Diabetic Care Pathway

Michael Shannon, MD

Endocrinologist and PSW Medical Director

Diabetes Pathway– 2019 PSW Key Goals

• Patients with diabetes need appropriate A1c goals

– Medicare/HEDIS quality target: A1c < 9%

– Clinical targets vary by patient:

• Most patients A1c < 7%

• Patients with limited life expectancy, significant comorbidities, or

hypoglycemia risk < 8%

• Young healthy low risk patients may aim for < 6.5%

• Statin adherence for diabetics

• Aspirin if ASCVD present (common in diabetics)

Diabetes Pathway– 2019 Changes

• Diabetic patients with CVD need drug with CV benefit, either

– SGLT-2 inhibitor – especially if patient has CHF or chronic renal

disease (ACC: Jardiance; ADA: Jardiance > Invokana)

– GLP-1 agonist (ACC: Victoza; ADA: Victoza > Ozempic > Bydureon)

• First injectable for most patients is GLP-1 agonist, not insulin

• ADA classifies other drugs based on secondary goals

Diabetes Pathway – 2019 Key Points

The Foundation

Diabetes Education • Nutrition Therapy • Weight Management

If Established CVD Add Either: If no known CVD Choose From:

1. GLP-1 Agonist (first line injectable

per ADA). Preferred for weight loss,

low hypoglycemia

2. SGLT-2 Inhibitor: Preferred for

weight loss, low hypoglycemia

3. Sulfonylurea: use glimepiride (NOT

glyburide), preferred for cost

4. Basal insulin: preferred for efficacy

(use if A1c > 11%, hyperglycemic

symptoms, suspect DM1)

Start with Metformin ER

(Extended Release)

• 500 mg tablets

• Increase weekly to

• Target dose of 2000 mg/day

Refer to Certified Diabetes

Educator at Diagnosis or

Refresher

1. SGLT Inhibitor with CV Outcomes:

a. ACC: Jardiance

b. ADA: Jardiance >

Invokana

2. GLP-1 Agonist with CV Outcomes:

a. ACC: Victoza

b. ADA: Victoza > Ozempic >

Bydureon

If patient has CVD with CHF or CKD,

SGLT-2 inhibitor is preferred (ADA).

Choose one even if patient at A1c

goal!

Place in therapyMedication

class

A1C

lowering

Established CVD:

Recommended by ACC or

ADA-EASDADA Recommendations

PSW Formularies

Tier 1: $

Tier 2: $$

Tier 3: $$$

Tier 4: $$$$

Cost/30 days

(AWP – 2016 Q1 prices)

1 Metformin 1-2% Trend to Benefit FIRST LINE Tier 1 <$10

1

If patient has established CVD

GLP-1 agonist 0.5-1.5%

ADA: Recommends Victoza >

Ozempic > Bydureon

ACC: Recommends Victoza

1. With established CVD

2. To reduce hypoglycemia

3. To reduce weight gain

Victoza: Tier 3*

Trulicity: Tier 3

Bydureon: Tier 4*

Ozempic: Humana

Tier 3; Premera

NF/Tier 3**

Once daily:

Victoza - $475-500

Once weekly:

Ozempic - $773

Bydureon - $515

Trulicity - $508-540

2

If no established CVD

Preferred 1st Injectable per ADA

1

If patient has established CVD SGLT-2

inhibitor 0.5-1.0%

ADA: Recommends

Jardiance > Invokana

ACC: Recommends Jardiance

Favor class if CVD with CHF or

Chronic Renal Disease

1. With established CVD (esp.

with renal disease and CHF)

2. To reduce hypoglycemia

3. To reduce weight gain

Jardiance: Tier 3*

Invokana: Humana

Tier 3; Premera

Tier 3/NF**

All around $435

*same price for different

doses of same med 2

If no established CVD

2

Sulfonylurea

(glimepiride

preferred)

1-2% --- If cost is major factor

Glimepiride: Tier 1

<$10

3 Basal Insulin unlimited ---

Recommend using after GLP-1

injectable unless A1c > 11%,

symptoms of hyperglycemia, or

suspect may be type 1 diabetic

Lantus & Levemir

(vials/pens): Tier 3

Toujeo pen: Tier 3

Basaglar: NF

Tresiba: Tier 3

NPH: Tier 3

Assuming average dose of

0.45 units/kg, 120 kg pt (54

units/day, 2 vials or 1 box

pens)

Glargine: $597

Detemir: $645

NPH: $304

4TZD

0.5-1.5% --- If cost is major factor

pioglitazone: Tier 1

piog+met: Tier 2

piog+glime: Tier 2

$40-$200

Depends on if insured and

pharmacy

4 DPP-4 inhibitor0.5-0.8% --- To reduce hypoglycemia

Januvia, Janumet,

Jentadueto:

Tier 3*

All around $390

How to Choose Diabetes Pharmacotherapy

Selection Color Key: 31 42 First Choice

Option

Second Choice

Option

Third Choice

Option

Fourth Choice

Option

*Premera requires trial of metformin before coverage; **2019 Ozempic and Invokana Premera coverage may vary

GLP-1 agonists are recommended as

first injectable (ADA 2018) but start

insulin first if:

a. A1c is > 11% OR

b.Hyperglycemia is severe OR

c. Presence of symptoms or

catabolic features (weight loss,

ketosis) OR

d.Unable to achieve A1c targets on

2 agents beyond metformin

How to initiate/titrate

1.Start with basal insulin 10 units

(or 0.1-0.2 units/kg) at bedtime

2.Adjust by 3 units every 3-4 days

until fasting blood sugar is 80-

110 mg/dL

• Bolus Insulin dosing: Start

with 4 units, adjust by 1-2

units every 3-4 days until

blood sugar 2 hours after

meal with which insulin is

administered is <180

mg/dL

• Consider addition of

GLP-1 agonist OR

prandial insulin before

largest meal

(basal-plus regimen).

• Consider Basal-GLP1

combination product

If blood sugar goals not obtained or repeated

A1c not progressing as expected, consider

additional therapy as below:

If you write for vials, write for syringes.

If you write for pens, write for tips

If you are giving insulin, please make sure the patient

has test strips.

How to Use Insulin

Diabetes Care Schedule Recommendations Measure Timing Metric Definition

MonitorHemoglobin A1c at Goal:

Shared decision making

Age < 65, default < 7%

Age > 65, default < 8%

Check A1c :

Every 3 months until at goal

Every 6 months once at

goal

At Goal:

Age 18-65: A1c obtained in the past 12 months and the most recent value is < 7.0%

Age > 65: A1c obtained in the past 12 months and the most recent value is < 8.0%

Blood Pressure

Controlled:

Goal < 140/90 mmHg

(Per ADA and JNC 8)

Measure every office visit Age 18-75 and most recent BP < 140/90

Per ADA: First-line pharmacologic therapy for HTN in patients with DM: ACEI or ARB.

NB: Per JNC-8: Initial HTN treatment in DM: CCB, thiazide diuretic, ACEI or ARB in nonblack population; thiazide or CCB

in general black population.

Lipid Screening At diagnosis and

“periodically” (ADA)

Per 2013 ACC/AHA guideline: All patients with DM should be a statin, baring contraindications, HEDIS/Quality Measures

target age 40-75.

Per ADA: Screening lipid profile is “reasonable” at diabetes diagnosis, at an initial medical evaluation and/or at age 40

years, and periodically (1-2 years) thereafter.

Nephropathy Screening: Yearly Age 18-75: Urine albumin to creatinine ratio or “medical attention for nephropathy” (visit for CKD) within the last 12

months. Patients prescribed ACE I or ARB excluded from metric.

Per ADA: Refer patients with “advanced kidney disease” to nephrology. Improved quality and decreased costs for CKD

IV. Yearly urine albumin/Cr still “reasonable” in patients on ACE/ARB.

Foot Exam Yearly All patients: Complete foot exam (change in 2015 HEDIS definition) in the past 12 months. Complete foot exam includes

3 components: visual inspection and palpation, sensation testing and vibratory testing.

Per ADA: Provide general foot self-care education to all patients.

Retinopathy screening Yearly

If normal exam: Every two

years “may be considered”

(ADA)

All patients: Retinal exam performed in the past 24 months

Per ADA: 1. If no retinopathy on exam, then q2 yrs “may be considered.”

2. Optimization of blood pressure and glycemic control slow the development of retinopathy.

Diabetes Care Schedule Recommendations Measure Timing Metric Definition

Diabetics with Known

Cardiovascular Disease –

Appropriate SGLT-2 or GLP-1

At each visit If patient has diabetes and cardiovascular disease, put them on either:

SGLT2: Jardiance (ACC recommendation), Jardiance > Invokana (ADA-EASD)

GLP-1: Victoza (ACC recommendation ), Victoza > Ozempic > Bydureon (ADA-EASD)

If diabetes and ASCVD with either CHF and/or renal disease, use SGLT-2

Depression Screening Yearly All patients: Patients with a documented PHQ2 or PHQ9 in the past 12 months.

Per ADA: Age > 65 a “high-priority” population.

Diabetes Tobacco Non-UseYearly

All patients: Patient has tobacco use status documented in the diabetes flow sheet within the past 12 months.

Per ADA: Advise all patients not to smoke or use tobacco products

Pneumococcal vaccines

PPSV < age 65

PPSV and PCV > age 65

Per ADA and ACIP/CDC: Age < 65: PPSV 23 vaccine

Age > 65: Both PPSV 23 and PCV 13, separated by 12 months

Influenza vaccine

yearly

All patients: Yearly influenza vaccine (ADA and ACIP/CDC)

Treat

Statin Therapy Always age 40 to 75 Per ACC/AHA guideline (and consistent with ADA):

Age 40-75: Moderate-Intensity statin recommended unless any one of three:

10-year ASCVD risk > 7.5, LDL > 190 or clinical ASCVD then high-intensity statin recommended.

Aspirin therapy Always, as appropriate Per ADA: If ASCVD: Daily aspirin (75-162 mg) or antiplatelet medication

Also if 10 year CV risk>10%. NB: Most men > age 50 and women > age 60 with one additional major risk factor

(family hx ASCVD, HTN, tobacco use, dyslipidemia, albuminuria)

Refer

Refer to Diabetes Education

and Nutrition TherapyAt diagnosis and yearly if A1c not at

goal, and then yearly.

Most insurance provider cover these services.

ADA-EASD 2018: Glucose-lowering medication in type 2 diabetes

Melanie J. Davies et al. Dia Care 2018;41:2669-2701

2018 ACC Expert Consensus Decision Pathway on Novel Therapies for CV Risk Reduction in

Patients With Type 2 Diabetes and ASCVD (Fig 2)

• Call to action

• Where to start to apply to practice

• What resources to use and who to contact

Next Steps