Insulin and Oral Antidiabetic Drugs Including SGLT2 Inhibitors
|
|
- Ira Fitzgerald
- 6 years ago
- Views:
Transcription
1 Insulin and Oral Antidiabetic Drugs Including SGLT2 Inhibits S. S E THU K. R E D DY, M D, M B A, F R C P C, FAC P, M AC E PAST-CHIEF O F ADULT D I ABETES, J OSLIN D I ABETES C E N TER PAST-CHAIR O F ENDOCRINOLO GY, D I ABETES & M E TABOLISM, C L E V E LAN D C L I N IC S E THU. K. R EDDY@GMAIL.C O M
2 Objectives: By participating in this activity, one should be able to: Determine the clinical utility of new insulin into one's practice Choose appropriate al agents beyond metfmin in a patient-centric manner Interpret the clinical relevance of recent cardiovascular outcome trials in diabetes
3 Questions Is insulin atherogenic? Carcinogenic? What are advantages of newer insulins? What to choose after metfmin? Should we start earlier combination therapy? What do recent CV safety trials mean f me in the clinic? What s new with SGLT inhibits?
4 To insulin Not to insulin? Insulin and Cancer Sty Diabetes / Obesity insulin resistance linked to increased incidence of a variety of solid cancers Hyperinsulinemia potentially leading to IGF-1 recept activation Many tums expressing insulin recepts;? Insulin use leading to growth of pre-existing tum cells Optimal route of insulin delivery? Precision medicine approach to cancer and insulin therapy CLINICAL JUDGMENT: At present, the metabolic benefits outweigh the potential concerns of insulin therapy
5 Insulin and Atherosclerosis High insulin levels crelated with greater atherosclerosis Is the problem endogenous hyperinsulinemia exogenous hyperinsulinemia? Role of pro-insulin Insulin is a potent anabolic hmone f FAT as well Challenge of interpreting insulin therapy trials since patients requiring insulin often have me severe and longer duration diabetes CLINICAL JUDGMENT: No clear data that exogenous insulin increases clinical cardiac events and the metabolic benefits outweigh theetical concerns.
6 Atherosclerosis. Relevant animal model: Hyperinsulinemia with nmal insulin sensitivity with exposure to atherogenic diet Christian Rask-Madsen et al. Arterioscler Thromb Vasc Biol. 2012;32: Copyright American Heart Association, Inc. All rights reserved.
7 What are we looking f in insulin? Predictable in onset Predictable in duration Basal vs Prandial coverage Delivery devices to increase adherence and dosing accuracy Affdable CLINICAL JUDGEMENT: We can wk with any insulin if we could rely on its absption, distribution and metabolism.
8 Concentrated Insulins U-500 Regular Insulin Basal and bolus properties High risk of errs in dosing due to availability in a vial U-300 Insulin Glargine Slow initial onset and up to 5 days until steady state 15% higher doses than U-100 glargine (but unit-unit conversion initially advised) Less glycemic variability results in slightly less nocturnal hypoglycemia vs U-100 insulin glargine U-200 Insulin Degludec Similar anticipated benefits of reduced nocturnal hypoglycemia U-200 Insulin Lispro Rapid-acting Bioequivalent to U-100 insulin lispro 8
9 U-500 Regular Humulin R U-500 is highly concentrated and contains 5 times as much insulin in 1 ml as standard U-100 insulin Both have onset of action at 30 minutes U-500 insulin exhibits a delayed and lower peak effect relative to U-100 U-500 insulin typically has a longer duration of action compared with U-100 (up to 24 hours following a single dose) Clinical experience has shown that U-500 insulin frequently has time-action characteristics reflecting both prandial and basal activity 9
10 degludec Available only as FlexTouch pens U-200: 600 units/pen, max 160 units/inj U-100: 300 units/pen, max 80 units/inj Duration of action > 42 hours Half-life ~25 hours Detectable f at least 5 days Steady state in 2-3 days 10
11 U-300 glargine FDA approved February 2015 Available only as a pen: 450 Units/1.5 ml Maximum 80 units per injection Smaller depot surface area leading to a reduced rate of absption Provides flatter and prolonged pharmacokinetic and pharmacodynamic profiles and me consistency Onset after first dose ~ 6 hours Half-life is ~23 hours Steady state in 4-5 days Duration of action 36 hours 11
12 U-300 glargine Changing from QD long-acting intermediateacting insulin: Initial dose can be same as QD long-acting dose, f patients controlled on U-100 insulin glargine Expect that a higher daily dose of U-300 insulin glargine will be needed to maintain the same level of glycemic control (~15% higher) Changing from BID NPH insulin: Initial dose is 80% of the total daily NPH dosage (similar to conversion to U-100 insulin glargine) 12
13 Access to Insulin Quixotic Quest Po access Consider medical assistance programs Consider R and N (caveats re. mixing and timing) Full access Analogs Pens Newest Brands 13
14 Pathophysiology of Type 2 Diabetes: The Classic Triumvirate b-cell Dysfunction Hyperglycemia Increased Hepatic Glucose Production Decreased Glucose Uptake
15 Multiple, Complex Pathophysiological Abnmalities in T2DM incretin effect gut carbohydrate delivery & absption _ pancreatic insulin secretion pancreatic glucagon secretion HYPERGLYCEMIA _? hepatic glucose production renal glucose excretion peripheral glucose uptake Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
16 What Comes After Metfmin? Depends Patient characteristics Degree of hyperglycemia Risk of hypoglycemia Weight Combidities (renal, cardiac, hepatic) Access to treatment Patient preferences Agent characteristics BG lowering efficacy & durability Risk of inducing hypoglycemia Effect on weight Contraindications & side effects Cost and coverage Other
17 Monotherapy Efficacy * Hypo risk Weight Side effects Costs Dual therapy Efficacy * Hypo risk Weight Side effects Costs Healthy eating, weight control, increased physical activity & diabetes education Metfmin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (der not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific facts): Metfmin Sulfonylurea high moderate risk gain hypoglycemia low Metfmin Thiazolidinedione high low risk gain edema, HF, fxs low Metfmin DPP-4 inhibit intermediate low risk neutral rare high Metfmin SGLT2 inhibit intermediate low risk loss GU, dehydration high Metfmin GLP-1 recept agonist high low risk loss GI high Metfmin Insulin (basal) highest high risk gain hypoglycemia variable Triple therapy Metfmin Sulfonylurea If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (der not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific facts): TZD Metfmin Thiazolidinedione SU Metfmin DPP-4 Inhibit SU Metfmin SGLT-2 Inhibit SU Metfmin GLP-1 recept agonist SU Metfmin Insulin (basal) TZD DPP-4-i DPP-4-i TZD TZD TZD DPP-4-i SGLT2-i SGLT2-i SGLT2-i DPP-4-i Insulin SGLT2-i GLP-1-RA GLP-1-RA Insulin Insulin GLP-1-RA Insulin Insulin Combination injectable therapy If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on al combination, move to injectables, (2) on GLP-1 RA, add basal insulin, (3) on optimally titrated basal insulin, add GLP-1-RA mealtime insulin. In refracty patients consider adding TZD SGL T2-i: Metfmin Figure 2. Anti-hyperglycemic Basal Insulin Mealtime Insulin GLP-1-RA therapy in T2DM: General Diabetes Care 2015;38: ; Diabetologia
18 Monotherapy Efficacy * Hypo risk Weight Side effects Costs Dual therapy Efficacy * Hypo risk Weight Side effects Costs Healthy eating, weight control, increased physical activity & diabetes education Metfmin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (der not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific facts): Metfmin Sulfonylurea high moderate risk gain hypoglycemia low Metfmin Thiazolidinedione high low risk gain edema, HF, fxs low Metfmin DPP-4 inhibit intermediate low risk neutral rare high Metfmin SGLT2 inhibit intermediate low risk loss GU, dehydration high Metfmin GLP-1 recept agonist high low risk loss GI high Metfmin Insulin (basal) highest high risk gain hypoglycemia variable Triple therapy Metfmin Sulfonylurea If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (der not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific facts): TZD Metfmin Thiazolidinedione SU Metfmin DPP-4 Inhibit SU Metfmin SGLT-2 Inhibit SU Metfmin GLP-1 recept agonist SU Metfmin Insulin (basal) TZD DPP-4-i DPP-4-i TZD TZD TZD DPP-4-i SGLT2-i SGLT2-i SGLT2-i DPP-4-i Insulin SGLT2-i GLP-1-RA GLP-1-RA Insulin Insulin GLP-1-RA Insulin Insulin Combination injectable therapy If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on al combination, move to injectables, (2) on GLP-1 RA, add basal insulin, (3) on optimally titrated basal insulin, add GLP-1-RA mealtime insulin. In refracty patients consider adding TZD SGL T2-i: Metfmin Figure 2. Anti-hyperglycemic Basal Insulin Mealtime Insulin GLP-1-RA therapy in T2DM: General Diabetes Care 2015;38: ; Diabetologia
19 Monotherapy Efficacy * Hypo risk Weight Side effects Costs Dual therapy Efficacy * Hypo risk Weight Side effects Costs Healthy eating, weight control, increased physical activity & diabetes education Metfmin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (der not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific facts): Metfmin Sulfonylurea high moderate risk gain hypoglycemia low Metfmin Thiazolidinedione high low risk gain edema, HF, fxs low Metfmin DPP-4 inhibit intermediate low risk neutral rare high Metfmin SGLT2 inhibit intermediate low risk loss GU, dehydration high Metfmin GLP-1 recept agonist high low risk loss GI high Metfmin Insulin (basal) highest high risk gain hypoglycemia variable Triple therapy Metfmin Sulfonylurea If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (der not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific facts): TZD Metfmin Thiazolidinedione SU Metfmin DPP-4 Inhibit SU Metfmin SGLT-2 Inhibit SU Metfmin GLP-1 recept agonist SU Metfmin Insulin (basal) TZD DPP-4-i DPP-4-i TZD TZD TZD DPP-4-i SGLT2-i SGLT2-i SGLT2-i DPP-4-i Insulin SGLT2-i GLP-1-RA GLP-1-RA Insulin Insulin GLP-1-RA Insulin Insulin Combination injectable therapy If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on al combination, move to injectables, (2) on GLP-1 RA, add basal insulin, (3) on optimally titrated basal insulin, add GLP-1-RA mealtime insulin. In refracty patients consider adding TZD SGL T2-i: Metfmin Figure 2. Anti-hyperglycemic Basal Insulin Mealtime Insulin GLP-1-RA therapy in T2DM: General Diabetes Care 2015;38: ; Diabetologia
20
21
22 Some Rules of Thumb f Sequential Therapy The first agent added will be the most efficacious. The next agent will likely reduce A1c by % The third agent added will likely reduce A1c by %. Sulfonylureas: Optimal dose is half-maximal dose. Metfmin: Optimal dose is app mg per day
23 Development and Progression of Type 2 Diabetes and Related Complications 1,a Progression of Type 2 Diabetes Mellitus 4 7 years Insulin resistance Hepatic glucose production Insulin level Beta-cell function Postprandial glucose Fasting plasma glucose Development of Microvascular Complications Development of Macrovascular Complications Impaired Glucose Tolerance Frank Diabetes Diabetes Diagnosis a Conceptual representation. 1. Reprinted from Primary Care, 26(4), Ramlo-Halsted BA, Edelman SV, The natural histy of type 2 diabetes. Implications f clinical practice, , 1999, with permission from Elsevier. 23
24 Precedents Evolution of Therapeutic Approach Cancer Congestive Heart Failure Think of a Plane Maintenance: Fuel Landing gear Wing control Tail-fin control Engine Oil
25 LS Mean (±SE) Change in HbA 1C From Baseline, % Initial Therapy With Sitagliptin/Metfmin FDC vs Metfmin Monotherapy: HbA 1c Results Over 18 Weeks 1 0 FAS Population a 1 2 LS means difference 0.6; P< Week Sitagliptin/metfmin FDC 50/1,000 mg bid (n=559) Mean baseline HbA 1c =9.9% Metfmin 1,000 mg bid (n=564) Mean baseline HbA 1c =9.8% bid=twice a day; FAS=full analysis set; FDC=fixed-dose combination; LS=least-squares; SE=standard err. a Excludes data obtained after initiation of additional antihyperglycemic agents. 1. Used with permission from Blackwell Publishing Ltd. Reasner C et al. Diabetes Obes Metab. 2011;13: Copyright 2011 Blackwell Publishing Ltd. 25
26 Absolute Value in HbA 1c Over Time (LS Mean ±SE), % Sitagliptin Plus Metfmin FDC Resulted in Significant HbA 1c Reductions Through 44 Weeks 1 0 FAS Population Including data after initiation of additional OHA therapy 1 LS mean change from baseline a 1.8; 95% CI (-1.9, -1.6) Week Sitagliptin/metfmin FDC 50/1,000 mg sbid Metfmin 1,000 mg bid (n=569) (n=560) Mean baseline HbA 1c = 9.8% Mean baseline HbA 1c = 9.9% bid=twice daily; FAS=full-analysis-set; FDC=fixed-dose combination; LS=least-squares; OHA=al antihyperglycemic agent; SE=standard err. a Primary end point f this study was the change from baseline in HbA 1c at week Used with permission from Blackwell Publishing Ltd. Olansky L et al. Diabetes Obes Metab. 2011;13: Copyright 2011 Blackwell Publishing Ltd. LS mean difference 0.5; LS mean change from P<0.001 baseline a 2.3; 95% CI (-2.4, -2.1) 26
27 2nd line Antidiabetic Combination Therapy Principle: Two differently acting al anti-diabetic agents can have additive glucose-lowering effects if sufficient β-cell function remains 1st line Metfmin TZD SU / Glinides Acarbose Insulin Obesity Metfmin Yes* Yes Yes Yes Yes TZD Yes Yes Yes Yes Yes SU / Megl Yes Yes Yes Yes Yes Exenatide DPP4-I Yes Yes Yes (Yes) (Yes) (Yes) Acarbose Yes Yes Yes Yes Yes Insulin Yes Yes Yes Yes Yes Obesity Yes Yes Yes Yes Yes * TZD given if metfmin not tolerated. Anti-obesity agent (listat, sibutramine, rimonabant) not specifically indicated with an anti-diabetic agent, but widely used.
28 Journal of Diabetes and Its Complications 30 (2016)
29 Multiple, Complex Pathophysiological Abnmalities in T2DM GLP-1R agonists incretin effect DPP-4 inhibits A G I s gut carbohydrate delivery & absption Metfmin hepatic glucose production _ pancreatic insulin secretion pancreatic glucagon secretion HYPERGLYCEMIA Bile acid sequestrants Insulin Glinides S U s Amylin mimetics renal glucose excretion _ DA agonist s T Z D s? peripheral glucose uptake Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
30 Change in mean HbA1c level (A), weight (B), and total daily INS dose (C) in INS-treated type 2 diabetic patients after 4 months of dual therapy using INS MET ( ) INS TGZ ( ) and after 4 months of triple therapy using INS, MET, and TGZ [INS MET add TGZ ( ), INS TGZ add MET ( )]. *P < 0.05 vs. baseline, P < 0.05 vs. week 16, P < 0.05 vs. Suzanne M. Strowig et al. Dia Care 2004;27: by American Diabetes Association
31 Mean HbA1c values befe and during 6 months intervention in type 2 diabetic patients treated with either NPH MIX insulin twice daily (, control group) with insulin aspart befe meals, metfmin, and rosiglitazone (, triple therapy group). Mikael Kjær Poulsen et al. Dia Care 2003;26: by American Diabetes Association
32 Fig. 1. Netwk plot of available diabetes treatment combinations f studies with a treatment duration of 6 12 months (20 54 weeks). The number of studies available per direct comparison is provided in the netwk. The size of the node reflects the number of... Crystal Man Ying Lee, Mark Woodward, Stephen Colagiuri Triple therapy combinations f the treatment of type 2 diabetes A netwk meta-analysis Diabetes Research and Clinical Practice, Volume 116, 2016,
33 Fig. 4. Surface under the cumulative ranking curve (SUCRA) values of HbA1c by body weight f all triple therapies with data f HbA1c and body weight f studies with a treatment duration of 6 12 months (20 54 weeks). Higher SUCRA values f HbA1c indicate gr... Crystal Man Ying Lee, Mark Woodward, Stephen Colagiuri Triple therapy combinations f the treatment of type 2 diabetes A netwk meta-analysis Diabetes Research and Clinical Practice, Volume 116, 2016,
34 Multiple, Complex Pathophysiological Abnmalities in T2DM incretin effect gut carbohydrate delivery & absption _ pancreatic insulin secretion pancreatic glucagon secretion HYPERGLYCEMIA? _ hepatic glucose production renal glucose excretion peripheral glucose uptake Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
35 Treating the Pathophysiological Abnmalities in T2DM GLP-1R agonists incretin effect Glinides Insulin S U s pancreatic insulin secretion DPP-4 inhibits A G I s gut carbohydrate delivery & absption Amylin mimetics _ pancreatic glucagon secretion HYPERGLYCEMIA DA agonists? Metfmin Bile acid sequestrants hepatic glucose production renal glucose excretion _ T Z D s peripheral glucose uptake Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
36 Figure 1. Modulation of the intensiveness of glucose lowering therapy in T2DM PATIENT / DISEASE FEATURES Risks potentially associated with hypoglycemia and other drug adverse effects me stringent low Approach to the management of hyperglycemia HbA1c 7% less stringent high Disease duration newly diagnosed long-standing Life expectancy long sht Usually not modifiable Imptant combidities absent few / mild severe Established vascular complications absent few / mild severe Patient attitude and expected treatment effts highly motivated, adherent, excellent self-care capacities less motivated, non-adherent, po self-care capacities Potentially modifiable Resources and suppt system Readily available limited Diabetes Care 2015;38: ; Diabetologia 2015;58:429-
37
38
39 HbA 1c,% Earlier and Appropriate Intervention May Improve Patients Chances of Reaching Goal 1 Diet and exercise Published Conceptual Approach OAD monotherapy OAD up-titration OAD combination OAD basal insulin OAD multiple daily insulin injections 10 9 Mean HbA 1c of patients Conventional stepwise treatment approach Duration of Diabetes Earlier and proactive intervention approach OAD=al antidiabetic agent. 1. Adapted from Del Prato S et al. Int J Clin Pract. 2005;59(11): Copyright Adapted with permission of Blackwell Publishing Ltd. HbA 1c goal of 7%
40 Adapted from Juutilainen A et al. Diabetes Care 2007;30:292 Increased Hepatic Glucose Production Reduced Glucose Disposal Hyperglycemia Glucose ROS* Aging, Smoking Central obesity Dyslipidemia Microvascular complications Retinopathy Heart microangiopathy Insulin resistance FFA Macrovascular complications Nephropathy Aging, Smoking Central obesity Dyslipidemia *ROS = reactive oxygen species Courtesy of dr. M. Laakso
41 Type 2 Diabetes and Cardiovascular Risk Many studies in patients with DM have demonstrated that improved glucose control reduces microvascular complications. Does any particular glucose-lowering strategy is safe from a CV standpoint can actually lower macrovascular complications (e.g., MI, stroke, CV death)?. Expectation: Controlling f degree of glucose control, anti-diabetic agents are NEUTRAL with respect to development of CV disease.
42 Study Summary of 4 Main Trials T2DM DM Duration (yrs) Follow Up (yrs) Baseline A1c (%) Micro Vascular CVD Mtality UKPDS New UKPDS-FU New 10 No diff ADVANCE ACCORD VADT
43 Meta-Analysis Diabetic Medicine, Sept Seidu et al 19 RCTs App. 80,000 subjects Intensive control reduced risk of non-fatal MI by 10% (CI = ) No impact on all-cause CV mtality Multiple RF intervention reduced risk of non-fatal stroke by 47% (CI = )? Impact of baseline CV risk and duration of diabetes 43
44 Diabetes with Heart Disease: Same Label but a different wine 60 y.o. male, with 15 yr histy of diabetes, with known histy of hypertension developed angina at age 57; A1c of 8% on double therapy 60 y.o. male with 25 yr histy of hypertension and hypercholesterolemia; noncompliant; Admitted with new onset angina and found to have elevated fasting glucose of 180 mg/dl Reddy, S. Personal Opinion 44
45 CV death, MI ischemic CVA (%) Primary end point HR 1.00 [ ] P<0.001 (non-inferiity) y KM Saxagliptin 7.3% Placebo 7.2% 2 Placebo Months Saxagliptin Scirica BM, Bhatt DL Braunwald et al, Sexagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus. N Engl J Med Oct 3;369(14):
46 Primary end point White WB, Cannon CP, Heller SR et al, Alogliptin after acute conary syndrome in patients with type 2 diabetes. N Engl J Med Oct 3;369(14):
47 P R I M A RY R E S U LT S 8 T H J U N E
48 Glycemic Control Least Squares Mean HbA1c ± 1SD Overall LS Mean difference -0.29% (-0.32, -0.27), p< Green JB et al. NEJM 2015; DOI: /NEJMoa
49 Primary Composite Cardiovascular Outcome* PP Analysis f Non-inferiity * CV death, nonfatal MI, nonfatal stroke, hospitalization f unstable angina Green JB et al. NEJM 2015; DOI: /NEJMoa
50 Secondary Composite Cardiovascular Outcome* ITT Analysis f Superiity * CV death, nonfatal MI, nonfatal stroke Green JB et al. NEJM 2015; DOI: /NEJMoa
51 Hospitalization f Heart Failure* ITT Analysis * Adjusted f histy of heart failure at baseline Green JB et al. NEJM 2015; DOI: /NEJMoa
52 Individual end points Significantly me patients in the saxagliptin group than placebo were hospitalized f heart failure 2-year KM rate (%) Placebo (N=8 212) Saxagliptin (N=8 280) HR P-value f superiity CV death ( ) 0.72 MI ( ) 0.52 Ischemic stroke ( ) 0.38 Hosp f c. revasc ( ) 0.18 Hosp f UA ( ) 0.24 Hosp f heart failure ( ) All-cause mtality ( ) 0.15 Scirica BM, Bhatt DL Braunwald et al, Sexagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus. N Engl J Med Oct 3;369(14):
53 Hospitalization f heart failure: pooled analysis Sattar N, Results from SAVOR and EXAMINE. DPP-4 inhibits and CVD, EASD 2013 Sep 26.
54 Summary of DPP-4-i CVOT SAVOR-TIMI, EXAMINE, TECOS Conclusions No increased cardiac mtality in predominantly white, > 60 yrs, with established CVD and DM f 7-10 years 3.5% vs. 2.8% f admission f heart failure in saxa group Caveats Studies designed to meet FDA requirements and not patient/physician needs Median Follow-up f 3 years Minimal glucose control differences High penetrance of CV risk reduction strategies Hirshberg and Katz Curr Diab Rep (2015) 15:87 54
55 FDA: Two diabetes drugs may be linked to heart failure risk April 5, 2016
56 A Multicenter Observational Study of Incretin-based Drugs and Heart Failure Kristian B. Filion, Ph.D., Laurent Azoulay, Ph.D., Robert W. Platt, Ph.D., Matthew Dahl, B.Sc., Colin R. Dmuth, Sc.D., Kristin K. Clemens, M.D., Nianping Hu, M.D., Ph.D., J. Michael Paterson, M.Sc., Laura Targownik, M.D., M.S.H.S., Tanvir C. Turin, M.D., Ph.D., Jacob A. Udell, M.D., M.P.H., and Pierre Ernst, M.D., f the CNODES Investigats * N Engl J Med 2016; 374: UK, Canada and the US 29,741 of the patients were hospitalized f heart failure, representing an incidence rate of 9.2 events per 1000 persons per year. The study finds that the rate of hospitalization f heart failure did not increase with the use of incretin-based drugs as compared with al antidiabetic-drug combinations among patients with a histy of heart failure (hazard ratio, 0.86), among those without a histy of heart failure (hazard ratio, 0.82). DPP-4 inhibits and GLP-1 analogues had similar results. On top of the standard of care in the real wld, that these new sugar lowering drugs do not raise the risk of heart failure compared with other options in our medicine cabinet.
57 Docts: Blowing in the Wind
58 ? Effects on glucagon physiology
59 EMPA- REG Study Glycated Hemoglobin Levels. Zinman B et al. N Engl J Med DOI: /NEJMoa
60 Implications Relevance of outcomes from High-risk CV patients to usual clinic patients? Implications of varying lengths of the trials? Glucose Equipoise? As me trials are completed, implications f FDA Guidance 60
61 Cardiovascular Outcomes and Death from Any Cause. CV Outcomes with CVOT Empagliflozin MACE, CV Death, All Death and Hosp. f Heart Failure Zinman B et al. N Engl J Med DOI: /NEJMoa
62 SGLT2 inhibitrs and Anti-atherosclerosis
63 SGLT-2 inhibits Potential and novel pathways associated with CV effects Decreased BP Decreased uric acid Decreased SNS activity Decreased weight Decreased Glucose Decreased albuminuria Decreased oxidative stress Increased LDL Increased HDL Novel biomarkers?? Silvio E Inzucchi et al. Diabetes and Vascular Disease Research 2015; Copyright by SAGE Publications
64 What does all this mean f the clinician?
65 SGLT2 Inhibits
66 Clinical Caveats All appear to be well tolerated: Clinically indistinguishable Could be added to MF SFU Many are using in those taking insulin: achieving a better A1c with minimal intervention.? Less impact in those with A1c < 7.7%? Used to maintain A1c around 7.5% so? 4 X greater genital fungal infections in those with pri histy of Difficult to compare infection rates within class
67 Meta-analysis of SGLT2 inhibits led to 0.5 to 0.7% reduction in A1c vs. placebo active comparats Reduction in BP and uric acid levels touted Promotion of some weight loss Increase in LDL-cholesterol (app 5%) :? Significance
68 SGLT2i and DKA Type 1 DM Off-label use Euglycemic DKA Occ. ketones and Lower Bicarb: not necessarily DKA Type 2 DM Although many case repts, overall incidence not a surprise Baseline me severe hyperglycemia; me dehydration Mild increase in glucagon levels noted; leading to slightly higher glucagon/insulin ratio
69 SGLT2 inhibits (SGLT2i) decrease glucose by an insulin-independent mechanism. To minimize the risk of hypoglycemia, T1D patients may need to decrease their insulin dose, which is predicted to increase the rate of adipose tissue lipolysis and hepatic ketogenesis. In addition, SGLT2 inhibits have been demonstrated to increase plasma glucagon levels in T2D patients (12, 13), possibly to compensate f increased urinary excretion of glucose. In addition, it has recently been repted that SGLT2 inhibits increase preproglucagon gene expression by acting directly upon pancreatic α-cells (14). Furtherme, phlizin (a nonselective inhibit of SGLT1 and SGLT2) has been demonstrated to increase renal tubular reabsption of acetoacetate (9). If selective SGLT2 inhibits mimic this action of phlizin, it is possible that they could also decrease renal clearance of ketone bodies. Published in: Simeon I. Tayl; Jenny E. Blau; Kristina I. Rother; The Journal of Clinical Endocrinology & Metabolism 2015, 100, DOI: /jc ; Copyright 2015
70 Advice f All
71 Insulin and Oral Antidiabetic Drugs Including SGLT2 Inhibits S. S E THU K. R E D DY, M D, M B A, F R C P C, FAC P, M AC E PAST-CHIEF O F ADULT D I ABETES, J OSLIN D I ABETES C E N TER PAST-CHAIR O F ENDOCRINOLO GY, D I ABETES & M E TABOLISM, C L E V E LAN D C L I N IC S E THU. K. R EDDY@GMAIL.C O M
72 Hyperglycemia Three Dimensional View Type 2 Diabetes and CVD Point of CVOT Intervention Where we Should Intervene 0 Reddy, S. Personal Duration (Years) Int J Clin Pract Feb; 64(3):
73 Perspectives on SGLT2 Inhibition Potential advantages Insulin Independence Combined with other glucose lowering agents Utility independent of duration of DM Weight loss (75g urine glucose = 300kcal/day) Low risk of hypoglycemia Blood pressure lowering? Concerns Polyuria Electrolyte disturbances Low BP Increased hematocrit Bacterial urinary tract infections Fungal genital infections Increased LDL cholesterol Malignancies
74 ? Effects on glucagon physiology
75 Problem with Cardio-centric view of the Wld 60 y.o. patient with established CVD and only 7 year histy of Type 2 DM indicates a DIFFERENT patient from general internal medicine endocrinology Controlling glucose in these subjects is akin to rapidly hoping that once a nuclear warhead is detonated, peace talks can rapidly prevent the explosion Reddy, S. Personal Opinion 75
Pathogenesis of Type 2 Diabetes
9/23/215 Multiple, Complex Pathophysiological Abnmalities in T2DM incretin effect gut carbohydrate delivery & absption pancreatic insulin secretion pancreatic glucagon secretion HYPERGLYCEMIA? Pathogenesis
More informationSGLT2 Inhibition in the Management of T2DM: Potential Impact on CVD Risk
Managing Diabetes & CVD: Expling New Evidence & Opptunities ESC Congress, London, UK 30 August, 2015 SGLT2 Inhibition in the Management of T2DM: Potential Impact on CVD Risk Silvio E. Inzucchi MD Yale
More informationManagement of Hyperglycemia in Type 2 Diabetes, 2015: A Patient-Centered Approach
Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient-Centered Approach Update to a Position Statement of the American Diabetes Association (ADA) and the European Association f the Study of Diabetes
More informationMultiple Factors Should Be Considered When Setting a Glycemic Goal
Multiple Facts Should Be Considered When Setting a Glycemic Goal Patient attitude and expected treatment effts Risks potentially associated with hypoglycemia, other adverse events Disease duration Me stringent
More informationSilvio E. Inzucchi MD Section of Endocrinology Yale School of Medicine
Gegia Chapter of the American Association of Clinical Endocrinologists, 2017 Annual Meeting January 28, 2017 Silvio E. Inzucchi MD Section of Endocrinology Yale School of Medicine DIABETES MANAGEMENT GUIDELINES
More informationSGLT2 Inhibition in T2DM Management: Current Position and Future Promise
SGLT2 Inhibition, Diabetes and CVD: Where Does This Fit in CV Risk Management? ESC Congress, Rome, Italy 28 August, 2016 SGLT2 Inhibition in T2DM Management: Current Position and Future Promise Silvio
More informationOral Hypoglycemics and Risk of Adverse Cardiac Events: A Summary of the Controversy
Oral Hypoglycemics and Risk of Adverse Cardiac Events: A Summary of the Controversy Jeffrey Boord, MD, MPH Advances in Cardiovascular Medicine Kingston, Jamaica December 7, 2012 VanderbiltHeart.com Outline
More informationInsulin and Post Prandial
Insulin and Post Prandial Pr Luc Martinez PCDE Meeting Barcelona 2016 Conflicts of interest disclosure Advis consultant f Amgen Inc.; AstraZeneca Pharmaceuticals LP; GlaxoSmithKline; Ipsen; Lilly; Mayoly
More informationUpdates in Diabetes Care
Updates in Diabetes Care Disclosures Nothing to disclose Pharmacist Objectives 1. List strategies for improving diabetes care 2. Understand benefits and risks associated with newer pharmacotherapeutic
More informationAgenda. Indications Different insulin preparations Insulin initiation Insulin intensification
Insulin Therapy F. Hosseinpanah Obesity Research Center Research Institute for Endocrine sciences Shahid Beheshti University of Medical Sciences November 11, 2017 Agenda Indications Different insulin preparations
More informationDISCLOSURES. Learning objectives NAVIGATING THE TREATMENT OF TYPE 2 DIABETES: WHAT S NEW? Investigator Initiated Trial Support:
NAVIGATING THE TREATMENT OF TYPE 2 DIABETES: WHAT S NEW? Jane E-B Reusch MD Professor of Medicine, Biochemistry and Bioengineering Associate Director Center for Women s Health Research University of Colorado
More informationStephen Clement M.D. CDE Medical Director, Endocrine Services Inova Fairfax Hospital
Stephen Clement M.D. CDE Medical Director, Endocrine Services Inova Fairfax Hospital Financial Disclosures Consulting Panel for GSK on Hepatitis Vaccines Case Study BH is a 67 y/o female with T2 DM for
More informationManagement of Type 2 Diabetes Cardiovascular Outcomes Trials Tom Blevins MD Texas Diabetes and Endocrinology Austin, Texas
Management of Type 2 Diabetes Cardiovascular Outcomes Trials 2018 Tom Blevins MD Texas Diabetes and Endocrinology Austin, Texas Speaker Disclosure Dr. Blevins has disclosed that he has received grant support
More informationTREATMENT OF DIABETES AFTER METFORMIN GREGG GERETY, MD ALBANY MEDICAL COLLEGE, DIVISION OF COMMUNITY ENDOCRINOLOGY JULY 14, 2017
TREATMENT OF DIABETES AFTER METFORMIN GREGG GERETY, MD ALBANY MEDICAL COLLEGE, DIVISION OF COMMUNITY ENDOCRINOLOGY JULY 14, 2017 Outline Review treatment algorithms from ADA/ EASD & ACE/AACE. Review positive
More informationComprehensive Diabetes Treatment
Comprehensive Diabetes Treatment Joshua L. Cohen, M.D., F.A.C.P. Professor of Medicine Interim Director, Division of Endocrinology & Metabolism The George Washington University School of Medicine Diabetes
More informationTreating Diabetes To Lower Cardiovascular Disease Risk
Treating Diabetes To Lower Cardiovascular Disease Risk Anne Peters, MD Profess, USC Keck School of Medicine Direct, USC Clinical Diabetes Programs Disclosure of Financial Relationships 2015 Consultantship
More informationESC GUIDELINES ON DIABETES AND CARDIOVASCULAR DISEASES
ESC GUIDELINES ON DIABETES AND CARDIOVASCULAR DISEASES Pr. Michel KOMAJDA Institute of Cardiology - IHU ICAN Pitie Salpetriere Hospital - University Pierre and Marie Curie, Paris (France) DEFINITION A
More informationThe Many Faces of T2DM in Long-term Care Facilities
The Many Faces of T2DM in Long-term Care Facilities Question #1 Which of the following is a risk factor for increased hypoglycemia in older patients that may suggest the need to relax hyperglycemia treatment
More informationNo Increased Cardiovascular Risk for Lixisenatide in ELIXA
ON ISSUES IN THE MANAGEMENT OF TYPE 2 DIABETES JUNE 2015 Coverage of data from ADA 2015, June 5 9 in Boston, Massachusetts No Increased Cardiovascular Risk for Lixisenatide in ELIXA First Cardiovascular
More informationDiabete: terapia nei pazienti a rischio cardiovascolare
Diabete: terapia nei pazienti a rischio cardiovascolare Giorgio Sesti Università Magna Graecia di Catanzaro Cardiovascular mortality in relation to diabetes mellitus and a prior MI: A Danish Population
More informationManagement of Hyperglycemia in Type 2 Diabetes Celeste C. Thomas MD, MS
Management of Hyperglycemia in Type 2 Diabetes Celeste C. Thomas MD, MS Disclosures In compliance with the accrediting board policies, the American Diabetes Association requires the following disclosure
More informationMedical therapy advances London/Manchester RCP February/June 2016
Medical therapy advances London/Manchester RCP February/June 2016 Advances in medical therapies for diabetes mellitus Duality of interest: The speaker or institutions with which he is associated has received
More informationInitiation and Titration of Insulin in Diabetes Mellitus Type 2
Initiation and Titration of Insulin in Diabetes Mellitus Type 2 Greg Doelle MD, MS April 6, 2016 Disclosure I have no actual or potential conflicts of interest in relation to the content of this lecture.
More informationType 2 Diabetes: Where Do We Start with Treatment? DIABETES EDUCATION. Diabetes Mellitus: Complications and Co-Morbid Conditions
Diabetes Mellitus: Complications and Co-Morbid Conditions ADA Guidelines for Glycemic Control: 2016 Retinopathy Between 2005-2008, 28.5% of patients with diabetes 40 years and older diagnosed with diabetic
More informationIMPROVED DIAGNOSIS OF TYPE 2 DIABETES AND TAILORING MEDICATIONS
IMPROVED DIAGNOSIS OF TYPE 2 DIABETES AND TAILORING MEDICATIONS Dr Bidhu Mohapatra, MBBS, MD, FRACP Consultant Physician Endocrinology and General Medicine Introduction 382 million people affected by diabetes
More informationObesity, Insulin Resistance, Metabolic Syndrome, and the Natural History of Type 2 Diabetes
Obesity, Insulin Resistance, Metabolic Syndrome, and the Natural History of Type 2 Diabetes Genetics, environment, and lifestyle (obesity, inactivity, poor diet) Impaired fasting glucose Decreased β-cell
More informationWhat s New in Type 2 Diabetes? 2018 Diabetes Updates
What s New in Type 2 Diabetes? 2018 Diabetes Updates Gretchen Ray, PharmD, PhC, BCACP, CDE Associate Professor, UNM College of Pharmacy January 28, 2018 gray@salud.unm.edu OBJECTIVES Describe the most
More informationGLP 1 agonists Winning the Losing Battle. Dr Bernard SAMIA. KCS Congress: Impact through collaboration
GLP 1 agonists Winning the Losing Battle Dr Bernard SAMIA KCS Congress: Impact through collaboration CONTACT: Tel. +254 735 833 803 Email: kcardiacs@gmail.com Web: www.kenyacardiacs.org Disclosures I have
More informationLEADER and EMPA-REG. John Buse, MD, PhD. University of North Carolina School of Medicine Chapel Hill, NC, USA. Duality of Interest Declaration
1 LEADER and EMPA-REG John Buse, MD, PhD University of Nth Carolina School of Medicine Chapel Hill, NC, USA Duality of Interest Declaration I rept the following potential duality/dualities of interest
More information9/29/ Disclosure. Learning Objectives. Diabetes Update: Guidelines, Treatment Options & Trends
+ Diabetes Update: Guidelines, Treatment Options & Trends Melissa Max, PharmD, BC-ADM, CDE Assistant Professor of Pharmacy Practice Harding University College of Pharmacy + Disclosure Conflicts Of Interest
More informationDiabetes: Definition Pathophysiology Treatment Goals. By Scott Magee, MD, FACE
Diabetes: Definition Pathophysiology Treatment Goals By Scott Magee, MD, FACE Disclosures No disclosures to report Definition of Diabetes Mellitus Diabetes Mellitus comprises a group of disorders characterized
More information01/09/2017. Outline. SGLT 2 inhibitor? Diabetes Patients: Complex and Heterogeneous. Association between diabetes and cardiovascular events
MICROVASCULAR COMPLICATIONS Incidence of outcome g 1 Cardioprotective Effects of SGLT2s Relevant for Which T2 Diabetes Patient? SGLT 2 inhibitor? 58 year old, waist circumference 5 cm, PMH: IHD On statin,
More informationThe Flozins Quest for Clarity?
The Flozins Quest for Clarity? Choosing Wisely with Academic Detailing 2018 ARE THEY THE REAL DEAL Disclosure statements The Academic Detailing Service is operated by Dalhousie Continuing Professional
More informationDiabetes Guidelines in View of Recent Clinical Trials Are They Still Applicable?
Diabetes Guidelines in View of Recent Clinical Trials Are They Still Applicable? Jay S. Skyler, MD, MACP Division of Endocrinology, Diabetes, and Metabolism and Diabetes Research Institute University of
More informationCURRENT CONTROVERSIES IN DIABETES CARE
CURRENT CONTROVERSIES IN DIABETES CARE Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Declaration of full disclosure: No conflict of interest Diabetes Mellitus: U.S. Impact
More informationUpdate on Diabetes Cardiovascular Outcome Trials
Update on Diabetes Cardiovascular Outcome Trials Jay S. Skyler, MD, MACP Division of Endocrinology, Diabetes, and Metabolism and Diabetes Research Institute University of Miami Miller School of Medicine
More informationOverview T2DM medications. Winnie Ho
Overview T2DM medications Winnie Ho Diabetes in Australia 1.7 million Australians with diabetes, of these 85% have T2DM 2-fold excess risk CV death in patients with diabetes Risk factor for progression
More informationPharmacology Update for the Adult Patient - Newer Oral Medications for Diabetes
Pharmacology Update for the Adult Patient - Newer Oral Medications for Diabetes Brooke Hudspeth, PharmD, CDE, MLDE Director of Diabetes Prevention, Kroger Pharmacy Adjunct Assistant Professor, University
More informationManaging Perioperative Diabetes What s new? Kathryn A. Myers MD FRCPC Chair Chief Division of GIM Professor of Medicine Western University
Managing Perioperative Diabetes What s new? Kathryn A. Myers MD FRCPC Chair Chief Division of GIM Professor of Medicine Western University Objectives: By the end of this session, you will be able to: Identify
More informationMetabolic Karma. - Essential Solution in Type2 DM - Eun Gyoung Hong, M.D., Ph.D
2014 ICDM Breakfast Symposium. Oct 18, 2014 Grand Hilton, Seoul Metabolic Karma - Essential Solution in Type2 DM - Eun Gyoung Hong, M.D., Ph.D Department of Endocrinology and Metabolism, Hallym University
More informationDrug Class Monograph
Class: Dipeptidyl-Peptidase 4 (DPP-4) Inhibitors Drug Class Monograph Drugs: alogliptin, Januvia (sitagliptin), Janumet (sitagliptin/metformin), Janumet XR (sitagliptin/metformin), Jentadueto (linagliptin/metformin),
More informationInsulin Initiation and Intensification. Disclosure. Objectives
Insulin Initiation and Intensification Neil Skolnik, M.D. Associate Director Family Medicine Residency Program Abington Memorial Hospital Professor of Family and Community Medicine Temple University School
More informationNon-insulin treatment in Type 1 DM Sang Yong Kim
Non-insulin treatment in Type 1 DM Sang Yong Kim Chosun University Hospital Conflict of interest disclosure None Committee of Scientific Affairs Committee of Scientific Affairs Insulin therapy is the mainstay
More informationDisclosures of Interest. Publications Diabetologia Key points to emphasize
Disclosures of Interest No conflicts or disclosures How to Use the American Diabetes Association s Type 2 Diabetes Treatment Algorithm Rashida Downing, MD, FAAFP Primary Care Physician JenCare Medical
More informationDrug Class Monograph
Drug Class Monograph Class: Dipeptidyl-Peptidase 4 (DPP-4) Inhibitors Drugs: alogliptin, alogliptin/metformin, Januvia (sitagliptin), Janumet (sitagliptin/metformin), Janumet XR (sitagliptin/metformin),
More informationPreventing Serious Health Consequences of Type 2 Diabetes
Preventing Serious Health Consequences of Type 2 Diabetes The Evidence Hertzel C. Gerstein MD MSc FRCPC Professor and Population Health Institute Chair in Diabetes Research McMaster University and Hamilton
More informationMANAGING DIABETES IN 2016 WHAT TO ADD, WHEN AND WHY?
MANAGING DIABETES IN 2016 WHAT TO ADD, WHEN AND WHY? Faculty: Maria Wolfs MD, MHSc, FRCPC Assistant Professor, University of Toronto Staff Endocrinologist, St. Michael's Hospital Relationships with commercial
More informationWhat s New in Type 2 Diabetes? 2018 Diabetes Updates
What s New in Type 2 Diabetes? 2018 Diabetes Updates Jessica Conklin, PharmD, PhC, BCACP, CDE, AAHIP Associate Professor, UNM College of Phar macy jeconklin@salud.unm.edu Luis Gonzales, PharmD, PhC UNM
More informationDiabetes Mellitus: Implications of New Clinical Trials and New Medications
Diabetes Mellitus: Implications of New Clinical Trials and New Medications Estimates of Diagnosed Diabetes in Adults, 2005 Alka M. Kanaya, MD Asst. Professor of Medicine UCSF, Primary Care CME October
More informationUpdate on Insulin-based Agents for T2D
Update on Insulin-based Agents for T2D Injectable Therapies for Type 2 Diabetes Mellitus (T2DM) and Obesity This presentation will: Describe established and newly available insulin therapies for treatment
More informationWayne Gravois, MD August 6, 2017
Wayne Gravois, MD August 6, 2017 Americans with Diabetes (Millions) 40 30 Source: National Diabetes Statistics Report, 2011, 2017 Millions 20 10 0 1980 2009 2015 2007 - $174 Billion 2015 - $245 Billion
More informationDiabetes: Inpatient Glucose control
Diabetes: Inpatient Glucose control Leanne Current, PharmD, BCPS This activity is funded through the Medicaid section 1115(a) Demonstration Texas Healthcare Transformation and Quality Improvement Program
More informationUKPDS: Over Time, Need for Exogenous Insulin Increases
UKPDS: Over Time, Need for Exogenous Insulin Increases Patients Requiring Additional Insulin (%) 60 40 20 Oral agents By 6 Chlorpropamide years, Glyburide more than 50% of UKPDS patients required insulin
More informationCurrent principles of diabetes management
Current principles of diabetes management Prof. Martin Haluzík, MD, DSc. 3 Department of Medicine, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Czech Republic
More informationOlder Adults & Optimal Outcome. Individualizing Diabetes Management. Mary Moyer Janci BC-FNP BC-ADM CDE Teaching Associate Diabetes Care Center UWMC
Older Adults & Optimal Outcome Individualizing Diabetes Management Mary Moyer Janci BC-FNP BC-ADM CDE Teaching Associate Diabetes Care Center UWMC What is Diabetes? METABOLIC DISEASE Food breakdown (carbohydrates,
More informationA Practical Approach to the Use of Diabetes Medications
A Practical Approach to the Use of Diabetes Medications Juan Pablo Frias, M.D., FACE President, National Research Institute, Los Angles, CA Clinical Faculty, University of California, San Diego, CA OUTLINE
More informationManagement of Diabetes
Management of Diabetes Mellitus: Which Drugs for Which Patients? Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine baron@medicine.ucsf.edu Disclosure No relevant financial relationships
More informationPharmacology Updates. Quang T Nguyen, FACP, FACE, FTOS 11/18/17
Pharmacology Updates Quang T Nguyen, FACP, FACE, FTOS 11/18/17 14 Classes of Drugs Available for the Treatment of Type 2 DM in the USA ### Class A1c Reduction Hypoglycemia Weight Change Dosing (times/day)
More informationCase Studies in Type 2 Diabetes Mellitus: Focus on Cardiovascular Outcomes Trials
Case Studies in Type 2 Diabetes Mellitus: Focus on Cardiovascular Outcomes Trials Louis Kuritzky MD Clinical Assistant Professor Emeritus Department of Community Health and Family Medicine College of Medicine
More informationManagement of Diabetes Mellitus: A Primary Care Perspective. Screening for Diabetes Advantages of HbA1c as a Diagnostic Test
Management of Diabetes Mellitus: A Primary Care Perspective Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Declaration of full disclosure: No conflict of interest Screening
More informationCan We Reduce Heart Failure by Treating Diabetes? CVOT Data on SGLT2 Inhibitors and GLP-1Receptor Agonists
Can We Reduce Heart Failure by Treating Diabetes? CVOT Data on SGLT2 Inhibitors and GLP-1Receptor Agonists Robert R. Henry, MD Professor of Medicine University of California, San Diego Relevant Conflict
More information7/6/ ANNUAL MEETING DIABETES - KEEPING UP WITH CHANGES TECHNICIAN OBJECTIVES PROJECTED PREVALENCE OF DIABETES IN THE UNITED STATES:
TECHNICIAN OBJECTIVES Audience will be able to describe the differences between traditional and newer insulin products. DIABETES - KEEPING UP WITH CHANGES MARY HENCHER PHARMD, BCPS, CDE CLINICAL PHARMACIST,
More informationThe Death of Sulfonylureas? A Review of New Diabetes Medications
The Death of Sulfonylureas? A Review of New Diabetes Medications Kelly Hoenig, Pharm.D., BCPS Cedar Rapids Family Medicine Residency 2/4/17 Objectives Review GLP-1 Agonists, DPP-IV Inhibitors and SGLT-2
More informationManagement of Diabetes Mellitus: A Primary Care Perspective
Management of Diabetes Mellitus: A Primary Care Perspective Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Declaration of full disclosure: No conflict of interest Screening
More informationGlycemic control a matter of life and death
Glycemic control a matter of life and death Linda Garcia Mellbin MD PhD Specialist in Cardiology & Internal medicine Dep of Cardiology Karolinska University Hospital /Karolinska Institutet Mortality (%)
More informationAntihyperglycemic Agents in Diabetes. Jamie Messenger, PharmD, CPP Department of Family Medicine East Carolina University August 18, 2014
Antihyperglycemic Agents in Diabetes Jamie Messenger, PharmD, CPP Department of Family Medicine East Carolina University August 18, 2014 Objectives Review 2014 ADA Standards of Medical Care in DM as they
More informationCURRENT ISSUES IN DIABETES MANAGEMENT. Screening for Diabetes Advantages of HbA1c as a Diagnostic Test. Diagnosis of Diabetes 2013
CURRENT ISSUES IN DIABETES MANAGEMENT Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Declaration of full disclosure: No conflict of interest Screening for Diabetes 2013 BMI
More informationLATE BREAKING STUDIES IN DM AND CAD. Will this change the guidelines?
LATE BREAKING STUDIES IN DM AND CAD Will this change the guidelines? Objectives 1. Discuss current guidelines for prevention of CHD in diabetes. 2. Discuss the FDA Guidance for Industry regarding evaluating
More informationDiabetes 2013: Achieving Goals Through Comprehensive Treatment. Session 2: Individualizing Therapy
Diabetes 2013: Achieving Goals Through Comprehensive Treatment Session 2: Individualizing Therapy Joshua L. Cohen, M.D., F.A.C.P. Professor of Medicine Interim Director, Division of Endocrinology & Metabolism
More informationDiabetes and Cardiovascular Risk Management Denise M. Kolanczyk, PharmD, BCPS-AQ Cardiology
Diabetes and Cardiovascular Risk Management Denise M. Kolanczyk, PharmD, BCPS-AQ Cardiology Disclosures In compliance with the accrediting board policies, the American Diabetes Association requires the
More informationProfessor Rudy Bilous James Cook University Hospital
Professor Rudy Bilous James Cook University Hospital Rate per 100 patient years Rate per 100 patient years 16 Risk of retinopathy progression 16 Risk of developing microalbuminuria 12 12 8 8 4 0 0 5 6
More informationCurrent Clinical Practice Guideline for Diabetes Management
Current Clinical Practice Guideline for Diabetes Management Chaicharn Deerochanawong M.D. Professor of Medicine, i Rangsit Medical University it Diabetes and Endocrinology Unit Department of Medicine Rajavithi
More informationSince 2009, the medical management of
Article Real-wld experience of SGLT2 inhibits: A useful addition to the arsenal of antidiabetes medication. An Irish perspective Patricia Harkin, Ann Fitzpatrick, Ber Lynch, Siobhan Hatton, Ronan Canavan,
More informationNewer Drugs in the Management of Type 2 Diabetes Mellitus
Newer Drugs in the Management of Type 2 Diabetes Mellitus Dr. C. Dinesh M. Naidu Professor of Pharmacology, Kamineni Institute of Medical Sciences, Narketpally. 1 Presentation Outline Introduction Pathogenesis
More informationCV outcomes Studies and Implications for diabetes management. Seraj Abualnaja, MD, FRCPC Consultant Interventional cardiologist DSFH
CV outcomes Studies and Implications for diabetes management Seraj Abualnaja, MD, FRCPC Consultant Interventional cardiologist DSFH Case 49 y female with the following medical problems DM typ2 Hypertension
More informationManagement of Type 2 Diabetes
Management of Type 2 Diabetes Pathophysiology Insulin resistance and relative insulin deficiency/ defective secretion Not immune mediated No evidence of β cell destruction Increased risk with age, obesity
More informationDisclosure. Learning Objectives. Case. Diabetes Update: Incretin Agents in Diabetes-When to Use Them? I have no disclosures to declare
Disclosure Diabetes Update: Incretin Agents in Diabetes-When to Use Them? I have no disclosures to declare Spring Therapeutics Update 2011 CSHP BC Branch Anar Dossa BScPharm Pharm D CDE April 20, 2011
More informationBeyond Basal Insulin: Intensification of Therapy Jennifer D Souza, PharmD, CDE, BC-ADM
Beyond Basal Insulin: Intensification of Therapy Jennifer D Souza, PharmD, CDE, BC-ADM Disclosures Jennifer D Souza has no conflicts of interest to disclose. 2 When Basal Insulin Is Not Enough Learning
More informationSitagliptin: A component of incretin based therapy. Rezvan Salehidoost, M.D., Endocrinologist
Sitagliptin: A component of incretin based therapy Rezvan Salehidoost, M.D., Endocrinologist Agenda Mode of Action Evidences for sitagliptine cardiovascular safety of sitagliptin Ramadan study Impact of
More informationCANVAS Program Independent commentary
CANVAS Program Independent commentary Cliff Bailey Aston University, Birmingham, UK 2017 Disclosures and disclaimers Clifford J Bailey CJB has attended advisory boards, undertaken ad hoc consultancy, received
More informationAchieving Glycemic Control: When Optimized Basal Insulin Isn t Adequate
Achieving Glycemic Control: When Optimized Basal Insulin Isn t Adequate AAFP State Chapter Meeting Faculty Louis Kuritzky MD Clinical Assistant Profess Emeritus Department of Community Health and Family
More informationLearning and Earning with Gateway Professional Education CME/CEU Webinar Series. Diabetes Update July 6, :00pm 1:00pm
Learning and Earning with Gateway Professional Education CME/CEU Webinar Series Diabetes Update July 6, 2017 12:00pm 1:00pm Jennifer Pennock Holst, MD Endocrinology, Diabetes & Metabolism AHN Center for
More informationCurrent evidence on the effect of DPP-4 inhibitor drugs on mortality in type 2 diabetic (T2D) patients: A meta-analysis
Current evidence on the effect of DPP-4 inhibitor drugs on mortality in type 2 diabetic (T2D) patients: A meta-analysis Raja Chakraverty Assistant Professor in Pharmacology Bengal College of Pharmaceutical
More informationClinical Relevance of Blood Pressure Lowering Effect of Modern Antidiabetic Drugs
Clinical Relevance of Blood Pressure Lowering Effect of Modern Antidiabetic Drugs Professor Guntram Schernthaner Medical University of Vienna, Austria guntram.schernthaner@meduniwien.ac.at Agenda Glucose
More informationUpdate on Cardiovascular Outcome Trials in Diabetes Jay S. Skyler, MD, MACP
Update on Cardiovascular Outcome Trials in Diabetes Jay S. Skyler, MD, MACP Division of Endocrinology, Diabetes, and Metabolism and Diabetes Research InsAtute University of Miami Miller School of Medicine
More informationAge-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Obesity (BMI 30 kg/m 2 ) 1994 2000 2009 No Data 26.0% Diabetes 1994 2000 2009
More informationOBJECTIVES 4/7/2014. Diabetes Update Overview of the Diabetes Epidemic in the United States. ISHP Annual Spring Meeting
Diabetes Update 2014 ISHP Annual Spring Meeting Hayley Miller MD April 13, 2014 OBJECTIVES Review diabetes guidelines. Understand diabetes management targets. Discuss current therapeutic strategies. Overview
More informationUpdate on Insulin-based Agents for T2D. Harry Jiménez MD, FACE
Update on Insulin-based Agents for T2D Harry Jiménez MD, FACE Harry Jiménez MD, FACE Has received honorarium as Speaker and/or Consultant for the following pharmaceutical companies: Eli Lilly Merck Boehringer
More informationDiabetes new challenges, new agents, new order
Diabetes new challenges, new agents, new order Ken Earle St Georges University Hospitals NHS Foundation Trust Overview Cardiovascular disease unmet needs Treating evident and residual risk Integrating
More informationGLP-1 (glucagon-like peptide-1) Agonists (Byetta, Bydureon, Tanzeum, Trulicity, Victoza ) Step Therapy and Quantity Limit Criteria Program Summary
OBJECTIVE The intent of the GLP-1 (glucagon-like peptide-1) s (Byetta/exenatide, Bydureon/ exenatide extended-release, Tanzeum/albiglutide, Trulicity/dulaglutide, and Victoza/liraglutide) Step Therapy
More information9/12/2014. Main Pathophysiological Defect in T1DM. Main Pathophysiological Defects in T2DM. Personalizing Diabetes Care: The Alphabet Soup of Options
9/12/2014 Baptist Health South Florida 13th Annual Primary Focus Symposium June 28, 2014 Silvio Inzucchi MD Section of Endocrinology Yale University School of Medicine Half-Century of HTN & T2DM Medications
More informationType 2 Diabetes Mellitus 2011
2011 Michael T. McDermott MD Director, Endocrinology and Diabetes Practice University of Colorado Hospital Michael.mcdermott@ucdenver.edu Diabetes Mellitus Diagnosis 2011 Diabetes Mellitus Fasting Glucose
More informationADVANCE Endpoints. Primary outcome. Secondary outcomes
ADVANCE Trial-NEJM 11,140 type 2 patients with h/o microvascular or macrovascular disease or 1 vascular disease risk factor Control A1c to 6.5% vs standard tx Intensive arm received gliclazide XL 30 to
More informationCURRENT ISSUES IN DIABETES MANAGEMENT
CURRENT ISSUES IN DIABETES MANAGEMENT Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Declaration of full disclosure: No conflict of interest Screening for Diabetes 2011 BMI
More informationNew basal insulins Are they any better? Matthew C. Riddle, MD Professor of Medicine Oregon Health & Science University Keystone Colorado 15 July 2011
New basal insulins Are they any better? Matthew C. Riddle, MD Professor of Medicine Oregon Health & Science University Keystone Colorado 15 July 2011 Presenter Disclosure I have received the following
More informationDiabetic Management of the Cardiac Patient
Diabetic Management of the Cardiac Patient Dr Peter A Senior BMedSci MBBS PhD FRCP(E) Associate Professor, Director Division of Endocrinology, University of Alberta Disclosures Grants/Research Support:
More informationUpdates in Diabetes and Cardiovascular Disease Management: Are You Making the Link?
Updates in Diabetes and Cardiovascular Disease Management: Are You Making the Link? Denise Kolanczyk, PharmD, BCPS AQ Cardiology 1 Erika Hellenbart, PharmD, BCPS 2 Jennifer D Souza, PharmD, CDE, BC ADM
More informationCOPYRIGHT. Treatment of Type 2 Diabetes: What To Do When Treatment with Metformin is Inadequate? Can We Achieve Therapeutic Goals More Safely?
Treatment of Type 2 Diabetes: What To Do When Treatment with Metformin is Inadequate? Can We Achieve Therapeutic Goals More Safely? Martin J. Abrahamson, MD FACP Associate Professor of Medicine, Harvard
More informationUpdate on Therapies for Type 2 Diabetes: Angela D. Mazza, DO July 31, 2015
Update on Therapies for Type 2 Diabetes: 2015 Angela D. Mazza, DO July 31, 2015 Objectives To present the newer available therapies for the management of T2D To discuss the advantages and disadvantages
More informationTherapeutic strategy to reduce Glucagon secretion
Clinical focus on glucagon: α-cell as a companion of β-cell Therapeutic strategy to reduce Glucagon secretion Sunghwan Suh Dong-A University Conflict of interest disclosure None Committee of Scientific
More information