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Diabetes Update

Diabetes Update. Maximizing options to achieve optimal blood glucose control. Carla Cox, PhD, RD, CDE. Be able to identify 3 lifestyle recommendations that could change your patients life with diabetes

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Diabetes Update

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  1. Diabetes Update Maximizing options to achieve optimal blood glucose control Carla Cox, PhD, RD, CDE

  2. Be able to identify 3 lifestyle recommendations that could change your patients life with diabetes • Be able to list 3 classes of diabetes medications and their target tissues and when to consider using them • Understand the potential for technology to enhance your patients ability to partner in the management of their blood glucose Objectives

  3. American diabetes Association American Academy of Clinical Endocrinologists What ARE those BG Goals?

  4. ADA < 7% (with clinical judgment on co-morbid conditions) What ARE those BG Goals?

  5. What ARE those BG Goals?

  6. 50% of Kaiser Permanente Northwest patients who initiated metformin-sulfonylurea combination therapy failed to maintain A1C levels below 8%....and it was 3 YEARS before insulin was added and at that time mean A1C of 9% (Nichols et al, 2007) • UK population using 2 agents had A1C of at least 8% for 6.9 YEARS before further intensification of therapy with mean A1C of 9.1% (Khuntiet al, 2013) WE NEED TO DO BETTER THAN THIS! What’s the data?

  7. Lifestyle

  8. Lifestyle: Food

  9. It’s not just about the carbs anymore! Food

  10. Not evil, not promoting health Quality

  11. Think and teach balance: A fruit or vegetable with every meal – and don’t forget the whole grains!

  12. Lifestyle: Exercise

  13. Minimum • Aerobic Exercise 150 minutes per week (3-5 days per week) • Strength training 2-3 times per week • Stretching 5 days of the week Exercise – American College of Sports Medicine

  14. Exercise most days of the week • Include strength and aerobic exercise when possible – think about the order Exercise – diabetes specific

  15. Consider timing of the meal with exercise and present medication regimen • Follow minimum standards of ACSM (no evidence that stretching per se is needed) Exercise – diabetes specific

  16. Benefits • Helps to maintain/reach a healthy weight • Treatment of osteoarthritis and rheumatoid arthritis • Greater emotional health and better sleep!

  17. Benefits • Reduced risk of developing: • Diabetes • Heart disease • Stroke • Cancers • High blood pressure

  18. Monitoring

  19. Monitoring

  20. More data: 4 cookies for afternoon snack 10/16 ; ice cream sundae 10/18 More data: Took a walk 10/17 afternoon and had 2 cookies for afternoon snack Using the data

  21. More data: 4 cookies for afternoon snack 10/16 ; ice cream sundae 10/18 More data: Took a walk 10/17 afternoon and had 2 cookies for afternoon snack Using the data – what should we change?

  22. Medications Remember – the goal is BG control, not necessarily how we get there!

  23. When lifestyle doesn’t do it (or doesn’t happen) 1921 – Insulin is discovered (thank you dogs!) 1923 – Insulin is produced by Eli Lilly 1936 – first slower insulin (NPH type) • 1955 – Sulfonylureas • 1983 – 2nd generation of Sulfonylureas • 1997 - Thiazolidinediones Medications

  24. When lifestyle doesn’t do it (or doesn’t happen) - 2014 • Biguanide • Metformin/biguanide • Secretagogues • Glucatrol/Glipizide • Amaryl/glimiprimide • Meglitinides • Prandin/repaglinide • Starlix/nateglinide • TZD • Actos/Pioglitazaone • Alpha-Glucosidase Inhibitors • Precose/acarbose • Glyset/miglitol • GLP-1 (incretins and incretinmimetics) • Byetta/exenatide (BID) • Victoza/liraglutide (1/day) • Bydureon/exenatide (weekly) • Tanzeum/albiglutide (weekly) • Trulicity/dulaglutide (weekly) (11/18) • DPP-4 • Januvia/sitagliptin • Onglyza/saxagliptin • Tradjenta/linagliptin • Nesina/alogliptin • SGLT-2 (sodium-glucose co-transporter) • Invocana/Canagliflozin • Farxiga/Dapagliflozin • Jardiance/Empagliflozin • Combination drugs (such as Janumet) • Insulin • Basal • Bolus • Premixed Medications

  25. GLP-1 receptor agonistsA1C 1-1.5 http://www.globalrph.com/DPP-4-inhibitors.htm

  26. Monitor with renal insufficiency (CrCl< 30 mL/min) • Patients with history or risk of pancreatitis (insufficient clinical evidence to support this) • Patients with personal or family history of thyroid c-cell tumors (not seen in humans) • Individuals with stomach or intestinal issues may not be candidates Who should NOT use this medication

  27. DPP-4 inhibitors A1C .5-1 http://www.globalrph.com/DPP-4-inhibitors.htm

  28. Reduce dose in renal insufficiency (with the exception of Trajenta) Who should not use this medication

  29. SGLT-2 inhibitorsA1C .7-1

  30. Patients with hypovolemia • Caution with the elderly – especially using diuretics • Patients with GFR below 45 mL/min (Farxiga/Dapagliflozin) – below 60 mL/min) Who should not use this medication

  31. Phillips et al, We can change the natural history of type 2 diabetes, Diabetes Care 2014;37-2668-2676

  32. Phillips et al, We can change the natural history of type 2 diabetes, Diabetes Care 2014;37-2668-2676

  33. CefaluW, Del Prato S, LeRoith D et al. Beyond Metformin: Safety Considerations in the Decision-Making Process for Selecting a Second Medication for Type 2 Diabetes Management: Reflections from a Diabetes Care Editors Expert Forum. Diabetes Care 2014;37:267-2659. Medication review

  34. Using technology

  35. Using technology – reading the downloads

  36. Insulin delivery • Pens - .5 – 1 unit • Pumps (including V-Go) • U-500 insulin option • Blood glucose results • Meters • Sensors (additional layer) Delivering insulin anddiscovering results

  37. Pens, pumps, sensors

  38. 14455-AW R2 03/11

  39. Backcountry management: 4 days backpacking

  40. 3 Week CGMS

  41. Sensor data

  42. There is a relationship between frequency of A1C testing and better BG management results • Those testing annually had a 1.5% increase • Those testing every 3 months had a 3.8% decrease • Those who tested more often did not improve beyond the quarterly checks Diabetes Care 2014;37:2731-2737 A1C testing

  43. Patient is 54 year old patient with A1C of 8.5%. He has abdominal obesity and is sedentary. No significant joint problems. He works 50 hours per week, and works around the house on the week-ends. He is presently on Metformin and Glipizide. Renal and liver function tests are WNL. He denies symptoms such as frequent urination, thirst, excessive fatigue • What do you do? Case #1

  44. Patient is 54 year old patient with A1C of 8.5%. He has abdominal obesity and is sedentary. No significant joint problems. He works 50 hours per week, and works around the house on the week-ends. He is presently on Metformin and Glipizide. Renal and liver function tests are WNL • Consider referral to diabetes education – even a 2nd time • Add a medication – which one? • Make sure he is monitoring effectively (pre and post meal) • Have him return for f/u or follow up with SOMEONE in 1-2 weeks Case #1

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