new management strategies for diabetes in your patients · 3.5 metformin therapy for prevention of...

New Management Strategies for Diabetes in

Your Patients

Tom Blevins MDTexas Diabetes and Endocrinology

Austin, Texas

Dr. Blevins has disclosed that he has received grant support from Lilly, Mylan, and Novo Nordisk, and he is on the speaker’s bureau for Abbott Laboratories, Boehringer-Ingelheim, Lilly, Merck and Sanofi.

Disclosure

By completing this educational activity, the participant should be better able to:1. Integrate evidence-based guidelines for screening of diabetic

patients into practice, including routine testing of A1C, microalbumin, and LDL cholesterol.

2. Discuss new treatment options available in diabetes, such as once-weekly medications.

3. Incorporate various other screening modalities for diabetic patients to avoid complications, including foot and eye screening and recognize the importance of achieving control to avoid these complications.

4. Discuss different goals for various patient populations.

EDUCATIONAL OBJECTIVES

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Audience Polling Questions

30.3 million with diabetes

84+ millionwith pre-diabetes

Centers for Disease Control and Prevention: https://www.cdc.gov/chronicdisease/resources/publications/aag/diabetes.htm. Accessed March 2, 2019

Pre-Diabetes

3.2 Refer patients with prediabetes to an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program (DPP) to achieve and maintain loss of 7% of initial body weight and increase moderate-intensity physical activity (such as brisk walking) to at least 150 min/week.

3.3 Based on patient preference, technology-assisted diabetes prevention interventions may be effective in preventing type 2 diabetes and should be considered.

Section 3: Prevention and Delay of Type 2 Diabetes

3.5 Metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially for those with BMI >35 kg/m2, those aged >60 years, and women with prior gestational diabetes mellitus.

3.6 Long-term use of metformin may be associated with biochemical vitamin B12 deficiency, and periodic measurement of vitamin B12 levels should be considered in metformin-treated patients, especially in those with anemia or peripheral neuropathy.

3.7 Prediabetes is associated with heightened cardiovascular risk; therefore, screening for and treatment of modifiable risk factors for cardiovascular disease is suggested.

Prevention and Delay of Type 2 Diabetes

Criteria for the diagnosis of diabetes changed◦ Include two abnormal test results from the

same sample (i.e., fasting plasma glucose and A1C from same sample).

◦ Or 2 separate test samples. Recommended that the second test be performed without delay

If a patient meets the diabetes criterion of the A1C (two results >6.5%) but not FPG (>126 mg/dL), that person should nevertheless be considered to have diabetes

Classification and Diagnosis of Diabetes

Classification

Comprehensive MedicalEvaluation and Assessment of

Comorbidities

American Diabetes Association, Diabetes Care, 2019;42:S34-S45

Comprehensive Medical Evaluation and Assessment of Comorbidities

Medical Nutrition Therapy

Activity

A1C Testing

Patient and Disease Factors Used to Determine Optimal A1C Targets

Glycemic Targets in Older Patients

Glycemic Targets

7. Diabetes Technology

158 adults who had had type 2 diabetes for a median of 17 years age 35 to 79 years (mean, 60 years), were receiving multiple daily injections of insulin, and had hemoglobin A1C (HbA1C) levels of 7.5% to 9.9% (mean, 8.5%).

Mean HbA1C levels decreased to 7.7% in the CGM group and 8.0% in the control group at 24 weeks (P = 0.022). The groups did not differ meaningfully in CGM-measured hypoglycemia or quality-of-life outcomes. The CGM group averaged 6.7 days (SD, 0.9) of CGM use per week.

Limitation: 6-month follow-up

Haak T, et al. Flash glucose-sensing technology as a replacement for blood glucose monitoring for the management of insulin-treated type 2 diabetes: a multicenter, open-label randomized controlled trial. Diabetes Ther. 2017;8:55-73.

Professional CGM

8. Obesity Management for the Treatment of Type 2 Diabetes

Obesity Management for theTreatment of Type 2 Diabetes

Modest Weight Loss Has Benefits –Greater Weight Loss Is Associated With Greater Benefits

• Progression from prediabetes to diabetes1

• Measures of glycemia1

• Triglycerides and HDL cholesterol1• Systolic and diastolic blood pressure1

• Hepatic steatosis (measured by MRS)2• NASH activity score (measured by biopsy)1• Measures of feeling and function

– Symptoms of urinary stress incontinence1

– Measures of sexual function3

– Quality of life measures (IWQOL)4• Apnea-hypopnea index1

• Reduction in CVD events, mortality, remission of T2DM5,6

1. Cefalu WT et al. Diabetes Care. 2015;38:1567-1582. 2. Lazo M et al. Diabetes Care. 2010;33:2156-2163. 3. Wing RR et al. Diabetes Care. 2013;36:2937-2944. 4. Kolotkin RL et al. Obes Res. 2001;9:564-571. 5. Sjöström L et al. JAMA. 2012;307:56-65. 6. Sjöström L et al. JAMA. 2014;311:2297-2304.

−3.0%

−5.0%

−10.0%

−15.0%

MRS = magnetic resonance spectroscopy; NASH = nonalcoholic steatohepatitis; IWQOL = Impact of Weight on Quality of Life.

Effect of Low-Fat, Low-Carbohydrate, and Mediterranean Diets on Weight

34Shai I, et al. N Engl J Med. 2008;359:229-241.

Dietary Intervention Randomized Control Trial (DIRECT)(N=322 Adults with Obesity)

9085

78

0

20

40

60

80

100

Patie

nts

(%)

Weight Change Over 2 Years Adherence Over 2 Years

Low fat Mediterranean Low carbohydrate

Low fat Mediterranean Low carbohydrate

Effects of Different Diets on Glucose and Lipids Over Time

35

*P<0.001 vs other diets.FPG = fasting plasma glucose; HDL = high density lipoprotein; LDL = low density lipoprotein; T2D = type 2 diabetes.Shai I, et al. N Engl J Med. 2008;359:229-241. Schwarzfuchs D, et al. N Engl J Med. 2012;367:1373-1374.

Dietary Intervention Randomized Control Trial (DIRECT)

No diabetes(n=286)

T2D(n=36)

3.1

12.1

3.1

-32.8

1.3 1.2

-40

-30

-20

-10

0

10

20

Low fat

Mediterranean

Lowcarbohydrate

Mea

n FP

G (m

g/dL

)

*

Effect on FPG at 2 Years Effect on Lipids at 2 and 6 Years

Glucose-lowering Medication in Type 2 Diabetes: Overall Approach


To align with the ADA-EASD consensus report, the approach to injectable medication therapy was revised

(Fig. 9.2). A recommendation that, for most patients who need the greater efficacy of an injectable medication, a glucagon-like peptide 1 receptor agonist should be the first choice, ahead of insulin.

Injectable Meds

Intensifying to Injectable Therapies

Diabetic RetinopathyAn important cause of blindnessin adults1,2

Diabetic NephropathyLeading cause of chronic and end-stage kidney disease3

Cardiovascular Disease

StrokeHypertension in ~20–60%, increasing risk of stroke4

Diabetic NeuropathyLeading cause ofnon-traumatic lower extremity amputations6

CVD is major cause of morbidity and mortality5

Complications of Diabetes

1. Klein R, Klein BE. Chapter 21. In: Diabetes in America, 3rd edition. NIDDK, 2016. 2. Fong DS et al. Diabetes Care. 2003;26(suppl 1):S99-S102. 3. Afkarian M et al. JAMA. 2016;316:602-610. 4. Arauz-Pacheco et al. Diabetes Care. 2003;26(suppl 1):S80-S82. 5. Barrett-Connor E et al. Chapter 18. In: Diabetes in America, 3rd edition. NIDDK, 2016. 6. Mayfield JA et al. Diabetes Care. 2003;26(suppl 1):S78-S79.

CVD = cardiovascular disease

Microvascular Complications and Foot Care

Glucose Lowering Meds that Reduce Progression of Renal Disease

Lancet. 2019; 393: 31–39.

Retinopathy and Neuropathy

Foot Care

Cardiovascular Disease and Risk Management

Glucose Lowering Meds that Reduce Risk of CV Disease

Lancet. 2019; 393: 31–39

10.4 For individuals with diabetes and hypertension at higher cardiovascular risk (existing atherosclerotic cardiovascular disease or 10-year atherosclerotic cardiovascular disease risk >15%), a blood pressure target of <130/80 mmHg may be appropriate, if it can be safely attained

10.5 For individuals with diabetes and hypertension at lower risk for cardiovascular disease (10-year atherosclerotic cardiovascular disease risk, 15%), treat to a blood pressure target of <140/90 mmHg

Diabetes and Hypertension

Diabetes and Hypertension

Recommendations for the Treatment of Confirmed Hypertension in People with Diabetes


Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes and a history of ASCVD.

For patients with ASCVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used.

Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an acute coronary syndrome A and may have benefits beyond this period. B

Aspirin therapy (75–162 mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased cardiovascular risk, after a with the patient on the benefits versus increased risk of bleeding.

Antiplatelet Agents Recommendations

Diabetes Management in Older Adults

Motivational Interviewing

Get permission to proceed Open-ended (starting) questions (to get the ball rolling) “How have you been doing with checking your blood sugar?” “What’s been going on since we last saw each other?”

Reflective listening (keep it rolling) “It sounds like you are nervous about using insulin.”

Summarizing (stop, assess, move on) Elicit self-motivational statements “What concerns you about your A1C number?”

You provide information, client interprets it

Miller WR, Rollnick S. Behav Cogn Psychother. 2009;37:129-140.

Q and A

ACEi or ARB’s should be given to all patients with Type 2 diabetes even if normotensive without microalbuminuria to prevent/avoid development of nephropathy.

1. True2. False

Audience Polling #1True or False?

1. Fasting glucose of 150mg/dl2. One glucose of >200 with symptoms of polyuria3. Nonfasting glucose of 210mg/dl in an

asymptomatic patient4. A1C of 6.7% and a fasting reading of 130mg/dl-

both tests from the same tube of blood5. 2 and 4

Audience Polling #2The following findings can be used to diagnose diabetes:

1. Metformin2. ASA3. Certain SGLT‐2 inhibitors4. Certain GLP‐1 meds5. Lowering BP to <110/706. Meditation7. 2, 3, 48. 1, 3, and 5

Audience Polling #3Treatments that have been shown to reduce CV risk in patients with Type 2 diabetes and CAD include the following:

new management strategies for diabetes in your patients · 3.5 metformin therapy for prevention of...

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