Management of Type 2 Diabetes Mellitus Heather Corn, MD, MS Endocrinology, Diabetes, and Metabolism
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
Objectives Review available non-insulin therapies, and discuss patient selection Review available insulins Review appropriate monitoring of blood sugar and goal setting Discuss complications
Overview Non-insulin Agents Insulins Monitoring and Goals What about A1c
Oral Agents Metformin, metformin XR Still firstline therapy Good CV outcomes What s new(ish)? Can be used in GFR 30-60 But don t start anew if GFR 30-45
Sulfonylureas (second generation) glyburide, glimepiride, glipizide, glipizide XL Nothing new, dirt cheap **hypoglycemia risk** Remember the kinetics
Sulfonylureas Sulfonylurea Agents & Combination Products Drug Class Review. http://www.health.utah.gov/pharmacy/ptcommittee
Meglitinides Repaglinide and nateglinide (Prandin and Starlix) The forgotten class, niche drug Short-acting insulin secretagogues Good to treat prandial spikes
Thiazolidinediones Rosiglitazone and pioglitazone Heart failure, bladder cancer, worsened bone density Would not advise to start, may continue if not at risk for above
DPP4 inhibitors Sitagliptin, saxagliptin, linagliptin, alogliptin Decent adjunct therapies Can be used in CKD Dose adjustment required for all but tradjenta Can be costly
SGLT2 Inhibitors Invokana- canagliflozin Jardiance- empagliflozin Farxiga- dapagliflozin
SGLT2 Inhibitors
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<0.0001 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)
Amputations in Canagliflozin
GLP-1 agonists (injection)
GLP-1 Agonists Exenatide- Byetta Liraglutide- Victoza Albiglutide- Tanzeum Dulaglitide- Trulicity Lixisenatide (not available except in combo) Pramlintide- Symlin
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; 375:311-322. (LEADER)
Combination Covenience factor Usually expensive Don t forget to evaluate components separately
Basal Insulins NPH Glargine (lantus and basaglar) Levemir Toujeo tresiba
Bolus Insulins Novolog Humalog Apidra
Intermediate Afrezza Regular insulin
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
Diagnostic CGM Pt not able to see blood glucose values Helpful for pt who is not self-aware of glucoses
Therapeutic CGM
Insulin Pumps and Type 2 Diabetes Generally not indicated Can be used for insulin dependent patients
A1c Goals Find the right number for Current therapy Patient age and prognosis Hypogylcemia risk Complication status
Complications Retinopathy Neuropathy Renal Cardiovascular/macrovascular
Retinopathy Annual dilated eye exam Begin at diagnosis
Neuropathy Annual foot exam Need at least 2 of the 4 components Don t assume it must be diabetic neuropathy
Renal Annual screening microalbuminuria Confirm with repeat ACEi or ARB
Cardiovascular Statins for everyone Still check lipid panel Remember the CV outcomes aside from CAD (heart failure, A-fib)
Thank you for listening!