there are high levels of sugar (glucose) in the blood. Type 2 diabetes is the most common form of diabetes. Causes Diabetes
More informationDIABETES EDUCATION. *Read package insert each time you refill your medications in case there is new information SULFONYLUREAS
DIABETES EDUCATION *Read package insert each time you refill your medications in case there is new information SULFONYLUREAS ACTION: Sulfonylureas stimulate the pancreas to make more insulin (pancreas
More informationNew Non-Insulin Therapies for Type 2 Diabetes Mellitus
New Non-Insulin Therapies for Type 2 Diabetes Mellitus Ally P.H. Prebtani Associate Professor of Medicine Internal Medicine, Endocrinology & Metabolism McMaster University Canada Disclosure Relationships
More informationDiabetes Complications
Managing Diabetes: It s s Not Easy But It s s Worth It Presenter Disclosures W. Lee Ball, Jr., OD, FAAO (1) The following personal financial relationships with commercial interests relevant to this presentation
More informationType 2 diabetes mellitus, the sixth
Management of Blood Glucose in Type 2 Diabetes Mellitus CYNTHIA M. RIPSIN, MD, MS, MPH; HELEN KANG, MD; and RANDALL J. URBAN, MD University of Texas Medical Branch, Galveston, Texas Evidence-based guidelines
More informationAlgorithms for Glycemic Management of Type 2 Diabetes
KENTUCKY DIABETES NETWORK, INC. Algorithms for Glycemic Management of Type 2 Diabetes The Diabetes Care Algorithms for Type 2 Diabetes included within this document are taken from the American Association
More informationNew Pharmacotherapies for Type 2 Diabetes
New Pharmacotherapies for Type 2 Diabetes By Brian Irons, Pharm.D., FCCP, BCACP, BCPS, BC-ADM Reviewed by Charmaine Rochester, Pharm.D., BCPS, CDE; and Karen Whalen, Pharm.D., BCPS, CDE Learning Objectives
More informationMedications for Diabetes
AGS Diab Med Brochure 4/18/03 3:43 PM Page 1 Medications for Diabetes An Older Adult s Guide to Safe Use of Diabetes Medications THE AGS FOUNDATION FOR HEALTH IN AGING AGS Diab Med Brochure 4/18/03 3:43
More informationSUBJECT: DIABETES MEDICATION MANAGEMENT PROTOCOLS
SUBJECT: DIABETES MEDICATION MANAGEMENT PROTOCOLS PURPOSE To establish a process that will enable Certified Diabetes Educators (CDE) and/or staff with Board Certification in Advanced Diabetes Management
More informationEffective pharmacological treatment regimens for diabetes usually require
Medications Used in Diabetes in Patients Presenting for Anesthesia By Gabrielle O Connor, M.D., M.Sc., CCD, MRCP, FACP Dr. Gabrielle O Connor, a board certified endocrinologist who graduated from University
More informationWhat I need to know about. Diabetes Medicines. National Diabetes Information Clearinghouse
What I need to know about Diabetes Medicines National Diabetes Information Clearinghouse What I need to know about Diabetes Medicines Contents What do diabetes medicines do?... 1 What targets are recommended
More informationIssued and entered this 20 th day of December 2010 by Ken Ross Commissioner ORDER I PROCEDURAL BACKGROUND
STATE OF MICHIGAN DEPARTMENT OF ENERGY, LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE REGULATION Before the Commissioner of Financial and Insurance Regulation In the matter of XXXXX Petitioner
More informationInsulin degludec (Tresiba) for the Management of Diabetes: Effectiveness, Value, and Value-Based Price Benchmarks
Background: Insulin degludec (Tresiba) for the Management of Diabetes: Effectiveness, Value, and Value-Based Price Benchmarks Final Background and Scope November 19, 2015 The Centers for Disease Control
More informationEffective Treatment of Type 2 Diabetes
Faculty Disclosures Effective Treatment of Type 2 Diabetes Mellitus Dr. Milligan disclosed no relevant financial relationships with any commercial interests. Steven Milligan, MD Diplomat, American Board
More information6/22/2015. New medicines for type 2 diabetes when do you use them
New medicines for type 2 diabetes when do you use them 1. Oral Secretagogues (e.g. sulfonylureas) 2. Metformin 3. Alpha glucosidase inhibitors 4. Thiazolidinediones 5. GLP-1 receptor agonists 6. DPP-4
More informationlinagliptin, 5mg film-coated tablet (Trajenta ) SMC No. (746/11) Boehringer Ingelheim / Eli Lilly and Company Ltd
linagliptin, 5mg film-coated tablet (Trajenta ) SMC No. (746/11) Boehringer Ingelheim / Eli Lilly and Company Ltd 09 December 2011 The Scottish Medicines Consortium (SMC) has completed its assessment of
More informationDrug Class Review. Newer Diabetes Medications and Combinations
Drug Class Review Newer Diabetes Medications and Combinations Final Streamlined Update 1 Report June 2014 The purpose of Drug Effectiveness Review Project reports is to make available information regarding
More informationDavid Shu, MD, FRCPC Endocrinology, Royal Columbian Hospital October 8 th, 2010
David Shu, MD, FRCPC Endocrinology, Royal Columbian Hospital October 8 th, 2010 Objectives At the end of the talk, the participants will be able to: 1. Identify the increasing prevalence of type 2 diabetes
More informationInsulin Therapy In Type 2 DM. Sources of support. Agenda. Michael Fischer, M.D., M.S. The underuse of insulin Insulin definition and types
Insulin Therapy In Type 2 DM Michael Fischer, M.D., M.S. Sources of support NaRCAD is supported by a grant from the Agency for Healthcare Research and Quality My current research projects are funded by
More informationQuality Measures for Pharmacies
PL Detail-Document #320101 This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER January 2016 Quality for Pharmacies
More informationType 2 Diabetes Medications: SGLT2 Inhibitors
Type 2 Diabetes Medications: SGLT2 Inhibitors SGLT2 inhibitors are a class of type 2 diabetes medications used along with diet and exercise to lower blood glucose How are they taken? SGLT2 inhibitors is
More informationCardiac Rehabilitation New Brunswick: Tutorial Series. Diabetes Mellitus Overview, pharmacotherapy and exercise considerations
Cardiac Rehabilitation New Brunswick: Tutorial Series Diabetes Mellitus Overview, pharmacotherapy and exercise considerations Overview Prevalence of diabetes Definition and Diagnosis Risk factors and complications
More informationAdult Diabetes Clinician Guide
Kaiser Permanente National CLINICAL PRACTICE GUIDELINES Adult Diabetes Clinician Guide Introduction JANUARY 2016 This evidence-based guideline summary is based on the 2016 National Diabetes Guideline.
More information