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Clinical Update in Type 2 Diabetes

Clinical Update in Type 2 Diabetes. A Case Discussion Dr. Yancey R. Holmes, MD, FACE Ohio Valley Endocrinology. Topics for Discussion. Glycemic Targets Therapeutic Agents Case Discussion. Glycemic Targets. American Diabetes Association American Association of Clinical Endocrinologists

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Clinical Update in Type 2 Diabetes

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  1. Clinical Update in Type 2 Diabetes • A Case Discussion • Dr. Yancey R. Holmes, MD, FACE • Ohio Valley Endocrinology

  2. Topics for Discussion • Glycemic Targets • Therapeutic Agents • Case Discussion

  3. Glycemic Targets • American Diabetes Association • American Association of Clinical Endocrinologists • HbA1c • Fasting glucose • Post prandial glucose • Hypoglycemia

  4. Pharmacologic Agents • Sulfonylureas and Meglitinides • Metformin • Alpha-glucosidase Inhibitors • Thiazolidinediones • Dipeptidyl Pepdidase-4 Inhibitors

  5. Pharmacologic Agents • Welchol • Incretin Mimetic • GLP-1 AgonistsGLP-1 Analogs • Amylin Analogs

  6. Pharmacologic Agents • Human Insulin • Regular • NPH • Analog Insulin • Rapid • Basal • Mix

  7. Special Considerations • Heart Disease • Renal Impairment • Liver Disease • Frailty • Weight Gain

  8. Case Discussion

  9. Case 1 • 56 year old man referred by cardiologist • Diabetes diagnosed during hospitalization for acute MI associated with pulmonary edema • BMI 32 NYHA Class III functional status

  10. Case 1 • HbA1c 8.6% • Serum creatinine 1.3 • Discloses that he “ain’t takin’ no damn shots!”

  11. Case 1 Discussion • Drug naive patient with ischemic heart disease and systolic dysfunction • Confrontational needle-phobe

  12. Case 1 • Metformin: Will it get to goal? • Sulfonylurea: Hypoglycemia concerns? • TZD’s: Fluid retention? • DPP-4 Inhibitors?

  13. Case 2a • 42 year old woman referred by friend • Strong family history. Symptoms of post prandial fatigue. • Currently at her highest body weight. • Exercise is infrequent

  14. Case 2a • BMI 36 • HbA1c 7.8% • Expresses a good understanding of recommended lifestyle changes.

  15. Case 2a • Metformin • Sulfonylurea • TZD • DPP-4 • Injections???

  16. Case 2b • After successful adoption of healthy lifestyle changes and metformin she maintains HbA1c less than 6.5% over the next three years • She presents for follow up to discuss options to address weight gain and diabetes • BMI 32

  17. Case 2b • 9 months ago HbA1c 7.3% • Metformin was titrated to 1000 mg bid • 6 months ago HbA1c 6.4% • Back on track with exercise and associated 6 pound weight loss

  18. Case 2b • 3 months ago HbA1c 7.1% • Recent job change, stressed out. Feels certain she can get back on track without additional medicaiton • Now HbA1c 7.8% • Weight is up 12 pounds from last visit • Very frustrated with weight gain and constant hunger

  19. Case 2b • Metformin titration to 2500 mg? • Addition of Sulfonylurea? • Addition of TZD? • Addition of DPP-4 Inhibitor? • Addition of Basal Insulin • Addition of a GLP-1 Agent

  20. Case 3a • 40 year old man currently on Metformin and SU maximal dose • FBG 160-180 • PPG 160-200 • HbA1c 8.2% • BMI 27

  21. Case 3a • Addition of third oral agent? • Addition of GLP-1/Amylin • Introduction of insulin? • Human vs. Analog? • What kind of dosing regimen?

  22. Case 3b • Addition of basal insulin helped maintain good glycemic control over the next 18 months • Now HbA1c 7.8% • FBG 100-140 • PPG 180-220

  23. Case 3b • Oral agents? • Mealtime insulin • Mealtime amylin • Should anything be discontinued?

  24. Case 4a • 38 year old man presents for assessment after family member tests a blood sugar of 400 • He has already adopted many good dietary changes and saw the educator at the health department • Blood sugars range from 180-250 • HbA1c 9.8% • BMI 31

  25. Case 4a • Metformin with continued lifestyle modification? • Combination agent? • Insulin? • GLP-1/Amylin?

  26. Case 4b • After 5 years of maintaining HbA1c <7% on combination Metformin+TZD blood sugars are elevated • HbA1c 8.2% • 15 pound weight gain over past 3-6 months

  27. Case 4b • Third oral agent? • Insulin? • GLP-1/Amylin?

  28. Case 5 • 60 year old woman with type 2 diabetes for 2 years treated with SU • HbA1c has ranged from 8.2-6.8% over that time. Currently it is 7.5% • Recent attempts to titrate SU have lead to frequent hypoglycemia, particularly with exercise • She has been trying to exercise to stop her steady weight gain of 20 pounds over the past year

  29. Case 5 • Metformin? • DPP-4? • TZD? • Insulin? • GLP-1/Amylin?

  30. Case 6 • 36 year old woman recently relocated to your area presents for first visit • Diabetes diagnosed last year. • Subacute onset of symptoms with passive 15 pound weight loss • Started on Metformin and titrated to 1000 mg twice daily with good response

  31. Case 6 • Over past two months she has had recurrence of symptoms • Blood sugars frequently in the 300+ range • No change in routine • Has experienced a 25 pound passive weight loss • HbA1c now 10.5%

  32. Case 6 • Additional oral therapy? • GLP-1/Amylin? • What is her diagnosis?

  33. Thank you

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