Application of the Diabetes Algorithm to a Patient Apply knowledge gained from this activity to improve disease management and outcomes for patients with T2DM and obesity Note: The cases in this deck represent real patients and are designed to show how different physicians approach patient management. This information serves as a springboard for discussion, and does not imply AACE s endorsement of any specific treatment approach.
Case #3 John John is a 62 year-old African American man, with type 2 diabetes, diagnosed 10 years ago He works as a electrician and has irregular meal times He tries to avoid sweets He smokes 1 pack a day and drinks 1-2 beers a night He is 3 months late on his 6-month checkup He has a history of CAD, depression, and hypertension CAD = coronary artery disease
Case #3, John Diabetes Checkup John reports feeling anxious sometimes for no clear reason; at these times, his hands become clammy and tremble and he becomes sweaty Height: 6 2, Weight: 234 lbs, BMI: 30 kg/m 2 BP 184/100 mm Hg, HR 90 bpm ROS negative except poor glucose control BMI = body mass Index; BP = blood pressure; HR = heart rate; lb = pounds; ROS = review of systems
A1C = glycated hemoglobin; ASA = aspirin; BID = twice daily; BMI = body mass Index; BP = blood pressure; CGM = continuous glucose monitoring; egrf = estimated glomerular Current labs: - A1C: 9.4%; Case #3, John Diabetes Checkup - Home blood glucose ranges: FPG 180-200 mg/dl; premeal 200-250 mg/dl Serum creatinine: 2.3 mg/dl, LFTs normal, urine albumin: 92 mg/g creatinine, TC 153 mg/dl, LDL 70 mg/dl, HDL 41 mg/dl, TG 225 mg/dl egfr 44 ml/min Current medications: Metformin, 1000 mg BID Glimepiride, 4 mg QD Sitagliptin, 100 mg QD ASA, 81 mg QD Benazepril, 40 mg QD Simvastatin, 40 mg QD Escitalopram, 10 mg QD
What do John s symptoms of anxiety, trembling, sweating, and clammy hands suggest? (a) (b) (c) (d) Hyperglycemia Hypoglycemia Hypothyroidism GERD? GERD = gastroesophageal reflux disease
H.Rettinger, M.D. Symptoms of Hypoglycemia Are Like Falling in Love for the First You get nervous and jittery You get hot and sweaty Time! Your heart starts beating rapidly And last you want to say something intelligent, but only gibberish comes out!
John s Self-monitoring Blood Glucose Download Frequent episodes of hypoglycemia due to sulfonylurea and chronic kidney disease
What would you do next to adjust John s treatment? (a) (b) (c) (d) Stop metformin and add basal insulin Stop glimepiride and add basal insulin Only continue sitagliptin and add basal insulin Stop all oral medications and start basal/bolus insulin?
Road Map To Achieve Glycemic Goals: John s A1C = 9.4% AGI = alpha glucosidase inhibitor; BG = blood glucose; DPP-4 = dipeptidyl peptidase 4; FBG = fasting blood glucose; GLP = glucagon-like peptide-1; MET = metformin; NAFLD = John is already on triple therapy with A1C still >9%; likely having hypoglycemia He may continue sitagliptin, as this will decrease potential need for bolus insulin and reduce post-prandial glycemic variability; however, due to his increased Cr, his sitagliptin dose should be reduced to 50 mg Basal insulin should be initiated Hypoglycemia was driven by the SU and that is why it was stopped Garber AJ, et al. Endocr Pract. 2017, doi:10.4158/ep161682.cs.
How will you manage John s current BP? John s current BP is 182/100 mm Hg, pulse 90: how will you approach management of his BP? (a) Counsel on diet and lifestyle changes (b) Start John on a beta-blocker, carvedilol 6.25 mg BID (given known CAD, rapid pulse) and schedule a follow up visit in 1 week (c) Recommend reductions in his alcohol consumption (d) Recommend a smoking cessation program (e) All of the above? BID = twice daily; BP = blood pressure; CAD = coronary artery disease; mg = milligram; mm Hg = millimeter of mercury
John starts with basal analog insulin 10 units at bedtime John gave himself the first injection in the office, using an insulin pen He was provided with a self-titration schedule He was prescribed carvedilol 6.25 mg BID (does not increase blood glucose) He was counseled to perform SMBG fasting and at bedtime He was taken off glimepiride He was taken off SU BID = twice daily; BP = blood pressure; mg = milligrams; SMBG = self-monitored blood glucose.
John BP Check-up Visit At 1-week follow up, John s BP is 156/92 mm Hg His carvedilol dose is increased to 12.5 mg BID His wife is very supportive in helping him make dietary changes He is referred to a dietitian for help with specific food questions He is doing well with insulin pen injections, and has been following his self-titration schedule BID = twice daily; BP = blood pressure; mg = milligram; mm Hg = millimeters of mercury.
John 3-month Checkup Height: 6 2, Weight: 228 lbs, BMI: 29 kg/m 2 BP 130/84 mm Hg, HR 68 bpm Foot and fundoscopy exam: no change since prior visit Labs: A1C: 7.9% Serum creatinine: 2.3 mg/dl Urine albumin : 60 mg/g, LFTs normal Current medications: Sitagliptin, 50 mg QD ASA, 81 mg 50 U/d long-acting insulin analog Benazepril, 40 mg QD Simvastatin, 40 mg QD Escitalopram, 10 mg QD Carvedilol, 12.5 mg BID A1C = glycated hemoglobin A1C; ASA = Aspirin; BID = twice daily; BMI = body mass Index; BP = blood pressure; dl = deciliter; FBG = fasting blood glucose; g = gram; HDL = high density lipoproteins; HR = heart rate; lb = pounds; kg = kilogram; LDL = Low density liproproteins; LFT = liver function test; m 2 = meters square; mg = milligram; ROS = review of systems; SMBG = self blood glucose monitoring; SQ = Subcutaneous; TC = total cholesterol; TG = triglycerides; WNL = within normal limits; QD = once daily; hs = before bed.
John SMBG Log John brought in examples of his SMBG log Time BG (mg/dl) Time BG (mg/dl) Time BG (mg/dl) 8:00 (fasting) 126 7:30 (fasting) 134 8:00 (fasting) 136 1:00 (post-lunch) Missed reading 1:00 (post-lunch) 214 1:00 (post-lunch) 229 5:30 (post-dinner) 210 6:30 (post-dinner) Missed reading 5:30 (post-dinner) 240 9:30 (bedtime) 242 10:00 (bedtime) 219 9:30 (bedtime) 197 BG= blood glucose; dl = deciliter; mg = milligram; SMBG=self-monitoring of blood glucose
John What is the best option? (a) Increase his basal insulin dose (b) Add a rapid-acting insulin with each meal (c) Add rapid acting analog to his largest meal (d) Switch to premix insulin?
Options When Not at Goal with One Injection of Basal Insulin Basal Plus Add prandial insulin at main meal or Switch to Basal/Bolus or Switch to a premixed insulin analog Divide dose in half and give twice daily (breakfast and dinner) after meals if feeding uncertain
John Basal Plus Bolus Mealtime Insulin Use rapid-acting analogs, not regular insulin Easier timing, less postprandial hypoglycemia Can be taken up to 15 minutes after starting to eat May start with 1 injection, at largest meal; however most patients need a dose with each meal 4 units and titrate OR by weight - 0.1 U/kg OR 1 U/15 gms CHO and titrate Titrate to: <140 mg/dl 2 hours post-prandial OR <110 mg/dl next meal or bedtime Stop oral SUs/glinides when prandial insulin is started CHO = carbohydrates; dl = deciliter; kg = kilogram; mg = milligram, SU = sulfonylurea; U = unit.
John 3-month Follow-up Height: 6 2, Weight: 210 lbs, BMI: 27 kg/m 2, BP: 130/78 mm Hg, HR: 80 bpm Foot exam: no change since prior visit Labs: A1C: 6.4%; FPG: 94-100 mg/dl; 2-h PPG: 110-118 mg/dl Serum creatinine: 2.1 mg/dl Urine albumin: 20 mg/g, LFTs normal Current medications: 50 U long-acting analog insulin SQ hs 12 U rapid-acting insulin SQ with breakfast and lunch 15 U rapid-acting insulin SQ with dinner John will follow up in 3 months Benazepril 40 mg QD Simvastatin 40 mg QD Escitalopram 10 mg QD Carvedilol 12.5 mg BID ASA 81 mg QD ASA = Aspirin; A1C = glycated hemoglobin A1C; BID = twice daily; BMI = body mass Index; BP = blood pressure; dl = deciliter; FBG = fasting blood glucose; HDL = high density lipoproteins; g= gram; HR = heart rate; kg = kilogram; m 2 = meter squared; lb = pounds; LDL = low density lipoproteins; LFT = liver function test; mg = milligram; PPG = postprandial glucose; ROS = review of systems; SMBG = self-monitoring of blood glucose; SQ = subcutaneous; TC = total cholesterol; TG = triglycerides; U = units; WNL = within
And Finally: The 5 Keys of Successful Diabetes Self-management 1. Know your metabolic targets (A1C, lipids, blood pressure) 2. Understand how to achieve your metabolic targets 3. Stop smoking 4. Take your medicines 5. Make sure your doctor/provider understands the complexities of diabetes management Unger J. Diabetes Management in Primary Care, 2 nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2012.