boot camp 5 meds slides 2019 - diabetes education services · according to the aace and ada...
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Diabetes Boot Camp – Class 5
2019
www.DiabetesEd.net
Beverly Dyck Thomassian, RN, MPH, BC-ADM, CDEPresident, Diabetes Education Services
Please Download Medication PocketCards for this section –DiabetesEd.net > Resources
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Diabetes Meds for Type 2: Objectives
1. Describe the main action of the
different categories of type 2
diabetes medications.
2. List the side effects and clinical
considerations of each category
of medication.
3. Apply the ADA and AACE
algorithm to determine best
medication match based on
individual characteristics.
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Poll question 1
� When starting people with diabetes on
medications, what is the most important factor
to consider?
a. Their level of adherence
b. Their diabetes pathology
c. Their education level
d. Their preferences, needs and values
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ADA-EASD Position Statement: Management of Hyperglycemia in T2DM
“...providing care that is respectful of and responsive to
individual patient preferences, needs, and values -
ensuring that patient values guide all clinical decisions.”
• Gauge patient’s preferred level of involvement.
• Explore, where possible, therapeutic choices.
• Utilize decision aids.
• Shared decision making – final decisions re: lifestyle
choices ultimately lie with the patient.
Diabetes Care 2012;35:1364–1379
Diabetologia 2012;55:1577–1596
Take a Person Centered Approach
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Diabetes Agents Considerations
� Diabetes medications can be
used as monotherapy, in combo
or with insulin
� Meds reduce A1c 0.5 – 2.0%
� Each new added class drops A1c
an additional 0.7- 1.0%
� Not to be used during
preconception, pregnancy or
when breastfeeding
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Medication Taking Behaviors
� 23% of time, if A1c, B/P, lipids
above target - med taking behavior
� Adequate medication taking is defined as 80%
� If pt taking meds 80% of time and treatment goals not met, intensification should be considered.
� Barriers to taking meds include:� Forgetting to fill Rx, fear, depression, health
beliefs, medication complexity, cost, system factors, etc
� Work on targeted approach for specific barrier
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ADA Standards 2019
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ADA-EASD Position Statement: Management of Hyperglycemia in T2DM
Considerations
� Cost
� Hypoglycemia
� Age
� Weight
� Comorbidities
� Kidney disease
� Heart disease – CHF, CAD
� Liver dysfunction
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When goal is to minimize cost
� Go generic. Metformin and Sulfonylureas
� Walmart offers 3 month supply of following
meds for ~ $10
� Metformin and Metformin XR
� Glipizide, Glyburide, Glimepiride
� Other generics include
� Actos and Avandia
� Acarbose
� Can still cost up to $100 a month
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Poll question 2
� According to the AACE and ADA Glycemic
Control Algorithm, what is the first step to
control hyperglycemia in type 2?
a. Lifestyle modification and metformin
b. Try weight loss and exercise for 3 months
c. Start metformin
d. Start 2 meds if their A1c is 7.4%
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AntiHyperglycemic Therapy – 1st Step
�Metformin + Lifestyle Changes� Weight control
� Healthy eating
� Activity
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ADA Step Wise Approach to
Hyperglycemia 2019� Step 1 – Metformin + Lifestyle
� Step 2 - If A1c target not achieved after 3 months, Metformin + another med
� If CVD, CHF, or CKD, consider adding a second agent risk reduction (based on drug effects and patient factors).
� SGLT-2 Inhibitors – empagliflozin (Jardiance) and canagliflozin (Invokana)
� GLP-1 Receptor Agonist – liraglutide (Victoza), semaglutide(Ozempic)
� Step 3 - If A1c target still not achieved after 3 months, combine metformin plus one to two other (2-3 drugs)
� Step 4 - If A1c target not achieved after 3 months, add injectable therapy (basal insulin or GLP-1 RA) to drug combination.
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ADA Step Wise Approach to
Hyperglycemia 2019
� For all steps, consider including medications
with evidence of CVD and CKD risk reduction,
based on drug specific effects and patient
factors.
� Other Factors
� Minimize Hypoglycemia
� Minimize wt gain or promote wt loss
� Consider Cost
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Ominous Octet
Increased glucagon
secretion
Decreased
amylin, β-cell secretion
80% loss at dx
Increase
glucose
production
Increased
lipolysis
Decreased glucose
uptake
I
I
Decreased
satiation neuro-
transmission
Increased renal
glucose reabsorption
Decreased
Gut hormones
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Matching Meds to the Individual
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Poll question 3� John is started on Metformin 500mg
BID. Which of the following is true?
a. Hold metformin if blood glucose below 90 mg/dl.
b. Evaluate B12 levels before starting medication.
c. Metformin is considered weight neutral
d. Metformin can cause kidney damage, so increase fluid intake
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Biguanide derived from:Goat’s Rue Galega officinalis,French Lilac
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ConsiderationsBiguanide - Metformin (Glucophage®)
� Contraindications due to risk of lactic acidosis:
� creatinine >1.4 females, >1.5 males
� liver disease
� alcohol abuse
� over 80 years old
� risk of acidosis
� during IV dye study
� CHF requiring meds
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Metformin – How does it rate?
Question Answer
� Cause hypoglycemia?
� Cause weight gain?
� Affordable?
� Lowers CV risk?
� Can most tolerate /use?
(GI, creat)
No
Yes
No
Yes
Yes/No
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Poll Question 4� Mary has newly diagnosed type 2 and
is concerned about taking glipizide (Glucotrol). Which of the following teaching point is most important for people on sulfonylureas?
a. Most people experience some weight loss.
b. 50% of people with diabetes have no improvement in BG levels.
c. Do not take with grapefruit juice.
d. If you feel shaky, eat something with sugar.
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Sulfonylureas –
� Action: tells
pancreas to squirt
insulin all day
� Who?
� Lean type 2
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Sulfonylureas - Squirts
� Action: Increase endogenous
insulin secretion
� Efficacy:
� Decrease FPG 60-70 mg/dl
� Reduce A1C by 1.0-2.0%
� Secondary failures: 5-10% shortly
after initial response, many more
later
� Usually after 5 or more years of
therapy due to natural history of DM 2
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Sulfonylureas
� Other Effects
� Hypoglycemia
� Weight gain
� Cleared by kidney, use caution for pts with
kidney problems
� Generally the least expensive class of
medication
� Amaryl safest for those with CV Disease
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� Action: tells pancreas
to squirt insulin with
meals
� Who?
� Targets post-prandial
hyperglycemia
Indication for “Fast Acting” Insulin
Secretagogues- Meglitinides
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Meglitinides - Squirts� Action: stimulate insulin secretion (rapid and short
duration) when glucose present
� Names:
� repaglinide (Prandin) � Dosing: 0.5 to 4 mg a.c. Max dose 16mg
� Metabolized by liver and mostly excreted in feces (some renally).
� nateglinide (Starlix)� Dosing: 120 mg tid with meals
� Metabolized by liver, excreted by kidney
� Efficacy:
� Decreases peak postprandial glucose
� Decreases plasma glucose 60-70 mg/dl
� Reduce A1C 1.0-2.0%
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Squirters – How does they rate?
Question Answer
� Cause hypoglycemia?
� Cause weight gain?
� Affordable?
� Lowers CV risk?
� Can most tolerate /use?
Yes
Yes
Yes
No
Yes/No
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Poll Question 5
� Fred is ready to take medications to get his blood sugar to target. Yet, he is very concerned about avoiding hypoglycemia, since his brother almost died from a hypoglycemic incident. Which medication class would you recommend?
a. Meglitinides
b. SGLT-2 Inhibitors
c. Sulfonylureas
d. Analog insulins
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• Reduced life expectancy
• Higher CVD burden
• Reduced GFR
• At risk for adverse events from
polypharmacy
• More likely to be compromised
from hypoglycemia
Less ambitious targets
A1c 7.0 – 8.0%
Focus on drug safety
Older Adults - Considerations
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What questions?
�72 yr old, thin, lives
alone, A1c 8.3%. DM
for 12 yrs. GFR 58.
Worried about
hypoglycemia.
� Insurance covers
medications
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DPP-4 Inhibitors – “Incretin Enhancers”Januvia (sitagliptin) – Tradjenta (linagliptin)
Onglyza (saxagliptin) Nesina (alogliptin)
� Action:� Increase insulin release w/ meals� Suppress glucagon
� Dosing: Januvia – 100mg a day Tradjenta – 5mg a dayOnglyza* – up to 5mg a day Nesina* – up to 25 mg a day
� Efficacy: Decreases A1c by 0.6 -0.8% � Indication: For type 2s*Can increase risk of heart failure
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DPP-IV Inhibitor Updates
� Can cause severe, disabling joint pain.� Contact Provider, Stop Medication
� Saxagliptin (Onglyza) and Alogliptin (Nesina) can increase risk of heart failure. � Notify provider for shortness of breath, edema,
weakness, etc.
� Side effects: headache and flu-like symptoms
� Report signs of pancreatitis
� No wt gain or hypoglycemia
� Lowers A1c 0.6% - 0.8%
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DPP-IV Inhibitors – How do they rate?
Question Answer
� Cause hypoglycemia?
� Cause weight gain?
� Affordable?
� Lowers CV risk?
� Can most tolerate /use?
No
No
No
No
Yes
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When goal is to avoid Hypoglycemia
� Avoid sulfonylureas
� Careful insulin dosing
� May need to up adjust glucose goals
� Monitor kidney function
� Reinforce for individuals on insulin to “PIE”
� Poke
� Inject
� Eat
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What is Next Step?
� 69 year old male, BMI 28, on Metformin
1000mg BID and Bydureon 2mg once a week.
� A1c 8.1%. Creat 1.2
� Pt is overweight, 11 yr history of diabetes and
recent Myocardial Infarction
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Poll Question 6
� For people on SGLT-2 Inhibitors, a
potential side effect is:
a. Balanitis
b. Hypertension
c. Kidney tenderness
d. Increased uric acid
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SGLT2 Inhibitors- “Glucoretics”
� Action: “Glucoretic” decreases renal reabsorption in the proximal
tubule of the kidneys (reset renal threshold and increase glucosuria)
� Side effects: hypotension, UTIs, increased urination, genital
infections (Fournier's gangrene, ketoacidosis)
� Expensive
% ‘f
Decreases GlucoseReabsorption
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Empagliflozin and Canagliflozin
gets special FDA CV approval
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SGLT2 Inhibitors- How do they rate?
Question Answer
� Cause hypoglycemia?
� Cause weight gain?
� Affordable?
� Lowers CV risk?
� Can most tolerate /use?
No
No
No
Yes?
Yes
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When goal is to avoid weight gain
� These meds are weight neutral� Metformin
� DPP-IV Inhibitors - Januvia, Onglyza, Tradjenta, Nesina
� AGIs - Acarbose
� These meds associated with wt loss� GLP-1 Receptor Agonists (Byetta, Bydureon,
Victoza, Trulicity, Ozempic)
� SGLT-2 Inhibitors (Canagliflozin, Dapagliflozin, Empagliflozin, Ertugliflozin)
� Symlin (Pramlintide)
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Poll Question 7Woman with diabetes is on max dose Metformin
and Sulfonylurea. Her A1c is 8.4. Has been trying
to lose weight with limited success. Which of
the following medications would be indicated to
improve BG without increasing weight?
a. Basal insulin
b. GLP-1 Receptor Agonists
c. Meglitinides
d. Bolus insulin
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Incretin Mimetics –
“Gut Hormone Imitators”
GLP-1 Agonists
� How do they work?
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GLP-1 Effects in Humans
Understanding the Natural Role of Incretins
Adapted from Flint A, et al. J Clin Invest. 1998;101:515-520Adapted from Larsson H, et al. Acta Physiol Scand. 1997;160:413-422Adapted from Nauck MA, et al. Diabetologia. 1996;39:1546-1553Adapted from Drucker DJ. Diabetes. 1998;47:159-169
Stomach:Helps regulate
gastric emptying
Promotes satiety and
reduces appetite
Liver:
↓↓↓↓ Glucagon reduces
hepatic glucose outputBeta cells:Enhances glucose-dependent
insulin secretion
Alpha cells:↓↓↓↓ Postprandial
glucagon secretion
GLP-1 secreted upon
the ingestion of food
↑↑↑↑ Beta-cellresponse
↑↑↑↑ Beta-cellresponse
GLP-1 degraded by DPP-4 w/in minutes
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• Majority of people with
type 2 are overweight
• Intensive lifestyle program
• Bariatric surgery (BMI >30)
• Medication Options
• Metformin
• GLP-1 receptor agonists
• SGLT-2 Inhibitors
Weight Considerations
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Poll Question 8
� Alice injects exenatide XR (Bydureon) once
a week. Which of the following should she
report immediately?
a. Bump at the injection site
b. Nausea
c. Sudden weight loss
d. Intense abdominal pain
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Incretin MimeticsExenatide (Byetta), Exenatide XR (Bydureon)
� Action:� Insulin release in response to meal
� Slows gastric emptying
� Causes Satiety
� Protects Beta Cells
� Exenatide Dosing: � 5-10 mcg before break, dinner
� Long acting version - 1x week
� Efficacy: Decreases A1c by 0.7%, wt by 3lbs
� Indication: For type 2s only - mono or in combo
�
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Incretin Mimetics –Exenatide XR - Bydureon
� Once a Week Dosing: 2mg
� Efficacy: Decreases A1c by 1.6%, wt by ~6lbs
� Indication: For type 2s only
� Other: – Available in pen or BCise injector
� Caution: Weight loss
� not indicated for pt’s w/ history of medullary thyroid tumor
� pancreatitis warning
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Incretin Mimetics –dulaglutide – Trulicity
� Once a Week Dosing: 0.75 – 1.5 mg
� Efficacy:
Decreases A1c by ~ 1%, wt by ~2lbs
� Indication: For type 2s only
� Other: Premixed Pen injector with
retracting needle
� Caution: not indicated for those with
history of medullary thyroid tumor -
pancreatitis warning
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Incretin Mimetics –Semaglutide (Ozempic)
� Once a Week Dosing: 0.5 – 1.0mg
� Efficacy:
reduced hemoglobin A1c by 1.5 to
1.8% points.
� 4.5- to 6.4-kg weight loss.
� Side effects: nausea, which
diminished over time. Report signs
of pancreatitis
� Black box–thyroid tumor warning
(avoid if family hx, notify MD of
hoarseness, lump).
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Incretin Mimetics - GLP-1 AnalogLiraglutide (Victoza)
Liraglutide Dosing: 1x daily, time not critical
• 0.6 x 1 week – if tolerated (nausea), go to >
• 1.2 x 1 week – if tolerated go to >
• 1.8 mg daily
� Efficacy: lowers; A1c by 1%, body wt by ~ 2.5kg. Reduces risk of CV events
� Indication: Monotherapy or in combo . Type 2 only
� Other: In pen
Black box–thyroid tumor warning (avoid if family hx, notify MD of hoarseness, lump).
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Liraglutide Approved for Weight Loss
� Saxenda and Victoza contain the same active
ingredient (liraglutide) at different doses
� Saxenda 3 mg and Victoza 1.8 mg
� Saxenda – as a treatment option for chronic weight
management in addition to a reduced calorie diet and
physical activity.
� Saxenda is approved for use in adults with a
� BMI of ≥ 30 or
� BMI of ≥ 27 or greater who have hypertension, type 2
diabetes, or dyslipidemia.
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For all GLP-1 Receptor Agonists
• Pancreatitis Warning• Please tell all patients
to report signs right away and discontinue meds
• Signs include:
• Sudden abdominal pain, nausea and vomiting
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Incretin Mimetics – How do they rate?
Question Answer
� Cause hypoglycemia?
� Cause weight gain?
� Affordable?
� Lowers CV risk?
� Can most tolerate /use?
(GI)
No
No
No
No
Yes/No
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� Action: decrease insulin resistance by making muscle and adipose cells more sensitive to insulin. Decrease free fatty acids
� Names:� pioglitazone (Actos) – bladder cancer warning
� Dosing: 15-45 mg daily
� rosiglitazone (Avandia) – restriction relaxed
� Dosing: 4-8 mg daily
� Efficacy/ Considerations� Reduce A1C ~0.5-1.0%
� 6 weeks for maximum effect
� $100 a month
� Can cause fluid retention, not indicated w/ CHF
Indications for Insulin Sensitizers Rosiglitazone (Avandia), Pioglitazone (Actos)
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Actos and Bladder Cancer
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TZDs – How do they rate?
Question Answer
� Cause hypoglycemia?
� Cause weight gain?
� Affordable?
� Lowers CV risk?
� Can most tolerate /use?
No
Generic
Yes
??
Watch CHF
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Indications for Glucosidase Inhibitors
Acarbose (Precose®), Miglitol (Glyset®)
Action: Slower
� Target post-prandial
blood glucose
� Minimal systemic
absorption
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Alpha-glucosidase Inhibitors� Action: blocks enzymes that digest starches in the small
intestine
� Name: acarbose (Precose)� Dosing: 75-300mg based on weight
� Efficacy� Decrease postprandial glucose 40-50 mg/dl
� Decrease A1C 0.5-1.0%
� Other Effects� Flatulence or abdominal discomfort
� Contraindicated in patients with inflammatory bowel
disease or cirrhosis
� Special Consideration� In case of hypoglycemia, treat with glucose tabs or milk
� (other starches are blocked by medication))
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Acarbose– How does it rate?
Question Answer
� Cause hypoglycemia?
� Cause weight gain?
� Affordable?
� Lowers CV risk?
� Can most tolerate /use?
No
Yes
No
Yes
No/Yes
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AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm 2019
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Poll Question 9
� George type 2, is losing weight and thirsty with an A1c of 10.3%. Using AACE guidelines, what is appropriate action?
a. Evaluate lifestyle changes for 3 months
b. Start insulin therapyc. Start metformin immediatelyd. Start metformin plus another
agent
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AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm 2019
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80 /20 Rule – Perfect Not Required
�