diabetes medications: an overview eric l. johnson, m.d. assistant professor department of community...
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Diabetes Medications:An Overview
Eric L. Johnson, M.D.
Assistant ProfessorDepartment of Community and Family Medicine
University of North DakotaSchool of Medicine and Health Sciences
Assistant Medical DirectorAltru Diabetes CenterAltru Health System
Grand Forks, ND
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Objectives
• Assess knowledge of usual diabetes medications
• Implement proper medication use per guideline management
• Improve knowledge of side effects and contraindications of diabetes medications
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Diabetes Mellitus
• Type 1: Usually younger, insulin at diagnosis
• Type 2: Usually older, often oral agents at diagnosis
• Type “1.5” (Latent Autoimmune), mixed features
• Gestational: Diabetes of Pregnancy
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U.S. Prevalence of Diabetes 2010
• Diagnosed: 26 million people—8.3% of population (90%+ have Type 2)
• Undiagnosed: 7 million people
• 79 million people have pre-diabetes
CDC 2011
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Diabetes DiagnosisCategory FPG (mg/dL) 2h 75gOGTT A1C
Normal <100 <140 <5.7
Prediabetes 100-125 140-199 5.7-6.4
Diabetes >126** >200 >6.5Or patients with classic hyperglycemic symptoms with plasma glucose >200
** On 2 separate occasionsDiabetes Care 34:Supplement 1, 2011Diabetes Care 34:Supplement 1, 2011
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*IFG=impaired fasting glucose.Copyright® 2000 International Diabetes Center, Minneapolis, USA. All rights reserved. Adapted with permission.
Natural History of Type 2 Diabetes
Years of Diabetes
Glu
cose
(mg/
dL)
50 –
100 –
150 –
200 –
250 –
300 –
350 –
0 –
50 –
100 –
150 –
200 –
250 –
-10 -5 0 5 10 15 20 25 30
Rel
ativ
e Fu
nctio
n (%
)
Fasting Glucose
Postmeal Glucose
Obesity IFG* Diabetes UncontrolledHyperglycemia
Insulin Resistance
-cell Function-Cell Failure
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The Ominous OctetIslet -cell
ImpairedImpairedInsulin SecretionInsulin SecretionImpairedImpairedInsulin SecretionInsulin Secretion
NeurotransmitterNeurotransmitterDysfunctionDysfunction
Decreased GlucoseDecreased GlucoseUptakeUptakeDecreased GlucoseDecreased GlucoseUptakeUptake
Islet -cell
IncreasedIncreasedGlucagon SecretionGlucagon SecretionIncreasedIncreasedGlucagon SecretionGlucagon Secretion
IncreasedIncreasedLipolysisLipolysisIncreasedIncreasedLipolysisLipolysis
Increased GlucoseIncreased GlucoseReabsorptionReabsorptionIncreased GlucoseIncreased GlucoseReabsorptionReabsorption
IncreasedIncreasedHGPHGPIncreasedIncreasedHGPHGP
DecreasedDecreasedIncretin EffectIncretin Effect
DecreasedDecreasedIncretin EffectIncretin Effect
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Targets for glycemic (blood sugar) control in
most non-pregnant adultsADA AACE
A1c (%) <7* ≤6.5Fasting (preprandial) plasma glucose 70-130 mg/dL <110 mg/dL
Postprandial (after meal) plasma glucose <180 mg/dL <140 mg/dL
• American Diabetes Association. Diabetes Care. 2010;33(suppl 1) • Implementation Conference for ACE Outpatient Diabetes Mellitus Consensus Conference Recommendations: Position Statement
at http://www.aace.com/pub/pdf/guidelines/OutpatientImplementationPositionStatement.pdf. Accessed January 6, 2006. • AACE Diabetes Guidelines – 2002 Update. Endocr Pract. 2002;8(suppl 1):40-82.
*<6 for certain individuals
Goals of Glucose Management
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A1C ~ “Average Glucose”
American Diabetes Association
A1C eAG
% mg/dL mmol/L
6 126 7.0
6.5 140 7.8
7 154 8.6
7.5 169 9.4
8 183 10.1
8.5 197 10.9
9 212 11.8
9.5 226 12.6
10 240 13.4
Formula: 28.7 x A1C - 46.7 - eAG
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Diabetes Medications
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Diabetes Medications
• Many new medications in last decade
• Three main categories– Oral agents (pills)- many different kinds old and new
– Insulin- newer, more modern insulins
– Newer, non-insulin injectable medications
• Choices allow individualization of treatment plan
• Different medications, different indications, different situations
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Glucose-lowering Potential of Diabetes Therapies*
Treatment FPG HbA1C
Sulfonylureas 50-60 mg/dl 1-2%
Metformin 50-60 mg/dl 1-2%
-Glucosidase Inhibitors (Precose) 15-30 mg/dl 0.5-1% Repaglinade (Prandin) 60mg/dl 1.7%
Thiazolidinediones 40-60 mg/dl 1-2%
Gliptins (Januvia,Onglyza) targets ppd 0.5 - 0.8%
*based on package insert data as monotherapy
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Glucose-lowering Potential of Injection Diabetes Therapies*
Treatment FPG HbA1C
Exenatide (Byetta) targets ppd 1-1.5%
Liraglutide (Victoza) targets ppd 1-1.5%
Pramlintide (Symlin) targets ppd 1-2%
Insulin Limited by 1.5-3.5%
hypoglycemia
*based on package insert data as monotherapy
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ADA/EASD consensus algorithmto manage type 2
MET: metformin; SU: sulfonylurea. Nathan et al. Diabetes Care 2009;32(1): 193-203
aSU other than glyburide or chlorpropamide. bInsufficient clinical use to be confident regarding safety.
No No hypoglycemiaWeight loss
Nausea/vomiting
Lifestyle and MET + intensive insulin
Lifestyle and MET+ basal insulin
Lifestyle and MET+ SUa
At diagnosis:
Lifestyle +
MET
Step 1 Step 2 Step 3
Lifestyle and MET + pioglitazone
No No hypgglycemiaedema/CHF
Bone loss
Lifestyle and MET + GLP-1 agonistb
Lifestyle and MET + pioglitazone
+ SUa
Lifestyle and MET+ basal insulin
Tier 2: Less well-validated studies
Tier 1: Well-validated core therapies
Reinforce lifestyle interventions at every visit and check A1C every 3 months until A1C is <7% and then at least every 6 months. The interventions should be changed if A1C is ≥7%.
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Key Points of Medication Selection in
Type 2• Metformin at diagnosis unless a
contraindication
• Second line agents- basal insulin or many other meds
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Oral Diabetes Medications
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Sulfonylureas• Oldest oral medications
• Stimulate pancreas to secret more insulin
• Effective, inexpensive
• Glyburide, Glipizide, Glimiperide
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Caveats with Sulfonylureas
• Hypoglycemia (particularly in elderly)
• Premature B-cell exhaustion?
• Caution in liver disease, renal disease
• Weight gain
• Rash
• Avoid if anaphylactic to sulfa
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Metformin
• Improves insulin resistance• Reduced Hepatic Glucose production• Effective, inexpensive• Extremely low incidence of hypoglycemia• Weight neutral or weight loss• Positive effects on lipid profiles• Long term use may result in better CVD
outcomes• Can be combined with virtually all other DM
meds
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Caveats with Metformin• Liver Disease• Renal Disease• GI upset• Heavy Alcohol Use• Intravascular Dye Studies (IVP, Angio,etc)• CHF• Not for persons over 80• Can result in B12 deficiency
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Thiazolidinediones (TZD’s)
• Pioglitazone (Actos)
• Rosiglitazone (Avandia)
• Improves insulin resistance
• Extremely low incidence of hypoglycemia
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Caveats with TZD’s
• CHF (or if hx/risk?)
• Patients already dealing with edema
• Potential weight gain
• Renal disease-fluid overload
• Current TZD’s rare liver disease, not recommended in active liver disease
• Heart disease risk? (Rosiglitazone-new restrictions)
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Gliptins(DPP-IV)
• DPP-IV inhibitors• Sitagliptin (Januvia) • Saxagliptin (Onglyza)
• Oral agents
• Weight neutral or weight loss
• Can use with Metformin, Sulfonylurea, TZD, or insulin (sitagliptin)
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Gliptins’ Caveats, Benefits
Caveats:• Hypoglycemia if used with sulfonyurea or
insulin• Nausea, rash
Benefits:
Few drug interactions; can be renally dosed
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“Niche” Drugs• Colesevelam (Welchol)
- adjunct to lower A1c and LDL- limited efficacy, cost
• Repaglinide (Prandin), Nateglinide (Starlix)- may replace SU if sulfa allergy
- Prandin may be useful in CKD• Acarbose (Precose), Miglitol (Glyset)
- limited efficacy, GI intolerance, cost• Bromocriptine (Cycloset)
- limited efficacy? Will be marketed• Salsalate -older NSAID, may lower blood sugar,
no indication yet
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Non-Insulin Injectable Medications
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Glucagon-like Peptide-1 (GLP-1)
• Gut hormone
• Stimulates pancreas to secret insulin
• Suppresses glucagon action
• Many target organs
• Weight regulation
• Caution in renal or hepatic impairment
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GLP-1
• Exenatide (Byetta) GLP-1 mimetic• Liraglutide (Victoza) GLP-1 analog• Both available in pen injectors (easy)• Modest weight loss• Combined with other agents except
DPP-IV inhibitors or insulin (exenatide has basal insulin data)
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GLP-1 Caveats
• Nausea, vomiting
• Pancreatitis
• Medullary thyroid carcinoma in rodents (liraglutide)
• Hypoglycemia combined with sulfonyurea
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Pramlintide-Synthetic Amylin(Symlin)
• Amylin secreted by normal pancreas along with insulin to regulate blood glucose
• Enhances Postprandial control. Used in Type 1 and Type 2 patients
• Used as adjunct to insulin• Available in pen injector• Possible significant hypoglycemia
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Combination Drug Therapy
• Consider early if failing monotherapy
• Generally additive or synergistic effects
• Triple or quadruple non-insulin drug therapy
-limited benefit in many
-safe for many
• Insulin is often a better,more potent choice
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Insulin Therapies
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Insulin Therapy
• All Type 1 patients at diagnosis• All type 2 patients will require insulin if they
live long enough
-7 to 10 years post diagnosis
-A1C >9%
-Function of many non-insulin meds based on presence of native insulin
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Beta-cell function declines as diabetes progresses
Beta-cell function (%)
Beta-cell decline exceeds 50% by time of diagnosis
4 4 12 8 0 8 12
0
50
100
75
25 Type 2 Diabetes
IGT
Years from diagnosis
Postprandial
Hyperglycemia
Diagnosis
Insulininitiation
Beta-cell function decline over time
Lebovitz H. Diabetes Rev 1999;7:139-153.
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Insulin Therapy
• Modern insulins safer and more predictable
• Most insulin types come in pen injectors
• Pen injectors easy to use, to teach, less cumbersome than vials/syringes
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Rapid Acting Insulin
• Aspart (Novolog) • Lispro (Humalog)
• Glulisine (Apidra)
• (Human Regular)
• Taken with meals and snacks
• “Bolus” insulin
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Long-Acting Insulin
• Detemir (Levemir)
• Glargine (Lantus)
• Human NPH (N)
• Taken 1 or 2 times daily
• “Basal” insulin
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Insulin Time Action Curves
0
20
40
60
80
100
120
140
0 2 4 6 8 10 12 14 16
Insu
lin
Eff
ect
Hours
18 20
Intermediate (NPH)
Long(Detemir,Glargine)
Short (Regular)
Rapid (Lispro,Glulisine, Aspart)
adapted from R. Bergenstal, IDC
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Basal Insulin in Type 2 Diabetes
• Glargine (Lantus), Detemir (Levemir)
• Good, potent add-on for improved A1C
• Second line agent for many patients
• A1C >9, diabetes longer than 5 to 7 years
• AACE: ? Weight benefit with Detemir
• Pen injectors easy
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Basal Insulin in Type 2 Diabetes
• Some oral meds may be continued
-metformin, maybe TZD, maybe SU, maybe gliptin (sitagliptin)
• Glargine (Lantus) or Detemir (Levemir) started at 10 units at HS
• Increase 3 units every 3 to 5 days until fasting blood sugars <110 (or <140)
• Most type 2 on 50-80+ units/day
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Adding Bolus Insulin in Type 2 Diabetes
• Lispro (Humalog)
• Aspart (Novolog)
• Glulisine (Apidra)
• Pen injectors
• Why is bolus insulin important in Type 2?
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Fasting and Postprandial Glycemic Excursions as a Function of A1C
Monnier L et al. Diabetes Care. 2003;26:881-885.
0
20
60
80
2(7.3–8.4)
3(8.5–9.2)
4(9.3–10.2)
5(>10.2)
1(<7.3)
40
Co
ntr
ibu
tio
n (
%)
A1C (%) Quintiles
Postprandial hyperglycemia
Fasting hyperglycemia
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Adding Bolus Insulin in Type 2 Diabetes
• 1 injection basal/1 injection bolus good 2 injection program- better than split basal
• 90/10 rule (90% basal, 10% bolus)• Start with largest meal of the day • Add other meal doses later• Usually stop TZD, always stop SU• Easy with pens
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Premix Insulins
• 70/30, 75/25, 50/50
• Combine R or rapid acting with NPH or an “NPH-like” component
• Certain applications may be appropriate
• Limitation: change 2 insulins at once
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Case Studies
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Case #1
• 42 y/o Hispanic female with hx of GDM 6 years ago, term 10 lb 5 oz male infant
• Not seen for follow-up in 3 years• FBS done at annual pap/px is 149
Does this patient have type 2 diabetes? What next?
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Case #1
• Diagnosis of diabetes generally requires two abnormal values
• Patient at high risk for type 2
• GDM is a pre-diabetes condition
Repeat FBS three days later…….
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Case #1
• Repeat FBS 135
• Dx: type 2 diabetes (FBS >126 on two separate occasions)
• What should be done next for this patient?
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Case #1
• Patient had tubal ligation after last delivery
• Start metformin 500mg BID, advance to 850-1000 mg BID
• Most newly-diagnosed patients should start metformin (current ADA recommendation)
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Case #1
• Diabetes Educator and Dietician
• SBGM with appropriate targets
• Check fasting lipids, monitor Blood Pressure
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Case Study#2
• 54 y/o white male
• Diagnosed with type 2 diabetes after 2 fasting blood sugars of 154 and 142
• Also has high blood pressure and cholesterol disease (common in type 2)
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Case Study #2
• Metformin 500 mg prescribed twice daily, titrated to 1000mg BID
• ASA 81 mg daily
• Referred to Diabetes Educator and Dietician for meal planning
• Recommend developing graduated exercise plan (exercise prescription)
• Six months after diagnosis, A1C = 6.8% (target <7%)
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Case Study #2
• Three years later, patient’s A1C has risen to 8.4% (target <7%)
• Blood pressure and cholesterol effectively treated
• Now what?
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Case Study #2
• Choices include– Adding a basal insulin once daily– Adding any other oral agent– Adding exenatide twice daily or liraglutide
once daily
• Any of these are good choices
• Choice may be made on individual factors
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Case Study #2
• Patient chose additional oral agent (sitagliptin), but others would be OK
• A1C: 6 months later = 7.4% (target <7%) 3 years later = 8.1% (target <7%)
Now what?
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Case Study #2
• Sitgliptin, metformin continued
• Basal insulin started with titration
• Eventually added bolus insulin with largest meal (90/10 rule)
• Likely will add bolus with other meals over time
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Medication Combinations• Sulfonylureas: Virtually any in type 2• Metformin: Virtually any in type 2• TZD: Virtually any in type 2• Gliptins: metformin, TZD, insulin (sitagliptin)• Insulin: metformin, TZD, sulfonylurea, amylin,
sitagliptin• Amylin: only in insulin regimens• Exenatide/Liraglutide: metformin, sulfonyureas,
TZD
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Medication Indications
• Type 1 Diabetes: Insulin, amylin (amylin only in combination with insulin)
• Type 2 Diabetes: All oral agents, exenatide, liraglutide, amylin, insulin (amylin only in combination with insulin)
• Prediabetes: none (yet), case by case, i.e., PCOS
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Summary
• Diabetes is common
• Understand Medications and Indications
• Type 1 diabetes: Insulin regimen (pumps)
• Type 2 diabetes: Lots of choices, but nearly all will need insulin eventually
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Acknowledgements
• North Dakota Department of Health, Karalee Harper• Centers for Disease Control• Office of Continuing Medical Education, UNDSMHS,
Mary Johnson• Department of Family and Community Medicine,
UNDSMHS, Melissa Gardner• Brandon Thorvilson, UNDSMHS IT• Disclosure: Novo Nordisk Speaker’s Bureau
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Contact Info/Slide Decks/Media
[email protected]@altru.org
Phone701-739-0877 cell
Slide Decks (Diabetes, Tobacco, other)http://www.med.und.edu/familymedicine/slidedecks.html
iTunes Podcasts (Diabetes) (Free downloads)http://www.med.und.edu/podcasts/ or iTunes>> search UND Medcast (updated soon)
WebMD Page: (under construction)http://www.webmd.com/eric-l-johnson
Diabetes e-columns (archived): http://www.ndhealth.gov/diabetescoalition/DrJohnson/DrJohnson.htm