Disclosures. Objectives 11/2/2015. Type 2 Diabetes Mellitus: Medication Update. Diabetes Recommendations. Main Pathophysiological Defects in T2DM

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1 Type 2 Diabetes Mellitus: Medication Update Which One Should the NP Use? Iowa Nurse Practitioner Society Dr. Dixie Harms, DNP, ARNP, FNP-C, BC-ADM, FAANP November 2015 Disclosures Speaker s Bureau Novo Ndisk Objectives Diabetes Recommendations After completion of this class, the NP should be able to: Review the pathophysiology of diabetes. Describe pharmacotherapeutics f patients with diabetes. Apply knowledge of pharmacotherapeutics to selected case studies ADA Recommendations Published annually in January supplement of Diabetes Care Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient- Centered Approach Update to a Position Statement of the American Diabetes Association and the European Association f the Study of Diabetes Published: Diabetes Care 2015;38: American Association Of Clinical Endocrinologists And American College Of Endocrinology Clinical Practice Guidelines F Developing A Diabetes Mellitus Comprehensive Care Plan 2015 Obesity (BMI 30 kg/m 2 ) 1994 Diabetes Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults No Data <14.0% 14.0% 17.9% 18.0% 21.9% 22.0% 25.9% > 26.0% Main Pathophysiological Defects in T2DM incretin effect gut carbohydrate delivery & absption - pancreatic insulin secretion pancreatic glucagon secretion HYPERGLYCEMIA? No Data <4.5% 4.5% 5.9% 6.0% 7.4% 7.5% 8.9% >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at hepatic glucose production - peripheral glucose uptake Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine

2 Glycemic Management of Type 2 Diabetes Therapeutic Lifestyle Change Incretin secretion, action in the natural histy of type 2 diabetes ENDOCRINE TODAY March Components of Therapeutic Lifestyle Change AACE Recommendations: Therapeutic Lifestyle Changes Healthful eating Sufficient physical activity Sufficient sleep Avoidance of tobacco products Limited alcohol consumption Stress reduction Parameter Weight loss (f overweight and obese patients) Physical activity Diet Treatment Goal Reduce by 5% to 10% 150 min/week of moderate-intensity exercise (eg, brisk walking) plus flexibility and strength training Eat regular meals and snacks; avoid fasting to lose weight Consume plant-based diet ( in fiber, low calies/glycemic index, and in phytochemicals/antioxidants) Understand Nutrition Facts Label infmation Incpate beliefs and culture into discussions Use mild cooking techniques instead of -heat cooking Keep physician-patient discussions infmal 9 10 AACE Recommendations: Healthful Eating AACE Recommendations: Medical Nutritional Therapy Carbohydrate Fat Protein Micronutrients Specify healthful carbohydrates (fresh fruits and vegetables, legumes, whole grains); target 7-10 servings per day Preferentially consume lower-glycemic index foods (glycemic index sce <55 out of 100: multigrain bread, pumpernickel bread, whole oats, legumes, apple, lentils, chickpeas, mango, yams, brown rice) Specify healthful fats (low mercury/contaminant-containing nuts, avocado, certain plant oils, fish) Limit saturated fats (butter, fatty red meats, tropical plant oils, fast foods) and trans fat; choose fat-free low-fat dairy products Consume protein in foods with low saturated fats (fish, egg whites, beans); there is no need to avoid animal protein Avoid limit processed meats Routine supplementation is not necessary; a healthful eating meal plan can generally provide sufficient micronutrients Chromium; vanadium; magnesium; vitamins A, C, and E; and CoQ10 are not recommended f glycemic control Vitamin supplements should be recommended to patients at risk of insufficiency deficiency Consistency in day-to-day carbohydrate intake Carb counting Limitation of sucrose-containing -glycemic index foods Adequate protein intake Heart-healthy diets Weight management Exercise Self-moniting blood glucose

3 Glycemic Management of Type 2 Diabetes Antihyperglycemic Therapy Principles of the AACE/ACE Type 2 Diabetes Algithm Glucose Targets Ongoing lifestyle optimization essential Requires suppt from full diabetes team Set A1C target based on individual patient characteristics and risk 6.5% optimal if it can be achieved safely Targets may change over time Glucose moniting essential to evaluating therapy effectiveness FPG and PPG regularly monited by patient with SMBG A1C and SMBG recds monited by clinician 13 FPG, fasting plasma glucose; PPG, postprandial glucose; SMBG, self-moniting of blood glucose. 14 Principles of the AACE/ACE Type 2 Diabetes Algithm Choose medications based on individual patient attributes Minimize risk of hypoglycemia Minimize risk of weight gain Combine agents with complimentary mechanisms of action f optimal glycemic control Priitize safety and efficacy over medication cost Medication cost small ption of total cost of diabetes Risk of adverse effects considered part of cost of medication Antihyperglycemic Medications Evaluate treatment efficacy every 3 months A1C, FPG, and PPG data Hypoglycemia Other adverse events (weight gain; fluid retention; hepatic, renal, cardiac disease) Combidities and complications Concomitant drugs Psychosocial facts affecting patient care ADA/EASD DM2 Treatment Algithm Monotherapy Dual therapy Triple therapy Efficacy * Hypo risk Weight Side effects Costs Efficacy * Hypo risk Weight Side effects Costs Healthy eating, weight control, increased physical activity & diabetes education Metfmin 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 moderate risk gain hypoglycemia low Metfmin Sulfonylurea TZD DPP-4-i SGLT2-i Metfmin Thiazolidinedione low risk gain edema, HF, fxs low Metfmin Thiazolidinedione SU DPP-4-i SGLT2-i Metfmin DPP-4 inhibit intermediate low risk neutral rare Metfmin DPP-4 Inhibit SU TZD SGLT2-i Metfmin SGLT2 inhibit intermediate low risk loss GU, dehydration SGLT-2 Inhibit Metfmin SU TZD DPP-4-i Metfmin GLP-1 recept agonist low risk loss GI 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): Metfmin GLP-1 recept agonist SU TZD Insulin Metfmin Insulin (basal) est risk gain hypoglycemia variable Metfmin Insulin (basal) TZD DPP-4-i SGLT2-i Oral Agents f DM2 Class Primary Mechanism of Action Agent(s) Available as Delay carbohydrate absption from Acarbose Precose generic -Glucosidase inhibits intestine Miglitol Glyset Decrease glucagon secretion Amylin analogue Slow gastric emptying Pramlintide Symlin Increase satiety Decrease hepatic glucose production Biguanide Metfmin Glucophage generic Increase glucose uptake in muscle Decrease hepatic glucose production? Bile acid sequestrant Colesevelam WelChol Increase incretin levels? Alogliptin Nesina Increase glucose-dependent insulin Linagliptin Tradjenta DPP-4 inhibits secretion Saxagliptin Onglyza Decrease glucagon secretion Sitagliptin Januvia Combination injectable therapy GLP-1-RA Insulin GLP-1-RA Insulin Basal Insulin Insulin Insulin GLP-1-RA 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 Mealtime Insulin GLP-1-RA Inzucchi SE, et al. Diabetes Care. 2012;35: Dopamine-2 agonist Activates dopaminergic recepts Bromocriptine Cycloset Nateglinide Starlix generic Glinides Increase insulin secretion Repaglinide Prandin DPP-4, dipeptidyl peptidase; HGP, hepatic glucose production. 3

4 Oral Agents f DM2 Effects of Agents Available f DM2 Class Primary Mechanism of Action Agent(s) Available as SGLT2 inhibits Increase urinary excretion of glucose Sulfonylureas Increase insulin secretion Thiazolidinediones Increase glucose uptake in muscle and fat Decrease HGP Canagliflozin Dapagliflozin Empagliflozin Glimepiride Glipizide Glyburide Pioglitazone Rosiglitazone Invokana Farxiga Jardiance Amaryl generic Glucotrol generic Dia eta, Glynase, Micronase, generic Actos Avandia FPG lowering PPG lowering GLP-1, glucagon-like peptide; HGP, hepatic glucose production; SGLT2, sodium glucose cotranspter 2. AGI = -glucosidase inhibits; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibits; FPG = fasting plasma glucose; GLP1RA = glucagon-like peptide 1 recept agonists; Met = metfmin; Mod = moderate; PPG = postprandial glucose; SGLT2I = sodium-glucose cotranspter 2 inhibits; SU = sulfonylureas; TZD = thiazolidinediones. *Mild: albiglutide and exenatide; moderate: dulaglutide, exenatide extended release, and liraglutide. 20 Continued on next slide Effects of Agents Available f DM2 Effects of Agents Available f T2D Met GLP1RA SGLT2I DPP4I TZD AGI Coles BCR-QR SU/ Glinide Insulin Pram NAFLD benefit SU/ Met GLP1RA SGLT2I DPP4I TZD AGI Coles BCR-QR Insulin Pram Glinide Mild Mild Neutral Neutral Mod Neutral Neutral Neutral Neutral Neutral Neutral Contraindicated contra- GU Exenatide Renal impairment/ GU in stage indicated infection 3B, 4, 5 CrCl <30 risk CKD mg/ml Dose Increased adjustment wsen hypo- hypo- May Increased risks of Neutral Neutral Neutral Neutral (except fluid glycemia glycemia linagliptin) retention risk and fluid retention SU/ Met GLP1RA SGLT2I DPP4I TZD AGI Coles BCR-QR Insulin Pram Glinide Mod to SU: mod marked Mild to Mod Mod Mild Mod Neutral Mild Neutral Glinide: (basal Mild mod* mild insulin premixed) Mod to marked (sht/ Mod to Mod to Mild Mild Mod Mild Mod Mild Mild Mod rapidacting marked marked insulin premixed) SU: mod to severe Hypoglycemia Mod to Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Glinide: Neutral severe* mild to mod Weight Slight loss Loss Loss Neutral Gain Neutral Neutral Neutral Gain Gain Loss GI adverse Mod Mod* Neutral Neutral* Neutral Mod Mild Mod Neutral Neutral Mod effects CHF Neutral Neutral Neutral Neutral Mod Neutral Neutral Neutral Neutral Neutral Neutral CVD Possible Neutral Neutral Neutral Neutral Neutral Neutral Safe? Neutral Neutral benefit Mod bone Bone Neutral Neutral Bone loss Neutral Neutral Neutral Neutral Neutral Neutral Neutral loss AGI = -glucosidase inhibits; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibits; GLP1RA = glucagon-like peptide 1 recept agonists; Met = metfmin; Mod = moderate; NAFLD, nonalcoholic fatty liver disease; SGLT2I = sodium-glucose cotranspter 2 inhibits; SU = sulfonylureas; TZD = thiazolidinediones. *Especially with sht/ rapid-acting premixed. AGI = -glucosidase inhibits; BCR-QR = bromocriptine quick release; Coles = colesevelam; CHF = congestive heart failure; CVD = cardiovascular disease; DPP4I = dipeptidyl peptidase 4 inhibits; GI = gastrointestinal; GLP1RA = glucagon-like peptide 1 recept agonists; GU = genitourinary; Met = metfmin; Mod = moderate; SGLT2I = sodium-glucose cotranspter 2 inhibits; SU = sulfonylureas; TZD = thiazolidinediones. *Caution in labeling about pancreatitis. Caution: possibly increased CHF hospitalization risk seen in CV safety trial. Fixed-Dose Combination Antihyperglycemic Agents Class Added Agent Available as DPP-4 inhibit SGLT2 inhibit Linagliptin empagliflozin Glyxambi Metfmin DPP-4 inhibit Alogliptin Linagliptin Saxagliptin Sitagliptin Kazano Jentadueto Kombilyze XR Metfmin glinide Repaglinide Prandimet Metfmin SGLT2 inhibit Metfmin sulfonylurea Metfmin thiazolidinedione Canagliflozin Dapagliflozin Glipizide Glyburide Pioglitazone Rosiglitazone* Janumet, Janumet XR Invokamet Xigduo XR Thiazolidinedione DPP-4 inhibit Pioglitazone alogliptin Oseni Thiazolidinedione sulfonylurea Pioglitazone Rosiglitazone Metaglip and generic Glucovance and generic ACTOplus Met Avandamet Duetact Avandaryl

5 Mrs. D, 90-year old Type 2 DM Case Study #1 Harms, 2012 Mrs. D has been diagnosed with diabetes f 10 years and comes to the clinic f a recheck. Combidities: HTN, hyperlipidemia Current meds: simvastatin 20 mg. daily, metoprolol 25 mg. BID, benazepril 10 mg. daily Last A1c 6.6%, FBG 120. Home glucose measurements repted as Lives in her own apartment, walks around her home, goes to church and once a week dinner with daughter. What should the NP do? All photos in this presentation are the sole property of Dixie Harms, ARNP SC, 49 year old female Case Study #2 October 2013 Glucose 298 A1C 12.9% fructoasamine 439 (nmal ) fasting insulin level 9 (nmal 2-27) C-peptide 2.2 (nmal 1.5 5) WEIGHT 191 LBS. BMI 30 Current meds NONE SC, 49-year old female January 2014 FBG 114 mg/dl A1c%--6.1% Total cholesterol 153 Trigs 63 HDL 44 LDL 96 Current Medication Metfmin 500 mg. 2 tablets BID WEIGHT 183 lbs SC, 49-year old female August 2014 FBG 130 A1c 6.0% Total cholesterol 183 Triglycerides 168 HDL 45 LDL 104 Current Medications Metfmin 500 mg. 2 tablets daily, lisinopril 5 mg. daily WEIGHT 175 lbs/bmi

6 SC, 49-year old female February 2015 Current medications Metfmin 500 mg. 2 tablets po BID, Lisinopril 5 mg. po QDAY, levothyroxine WEIGHT 184 lbs BMI 28.8 A1c 6.0% FBG 112 mg/dl Case Study #3 BH 62 year old female BH 62-year old female February 2012 WEIGHT 277 lb, BMI 46 A1C 6.0 FBG 101 mg/dl LIPIDS TC 186, trigs 105, HDL 50, LDL--115 MEDS Citalopram, ASA, sitagliptin/metfmin (Janumet) 50/500 one tablet po BID, Lisinopril/HCTZ 5/25 qday, fenofibrate 134 mg daily, levothyroxine Diabetes Meds Metfmin 1000 mg. BID, sitagliptin (Januvia) 100 mg. daily, pioglitazone (Actos) 45 mg. daily, levothyroxine A1c range , FBG 130s 180s Weight Maximum 285 lbs. Did not exercise Co-mbities HTN, hyperlipidemia, hypothyroidism, hypertriglyceridemia, depression BH 62 year old female May 2012 Laparoscopic gastric sleeve June 2012 Patient in f labs only WEIGHT A1C 5.3 FBG 88 mg/dl LIPIDS TC 191, TRIGS 102, HDL 54, LDL 115 MEDS none August 2012 Recheck WEIGHT 228 lbs, BMI 38 Meds Levothyroxine No labs done BH 62 year old female June 2013 WEIGHT 209 lbs, BMI 34.8 A1C 5.3% FBG 88 mg/dl LIPIDS TC 191, trigs 102, HDL 54, LDL 117 MEDS Levothyroxine 6

7 BH 62 year old female October 2013 WEIGHT 215 lbs, BMI 35 A1C 5.4% FBG 90 mg/dl LIPIDS TC 185, trigs 98, HDL 55, LDL 107 MEDS Levothyroxine Sodium-Glucose Transpter 2 (SGLT2) Examples Canagliflozin (Invokana) mg daily Dapagliflozin (Farxiga) 5-10 mg daily Empagliflozin (Jardiance) mg q am Target Organ: Kidney Actions: Inhibits SGLT2, reducing glucose reabsption and increasing urinary glucose excretion Side Effects: hyperkalemia, genital mycotic infection, increased cholesterol, increased magnesium, hypoglycemia, UTI, increased urination, increased hemoglobin, vulvovaginal pruritus, thirst, hypotension, constipation, fatigue, nausea, increased creatinine Contraindications: Type 1 DM, DKA, dehydration, hypotension, elderly hyperkalemia, increased creatinineclearance A1c Reduction Non-insulin Injectable Medications f DM2 Class Primary Mechanism of Action Agent(s) Available as GLP-1 recept agonists Increase glucose-dependent insulin secretion Albiglutide Dulaglutide Decrease glucagon secretion Exenatide Slow gastric emptying Exenatide XR Increase satiety Liraglutide Tanzeum Trulicity Byetta Bydureon Victoza GLP-1, glucagon-like peptide; HGP, hepatic glucose production; SGLT2, sodium glucose cotranspter 2. Incretin Mimetics Examples Exanitide (Byetta) 5 10 mcg BID subq Liraglutide (Victoza) mg q day subq Exanitide (Bydureon) 2 mg subq q week Albiglutide (Tanzeum) 30 mg subq weekly Dulaglitide (Trulicity) mg subq weekly Target Organ: pancreas Side Effects: hypoglycemia, severe (with sulfonylurea), pancreatitis, renal failure, nausea, hypoglycemia (with sulfonylurea), vomiting, jitteriness, dizziness, headache, dyspepsia, decreased appetite, GERD Contraindications: Type 1 DM, DKA, gastroparesis, GI disease, pancreatitis, severe renal impairment Black box warning: Thyroid C-cell tum risk Case Study #4 7

8 RG, 56-year old male RG, 56-year old male Diagnosed with diabetes in 2010 Salesman spends great deal of time on the road, eats in restaurants, no regular exercise Has been on metfmin 500 mg BID since 2010 Diabetic education September 2011 October 2011 A1c-7.1% January 2012 A1c 6.2% August 2012 A1c 6.0% April 2013 A1c 6.60% December 2013 A1c 7.5% FBG--141 WEIGHT/BMI 284/37 MEDS metfmin 500 mg. BID RG, 56-year old male April 2014 A1c 8.3% FBG 187 WEIGHT/BMI 285/37 Lipids TC 196, trigs 193, HDL 42, LDL--117 Meds Metfmin 500 mg. 2 tabs BID, benazepril 10 mg. daily Case Study #5 KT, 32 YEARS OLD Female with DM2 Comes in f diabetic education/med adjustment Histy diabetes x 2 years, no insurance until now Limiting carbs to grams per meal No exercise Labs: TC 175, HDL 28, LDL, 98, trigylcerides 198, Chol/HDL ratio 5.5 FBG 193, A1c 8.9% Meds: Glipizide 5 mg. daily, Sitagliptin (Januvia) 10 mg. daily Glargine (Lantus) 80 units subq daily Lisinopril 5 mg. daily WEIGHT 358 POUNDS. What should the NP do? Case Study #6 8

9 Mr. T is a 48-year old male who has had diabetes f 5 years. He is very active in school activities football team official, school bus driver. Combidities: Obesity (BMI 45), hyperlipidemia, hypertryglyceridemia Current medications: glimepiride 8 mg. daily, metfmin 1000 mg. BID, simvastatin 40 mg. daily, pioglitazone 30 mg. daily, lisinopril 20 mg. daily Last medical exam me than 6 months ago Weight 345 pounds Recent labs: FBG 258, A1C 11.4%, TC 350, Trigs 550, HDL 32, LDL?., microalbuminuria Patient resistant to take medication. He states that he can t change his diet because he is always hungry and never feels full. What should the NP do? Continue ACE/ARB Increase statin/add fenofibrate niacin Diabetes medications? Insulin Incretin mimetic Therapeutic lifestyle changes Discussed diet SMBG BID Exercise Recheck 3 weeks Three weeks later Patient repts Diet splitting meals with wife when eating out. Adds that he can t eat as much as usual because he feels full Exercise walking every evening Meds taking medications regularly, denies problems with injection of liraglutide Glucoses Checking BID, repts FBG have dropped from 250s to 150s on 1.2 mg daily Feeling good with me energy, vision clearing 9 pound weight loss 3 months later FBG 125, A1C 7.5%, TC 201, Trigs 158, HDL 35, LDL 114, negative microalbuminuria BP 124/76, weight down 14 pounds Taking liraglultide 1.8 mg daily Appetite fairly well controlled, has occasional breakthroughs but still watching diet fair Other meds: simvastatin 40 mg. daily, pioglitazone 30 mg. daily, lisinopril 20 mg. daily, metfmin 1000 mg. BID What should the NP do? January 2014 (pt hasn t had recheck >9 months) Wife going thru chemo f breast cancer Weight 356 pounds Not exercising watching diet A1c 9.8%, FBG 180 mg/dl Meds: liraglutide 1.8 mg daily, simvastatin 40 mg. daily, pioglitazone 45 mg. daily, metfmin 1000 mg. BID, lisinopril 20 mg. daily November 2014 Weight 336 pounds Now exercising & watching diet A1c 7.8%, FBG 170 mg/dl Meds: liraglutide 1.8 mg daily, simvastatin 40 mg. daily, pioglitazone 45 mg. daily, metfmin 1000 mg. BID, lisinopril 20 mg. daily, canagliflozin (Invokana) 100 mg. daily 9

10 Common Principles in AACE/ACE and ADA/EASD T2D Treatment Algithms ADA/EASD T2D Treatment Algithm: Sequential Insulin Strategies # Injections 1 Basal Insulin (usually with metfmin /- other non-insulin agent) Complexity low Start: 10U/day U/kg/day Adjust: 10-15% 2-4 U once-twice weekly to reach FBG target. F hypo: Determine & address cause; ê dose by 4 units 10-20%. Individualize glycemic goals based on patient characteristics Promptly intensify antihyperglycemic therapy to maintain blood glucose at individual targets Combination therapy necessary f most patients Base choice of agent(s) on individual patient medical histy, behavis and risk facts, ethno-cultural background, and environment Insulin eventually necessary f many patients SMBG vital f day-to-day management of blood sugar All patients using insulin Many patients not using insulin 2 3 If not controlled after FBG target is reached ( if dose > 0.5 U/kg/day), treat PPG excursions with meal-time insulin. (Consider initial Add 1 rapid insulin* injections GLP-1-RA Change to befe largest meal trial.) premixed insulin* twice daily Start: 4U, 0.1 U/kg, 10% basal dose. If Start: Divide current basal dose into 2/3 AM, A1c<8%, consider ê basal by same amount. 1/3 PM 1/2 AM, 1/2 PM. Adjust: é dose by 1-2 U 10-15% oncetwice weekly until SMBG target reached. twice weekly until SMBG target reached. Adjust: é dose by 1-2 U 10-15% once- F hypo: Determine and address cause; F hypo: Determine and address cause; ê cresponding dose by 2-4 U 10-20%. ê cresponding dose by 2-4 U 10-20%. If not If not controlled, Add 2 rapid insulin* injections controlled, consider basalbolusbolus. befe meals ('basal-bolus consider basal- ) Start: 4U, 0.1 U/kg, 10% basal dose/meal. If A1c<8%, consider ê basal by same amount. Adjust: é dose by 1-2 U 10-15% once-twice weekly to achieve SMBG target. F hypo: Determine and address cause; ê cresponding dose by 2-4 U 10-20%. mod. 55 Flexibility me flexible less flexible 56 Insulin Therapy Generic name Brand name Onset of Action Duration Basal insulins (long-acting) Glargine detemir U300 glargine NPH Degludec U-100 & U-200 Lantus Levemir Toujeo NPH Tresiba 1 hour 1 hour 6 hours minutes 24 hours 24 hours 36 hours hours 42 hours Rapid-acting insulins Lispro Humalog aspart Novolog 15 minutes 3 to 5 hours glulisine Apidra Sht-acting Regular Regular 30 to 60 minutes 5 to 8 hours Pre-mixed insulin 75/25, 70/30 50/50 Humalog Mix 75/25, Novolog 75/25 10 to 15 minutes 75/25 10 to 16 hours 70% NPH/30% regular 70/30, Humalog Mix 50/50, 70/30 5 to 15 minutes 70/30 10 to 16 hours Novolin 70/30 Humulin 70/30 50/50 10 to 15 minutes 50/50 10 to 16 hours 70% NPH/30% regular 30 to 70% NPH/30% regular 10 to 60 minutes 16 hours Rapid-acting inhaled insulin Afrezza Afrezza 10 to 20 minutes 3 hours 57 Mr. G, 78-year male with Type 2 DM Case Study #7 Mr. G has had diabetes f over 10 years Current meds: metfmin 500 mg. BID, pioglizatone 30 mg. daily, glimepiride 8 mg daily, benazepril 10 mg. daily, simvastatin 40 mg. daily Last A1c 9.6%, FBG 216. Related signs/symptoms: increasing swelling in lower extremities, weight gain, elevated creatinine Exercise: None except yardwk Diet: No special diet What should the NP do? 10

11 Mr. G, 78-year male with Type 2 DM Ms. N, 62-year old DM2 Discontinue metfmin Discontinue pioglitazone Continue glimepiride, benazepril and simvastatin Encourage TLC Start glargine 10 units subq daily SMBG BID Follow-up labs in 3 months Comes in f routine diabetes check after last check 8 months ago A1c 10.2%, FBG 216 this am SMBG not routinely Not watching diet, no exercise, not always compliant with medications. Currently on glargine 80 units BID Taking units lispro with meals (??) Also on ACE, fenofibrate, statin Intolerant of metfmin (all types) Thank you. Any Questions? Thank you. 11