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CLINICAL UPDATES: MANAGEMENT OF DIABETES MELLITUS

CLINICAL UPDATES: MANAGEMENT OF DIABETES MELLITUS. OBJECTIVES. Review and update anti-diabetic therapeutic agents VA-DoD Clinical Practice Guideline update DoD Formulary update HEDIS metrics and challenges. BACKGROUND. Risk : Relationship Lifetime risk First degree relative 30-40%

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CLINICAL UPDATES: MANAGEMENT OF DIABETES MELLITUS

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  1. CLINICAL UPDATES:MANAGEMENT OF DIABETES MELLITUS

  2. OBJECTIVES • Review and update anti-diabetic therapeutic agents • VA-DoD Clinical Practice Guideline update • DoD Formulary update • HEDIS metrics and challenges

  3. BACKGROUND • Risk: • Relationship Lifetime risk • First degree relative 30-40% • Offspring of one parent 30-40% • Offspring of two parents 80% • Sibling (or dizygotic twin) 30-40% • Monozygotic twin 80%

  4. BACKGROUND • UKPDS: • Intensive therapy  12% risk reduction in any diabetes related endpoint (NNT 20:1) • For every 1% decrease in A1C  35% risk reduction in microvascular endpoints • No difference in macrovascular disease between intensive vs conventional

  5. BACKGROUND SICU: Intensive 80-110 (100) vs conventional 180-200 (150) • 40% ICU mortality • 34% overall hospital mortality • 46% sepsis • 41% need for dialysis • 50% transfusion rate • 44% cardioneuropathy MICU: lower in-hospital mortality 43 vs 52.5% (P=0.009)

  6. BACKGROUND • Diabetes Prevention Program: • Intensive lifestyle modification (7% weight loss, exercise 150 minutes per week) vs Metformin • Outcome: incidence of type 2 diabetes over 3 years • Results: lifestyle intervention 58% lower incidence (NNT 7:1); metformin 31% (NNT 14:1)

  7. SULFONYLUREAS • Lower A1C by 1-2% • Stimulates insulin secretion (SUR1) • Not as effective in non-obese patients; better for newly diagnosed type II • Side effects: hypoglycemia and weight gain • Ex: glyburide, glipizide, glimepiride • GLINIDES: Repaglinide, Nateglinide  affect postprandial hyperglycemia

  8. BIGUANIDES • Metformin: • Inhibits hepatic glucose output-predominantly lowers fasting glucose; reduces insulin resistance • Lowers A1C by 1-2% • Effective in obese and non-obese patients • Side effects: GI, lactic acidosis, no hypoglycemia, weight loss

  9. Alpha-GLUCOSIDASE INHIBITORS • Acarbose, Miglitol • Inhibits luminal enzymes that allow carbohydrate absorption in small intestine • Useful for postprandial hyperglycemia • Lowers A1C by 0.5-1% • GI side effects, weight neutral

  10. THIAZOLIDINEDIONES • Increase peripheral glucose uptake, reduce insulin resistance, decrease hepatic output (PPAR-gamma – adipocyte differentiation) • Lowers A1C 1-1.5% • No hypoglycemia • Side effects: edema, CHF, increased fracture and bone loss, hepatitis (monitor LFTs) • Rosiglitazone (?increased cardiac risk), Pioglitazone

  11. GLP ANALOGUE • EXANITIDE/LIRAGLUTIDE: • Stimulates insulin secretion in a glucose dependent manner, suppresses glucagon, delays gastric emptying, decreases appetite • Side effects: nausea, vomiting, weight loss ~5lbs, pancreatitis • Lowers A1C 1%

  12. DPP4 INHIBITORS • Sitagliptin/Saxagliptin: • Inhibits breakdown of endogenous GLP • Lowers A1C <1% • Weight neutral, no GI side effects, URI

  13. PRAMLINTIDE • Amylin analogs: • Cosecreted with insulin (amylin), reduces postprandial glucose, delays gastric emptying, decreases glucagon, reduces appetite • Used with insulin, allows lower insulin dosage • Relatively weak, minimal weight loss, nausea, vomiting, severe hypoglycemia • Lowers A1C <1%

  14. Insulin therapy • Long acting/Basal: Glargine; Detemir • Intermediate acting: NPH • Short acting/bolus: Regular • Rapid acting/bolus: Aspart, Lispro, Glulisine

  15. Insulin therapy • Lantus can be administered qhs (monitors fasting glucose) or qam (monitors pre-dinner glucose) • Detemir qd or bid • NPH qhs, bid or tid, good for inpatient on tube feed and frequent NPO status • Regular for bolus/premeal therapy (frequent snackers), intermittent tube feed, qid for continuous tube feed • Novolog, Humalog: best for premeal bolus therapy without snacks in between, glucocorticoid therapy

  16. Starting insulin therapy Determine estimated total daily insulin requirement (IDD): Weight (kg) x 0.6-1.5 units Determine insulin sensitivity index (ISI): 1700/IDD = ISI (for ISS) Establish glucose goal (120-150) IDD/2 = basal (50% of IDD) The rest divided by 3 meals = bolus (50% premeal/3) + ISS

  17. Starting insulin therapy (cont.) • IDD= 80 • ISI = 1700/80 = 21 (every 1 unit of rapid acting insulin reduces glucose by 21 points) • Goal 120 • Basal insulin 80/2 = 40 units • Bolus insulin 40/3= 13 units before B,L,D + SS as follows:

  18. Starting insulin therapy (cont.) • < 70 ---- D50, OJ, call MD • 71-120 ---- do nothing • 121-140 ---- give 1 unit • 141-160 ---- give 2 units • 161-180 ---- give 3 units and so on • Remember use rapid acting insulin Novolog or Humalog (avoid Regular due to stacking risk) • SS used only before meal, not qhs (if no food)

  19. In the pipelines • Aleglitazar: PPAR dual agonist; reduces A1C in a dose dependent fashion (-0.36 to -1.35%); AE: edema, CHF, weight gain (dose 150 mg less side effects when compared with placebo/pioglitazone; improves lipid profiles (increased HDL/apo A1; decreased LDL/apo B/triglycerides); currently in phase III for cardiovascular outcomes • Albiglutide: albumin based peptide (resistant to degradation by DPP-4); ½ life: 5 days; long acting GLP-1 (30 mg weekly); AE: N/V/injection site rxn • Dulaglutide: antibody bound peptide; ½ life 90h; once weekly dosing GLP-1 analog • Exenatide: long acting 2 mg once weekly -2% vs 1.5 compared to twice daily regimen; similar weight loss 4 kg, increased injection site rxn • SGLT2 inhibitors(dapaglifozin, canagliflozin): cotransporter (Na-glucose) which reabsorbs >90% of glucose in the proximal tubules; weight loss upto 3.5 kg; ?UTI; drop in BP

  20. VA-DoD Clinical Practice Guidelines • A panel of experts in the management of diabetes has recently developed a clinical practice update to guide providers how to screen, diagnose, and treat diabetes based on the best available scientific evidence • http://www.healthquality.va.gov/Diabetes_Mellitus.asp

  21. VA-DoD Clinical Practice Guidelines The VA-DoD update has become available: -Is an evidence-based scientific approach to improve diabetic management -Should be utilized to ensure more than optimal care for diabetic patients

  22. DoD Formulary Updates

  23. Challenges • BUMED tracks diabetes “care” according to HEDIS metric measures i.e. A1C, LDL at every command periodically • Benchmark percentiles • Challenges: many

  24. Challenges Patient Contact Information: Issue: Unable to contact patients. Patient contact and follow-up is a significant challenge, especially in the military population, due to frequent mobility Patient Refusal: Issue: Patients refused to have labs drawn or come in for an appointment. Network Coverage Issue: Patient is receiving all primary care in the network (medicare, secondary insurance). Is patient willing to have an A1C drawn at the MTF under the premise of the medical home port needing to monitor the diabetes care for all their enrollees with diabetes? Obtaining Network Lab Data Issue: Patients obtain laboratory test done in a civilian sector and test is not accurately recorded in MHS records. Accurate Identification of Diabetes: Issue: 1) Previously diagnosed diabetic patients and those in the high risk category are not getting screened at this time; however, screening these patients could improve the numerator source and therefore overall screening rate. 2) Patient does not have diabetes mellitus.

  25. Challenges Improper Coding: Issue: Improper coding (i.e. exclusion denominators: polycystic ovarian syndrome 256.4; steroid-induced diabetes 249, 251.8, 962.0; gestational diabetes 648.8; prediabetes/hyperglycemia 790.29; IFG 790.21; IGT 790.22; metabolic syndrome 277.7) has been an important issue across DoD commands. However, once the list has been populated, it is a technical challenge to alter. Proposed Actions: 1) Identify source of error (MTF or network encounter) and gather data to share with EBHAB and BUMED Leadership. 2) While this issue is being looked at, these patients are likely at high risk for developing diabetes according to the above guidelines. Therefore, these patients should be screened and contacted regardless. However, they should NOT be coded as Diabetes Mellitus (unless strict criteria met).

  26. Diabetes Mellitus Proper Coding

  27. CarePoint Registry • For more information about CarePoint please contact Dr. Steven Heaston from the Navy and Marine Corps Public Health Center at Steven.Heaston@med.navy.mil • To request access to CarePoint please click on hyperlink https://carepoint.afms.mil/_layouts/CarePoint/Pages/Public/RequestAccountForm.aspx

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