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Barriers to Diabetes Control

Barriers to Diabetes Control. Mark E. Molitch , MD. NHANES: Achieving ADA Recommendations, 2003-2006. Individuals reaching glycemic control targets: HbA1c <7% 57.1% Individuals achieving other ADA goals of therapy: BP <130/80 mm Hg 45.5% LDL <100 mg/ dL 46.5%

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Barriers to Diabetes Control

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  1. Barriers to Diabetes Control Mark E. Molitch, MD

  2. NHANES: Achieving ADA Recommendations, 2003-2006 • Individuals reaching glycemic control targets: • HbA1c <7% 57.1% • Individuals achieving other ADA goals of therapy: • BP <130/80 mm Hg 45.5% • LDL <100 mg/dL 46.5% • Only 12.2% of individuals met all 3 goals Abbreviations: BP, blood pressure; HbA1c, glycosylated hemoglobin; LDL, low-density lipoprotein; NHANES, National Health and Nutrition Examination Survey Cheung BM, et al. Am J Med. 2009;122:443-453. 2

  3. Treatment Algorithm for Type 2 Diabetes At diagnosis: Lifestyle + Metformin STEP 1 HbA1c >7.0% STEP 2 Add DPP-4 inhibitor Add pioglitazone Add basal insulin Add sulfonylurea Add GLP-1 agonist Intensive insulin NOT glyburide, chlorpropamide NOT rosiglitazone STEP 3 Abbreviations: DPP-4, dipeptidyl peptidase-4; GLP-1, glucagon-like peptide Nathan DM, et al. Diabetes Care. 2009;32:193-203. 4

  4. Combination Therapy in Type 2 Diabetes:Decision Considerations • HbA1c efficacy • Reductions from baseline • Reaching target • Synergy of mechanisms of action • Side effects and toxicity profile • Frequency and severity of hypoglycemia • Effect on weight gain • Avoiding polypharmacy and complex regimens • Compliance and convenience • Cost 5

  5. Barriers to Diabetes Control • Clinical inertia • Financial • Adverse effects of oral agents • Insulin • Fear of injections • Fear of hypoglycemia • Complexity of management • Targets of treatment • Need to adjust to individual patient • Cultural 6

  6. Earlier and More Aggressive Intervention May Improve Treating to Target Compared With Conventional Therapy • Typical progression is to wait for HbA1c to reach 8–9% • before moving to next step Monotherapy Uptitrate dose of monotherapy Moving more aggressively to more potent treatment can achieve goal of HbA1c of < 7% more quickly Add 2nd and then 3rd drug Add basal insulin then multiple insulin injections per day

  7. Advantages & Disadvantages of Type 2 Diabetes Medications AACE/ACE Diabetes Algorithm for Glycemic Control. Endrocr Pract. 2009;15:540-559.

  8. Barriers to Insulin Therapy: Common Concerns Insulin therapy might cause: • Worsening insulin resistance • But reduction of glucose toxicity improves resistance • More cardiovascular risk • But reduction in glucose improves cardiovascular risk • Weight gain • Yes, it does occur with improved metabolic efficiency • Hypoglycemia • Very rare with type 2 diabetes • Common with type 1 diabetes as approaching optimum glycemic control 9

  9. Challenges and Opportunities in Minority Populations • Rapidly growing populations • High rates of type 2 diabetes and its complications • Groups with unique culture, health beliefs, myths, and food preferences • Diverse level of education and socio-economic status • Insufficient culturally oriented diabetes care, education, and research programs • Health care system and health professional barriers Cultural competency is key to approaching patients in a beneficial way 10

  10. Why We Cannot Always Extrapolate to Older Adults with Diabetes • Heterogeneity • Comorbid conditions • Functional limitations • Cognitive decline • Polypharmacy • Life expectancy versus • Time to incidence or progression of microvascular or macrovascular complications • Time to expected benefit of intervention 11

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