Diabetes treatment by the algorithm Joseph Dawley, M.D. Southwest Oklahoma Family Medicine Residency Oklahoma University Health Sciences Center Clinical Assistant Professor Objectives By the end of this presentation you should be able to: Understand the principles of Type 2 diabetes management Recognize lifestyle management strategies Know the goals for glycemic control Use the glycemic control algorithm Use the algorithm for adding/intensifying insulin Utilize the pre-diabetes algorithm 1
Disclosure I have nothing to disclose. Epidemiology Diabetes affects 8.3% of the U.S. population 25% of these have not been diagnosed 90% of these cases are Type 2 diabetes Another 35% of U.S. adults have pre-diabetes Up to 70% of people with pre-diabetes develop Type 2 diabetes 2
Epidemiology Non-Hispanic whites : 7.1% Asian Americans: 8.4% Hispanic Americans: 11.8% African Americans (ie, non-hispanic blacks): 12.6% Native Americans: 16.1% Morbidity and Mortality Relative to people without diabetes: Risk of death from any cause: 2x Risk of death from cardiovascular disease: 2-4x Risk of stroke: 2-4x 3
Morbidity and Mortality Diabetes is the: 7th leading cause of death according to death certificate data Leading cause of blindness among adults Leading cause of renal failure More than 60% of non-traumatic lower limb amputations are among diabetics Diabetes doubles the risk of periodontal disease Costs Direct costs: $116 billion Indirect costs: $56 billion 4
Principles for the treatment of Type 2 Diabetes 1.Lifestyle therapy 2.Weight loss Behavioral interventions Weight loss medications 3.A1C target 4.Glycemic control targets Principles for the treatment of Type 2 Diabetes 5.Choice of therapy 6.Minimizing risk of hypoglycemia is a priority 7.Minimizing risk of weight gain is a priority 8.Total cost of care 9.Stratified starting point based on A1c 5
Principles for the treatment of Type 2 Diabetes 10.Combination therapy is usually required 11.Comprehensive therapy includes BP and lipid control 12.Therapy must be evaluated frequently 13.Therapeutic regimen should be as simple as possible 14.This algorithm includes every FDA-approved class of medications for diabetes Lifestyle modifications and weight loss Nutrition; initial steps Maintain optimal weight Calorie restriction Plant-based diet; high in polyunsaturated and monounsaturated fatty acids 6
Lifestyle modifications and weight loss Nutrition; increased intensity of therapy Limit saturated fatty acids Avoid trans fatty acids Nutrition; highest intensity of therapy Structured counseling Meal replacement Lifestyle modifications and weight loss Physical activity; initial steps 150 mins of moderate exertion per week Strength training Increase as tolerated 7
Lifestyle modifications and weight loss Physical activity; increased intensity of therapy Structured program Wearable tech Physical activity; highest intensity of therapy Medical evaluation/clearance Medical supervision Lifestyle modifications and weight loss Sleep; initial steps Basic sleep hygiene ~7 hours per night Sleep; increased intensity of therapy Screening for OSA; Home sleep study Sleep; highest intensity of therapy Referral to a sleep lab 8
Lifestyle modifications and weight loss Behavioral support; initial steps Community engagement Alcohol moderation Behavioral support; increased intensity of therapy Discuss mood at office appointment Behavioral support; highest intensity of therapy Formal behavioral therapy/psychiatry referral Lifestyle modifications and weight loss Smoking cessation; initial steps No tobacco products Smoking cessation; increased intensity of therapy Nicotine replacement Smoking cessation; highest intensity of therapy Structured program 9
Lifestyle modifications and weight loss A1c and glycemic goals 10
Choosing Wisely Avoid using medications other than metformin to achieve hemoglobin A1c<7.5% in most older adults; moderate control is generally better. American Geriatrics Society. www.choosingwisely.org Choosing Wisely Avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia. Endocrine Society. www.choosingwisely.org 11
A1c < 7.5 The order of medications suggests a hierarchy of usage. The length of the green (or yellow) line represents the strength of recommendation. 12
A1c 7.5 Or no improvement within 3 months Emphasis is still on metformin if tolerable Other 1st line agents if not A1c 7.5 With no improvement from dual therapy at 3 months 13
A1c > 9 All depends on symptoms Remember to keep your eye on cost of care 14
Starting basal insulin Glycemic goal is <7% for most patients Pre-meal blood glucose <110mg/dl without hypoglycemia Intensifying therapy You may add a GLP-1 RA or an SGLT-2i or DPP-4i 15
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Prediabetes algorithm This should also be an important part of diabetes management. ASCVD Risk Factors ABCDE mnemonic 17
ASCVD Risk Factors High risk: DM with age < 40 and no other comorbidities Very high risk: DM, age >40 or other major ASCVD risks Extreme risk: DM with established clinical cardiovascular disease Prediabetes algorithm If we can treat early we may be able to defray some of the costs. 18
Summary Follow the algorithm, but individualize treatment to your patient Cost of treatment, compliance Maximize your weight loss strategies Manage hypertension, and hyperlipidemia The algorithm can help guide shared decision making DOWNLOAD THE APP! AACE/ACE Comprehensive Type 2 Diabetes Management Alg This algorithm for the comprehensive management of persons This app is available on itunes and Google Play 19
Thank you. 1. Endocr Pract.2017,doi:10.4158/EP161682.CS 2. Handelsman Y, Bloomgarden ZT, Grunberger G, et al. American Association of Clinical Endocrinologists and American College of Endocrinology: clinical practice guidelines for developing a diabetes mellitus comprehensive care plan--2015. Endocr Pract. 2015;21:1-87. 3. Balducci S, Alessi E, Cardelli P, Cavallo S, Fallucca F, Pugliese G. Effects of different modes of exercise training on glucose control and risk factors for complications in type 2 diabetic patients: a meta-analysis: response to Snowling and Hopkins. Diabetes Care. 2007;30:e25; author reply e26. 4. Wadden TA, West DS, Neiberg RH, et al. One-year weight losses in the Look AHEAD study: factors associated with success. Obesity (Silver Spring). 2009;17:713-722. 5. Diabetes Prevention Program Research Group, Ratner R, Goldberg R, et al. Impact of intensive lifestyle and metformin therapy on cardiovascular disease risk factors in the diabetes prevention program. Diabetes care. 2005;28:888-894. 6. Keogh JB, Clifton PM. Meal replacements for weight loss in type 2 diabetes in a community setting. J Nutr Metab. 2012;2012:918571. 7. American Diabetes Association. Standards of medical care in diabetes 2014. Diabetes Care. 2014;37(suppl 1):S14 S80. 8. George C, Bruijn L, Will K, Howard-Thompson A, Management of Blood Glucose with Noninsulin Therapies in Type 2 Diabetes. Am Fam Physician. 2015 Jul 1;92(1):27-34. 20