Management of Type 2 Diabetes Mellitus. Heather Corn, MD, MS Endocrinology, Diabetes, and Metabolism

Transcription

1 Management of Type 2 Diabetes Mellitus Heather Corn, MD, MS Endocrinology, Diabetes, and Metabolism

2 Disclosures Working for Intermountain Healthcare Some of the views represented are the opinion of ABIM-certified endocrinologist and not necessarily representative of any evidence-based literature

3 Objectives Review available non-insulin therapies, and discuss patient selection Review available insulins Review appropriate monitoring of blood sugar and goal setting Discuss complications

4 Overview Non-insulin Agents Insulins Monitoring and Goals What about A1c

5 Oral Agents Metformin, metformin XR Still firstline therapy Good CV outcomes What s new(ish)? Can be used in GFR But don t start anew if GFR 30-45

6 Sulfonylureas (second generation) glyburide, glimepiride, glipizide, glipizide XL Nothing new, dirt cheap **hypoglycemia risk** Remember the kinetics

7 Sulfonylureas Sulfonylurea Agents & Combination Products Drug Class Review.

8 Meglitinides Repaglinide and nateglinide (Prandin and Starlix) The forgotten class, niche drug Short-acting insulin secretagogues Good to treat prandial spikes

9 Thiazolidinediones Rosiglitazone and pioglitazone Heart failure, bladder cancer, worsened bone density Would not advise to start, may continue if not at risk for above

10 DPP4 inhibitors Sitagliptin, saxagliptin, linagliptin, alogliptin Decent adjunct therapies Can be used in CKD Dose adjustment required for all but tradjenta Can be costly

11 SGLT2 Inhibitors Invokana- canagliflozin Jardiance- empagliflozin Farxiga- dapagliflozin

12 SGLT2 Inhibitors

13 Cardiovascular Benefits EMPAREG CANVAS Canagliflozin achieved a 14% reduction in the risk of the composite primary endpoint of CV death, nonfatal MI, or nonfatal stroke (Hazard Ratio - HR: 0.86; 95% Confidence Interval - CI: 0.75 to 0.97), demonstrated an improved cardiovascular safety profile compared to placebo (p< for non-inferiority) and superiority compared to placebo (p=0.0158) Each component evenly contributed to this risk reduction, including nonfatal MI by 15% (HR: 0.85; 95% CI: 0.69 to 1.05), CV death by 13% (HR: 0.87; 95% CI: 0.72 to 1.06), and nonfatal stroke by 10% (HR: 0.90; 95% CI: 0.71 to 1.15)

14 Amputations in Canagliflozin

15 GLP-1 agonists (injection)

16 GLP-1 Agonists Exenatide- Byetta Liraglutide- Victoza Albiglutide- Tanzeum Dulaglitide- Trulicity Lixisenatide (not available except in combo) Pramlintide- Symlin

17 GLP-1 Agonists Very expensive- but most with savings cards CV benefit? Marso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med 2016; 375: (LEADER)

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19 Combination Covenience factor Usually expensive Don t forget to evaluate components separately

20 Basal Insulins NPH Glargine (lantus and basaglar) Levemir Toujeo tresiba

21 Bolus Insulins Novolog Humalog Apidra

22 Intermediate Afrezza Regular insulin

23 Monitoring Blood sugar checks as warranted for therapy Diagnostic CGM may be helpful Therapeutic CGM rarely helpful- unless on pump or highly reliable Insulin pump

24 Diagnostic CGM Pt not able to see blood glucose values Helpful for pt who is not self-aware of glucoses

25 Therapeutic CGM

26 Insulin Pumps and Type 2 Diabetes Generally not indicated Can be used for insulin dependent patients

27 A1c Goals Find the right number for Current therapy Patient age and prognosis Hypogylcemia risk Complication status

28 Complications Retinopathy Neuropathy Renal Cardiovascular/macrovascular

29 Retinopathy Annual dilated eye exam Begin at diagnosis

30 Neuropathy Annual foot exam Need at least 2 of the 4 components Don t assume it must be diabetic neuropathy

31 Renal Annual screening microalbuminuria Confirm with repeat ACEi or ARB

32 Cardiovascular Statins for everyone Still check lipid panel Remember the CV outcomes aside from CAD (heart failure, A-fib)

33 Thank you for listening!