Type 2 Diabetes Mellitus Care Guidelines – Updates in ...
Transcript of Type 2 Diabetes Mellitus Care Guidelines – Updates in ...
![Page 1: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/1.jpg)
Type 2 Diabetes Mellitus Care Guidelines – Updates in Treatment Recommendations
Matthew Freeby, MDUCLA Diabetes SymposiumNovember 2021
![Page 2: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/2.jpg)
Research (clinical trials): Abbott Diabetes & Novo Nordisk
Education: Endocrine Society, Pri-Med, Symposia Medicus
2
Disclosures
![Page 3: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/3.jpg)
Approach to Glycemic Control in Type 2 Diabetes Mellitus
3American Diabetes Association. Diabetes Care. 2021Qaseem A et al. Annals Int Medicine. 2018
![Page 4: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/4.jpg)
Guidelines for Glycemic Control: What’s Best for the Patient?
American Diabetes Association. Diabetes Care. 2019Draznin et al. Annals Int Medicine. 2018
• A1C < 7% for most patients• A1C goals may be adjusted based on risk
• Factors include: Older adult, CAD, Stroke, Dementia• Individualize or de-intensify based on hypoglycemia risk and other potential harmful effects
• Examples…• < 7.5 to 8% CAD, Stroke or > 70 years• < 8 to 8.5% Dementia or other significant co-morbidities
• A1C levels > 8.5% increase polyuria, polydipsia, renal dysfunction.
![Page 5: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/5.jpg)
-1.6-1.4-1.2
-1-0.8-0.6-0.4-0.2
0 4-6 Months
1 Year
2 Years
Primary Endpoint: A1C Change
Deakin T, et al. Cochrane. 2009.
Hem
oglo
bin
A1C
Diff
eren
ceDiabetes Education Outcomes –Clinical Benefits
Secondary EndpointsWeight Loss: -1.6 Kg
@ 12-14 months
Blood Pressure (SBP):
-5 mmHg @ 4-6 mos
Reduce DM Meds: NNT = 5
Group-based diabetes education: 11 studies, 1532 patients
![Page 6: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/6.jpg)
6ADA Guidelines. Diabetes Care. 2021
Type 2 Diabetes Management Guidelines: First-Line Therapy is Metformin
Click to add text
![Page 7: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/7.jpg)
Biguanides (Metformin)• A1C Effect: 1 to 2%• Upsides:
• Weight loss (2-3 kg) • PO Route • No Hypoglycemia
• Side effects, Limiting Factors: • GI side effects • Potential for B12 deficiency• Risk for lactic acidosis (rare)
• GFR < 30 (do not start with GFR < 45)• Relative: (1) Liver dysfunction, (2) Heart failure, (3) Age > 80 years, (4) Heavy alcohol intake
7
Peripheral glucose uptake; hepatic gluconeogenesis
![Page 8: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/8.jpg)
Metformin
Metformin ER
What About the Patient Who Doesn’t Tolerate Metformin?
Gastrointestinal side effects? Consider Metformin ER…
Blonde et al. GI Tolerability of Metformin
Past recalls….
![Page 9: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/9.jpg)
Medications to Treat Type 2 Diabetes Mellitus
1921
1946
1957
1995 2005 2013
Adapted from Nathan D. N Engl J Med 2007;356:437-440
![Page 10: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/10.jpg)
10ADA Guidelines. Diabetes Care. 2021
Type 2 Diabetes Management Guidelines: Shared Decision Making Based on Many Factors
![Page 11: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/11.jpg)
Type 2 Diabetes Mellitus: Second-Line Medication Choice…
• The choice for second-line therapy is not always straight forward. Consider based on multiple factors…
•Change in A1C (efficacy)
•Cost
•Hypoglycemia risk
•Side effects
•Weight Change
•Cardiovascular disease
11ADA/EASD Guidelines. Diabetes Care. 2021
![Page 12: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/12.jpg)
Sulfonylureas and Meglitinides• Examples
• Sulfonylureas: Glipizide, Glimepiride, Gyburide• Meglitinides: Repaglinide, Nateglinide
• A1C Effect: 1 to 2%• Upsides:
• Established, well-studied generic pill• Glinides lower hypoglycemia risk
• Side effects, Limiting Factors: • Hypoglycemia (erratic PO intake, elderly, renal dysfunction)• Weight gain (2 kg)
12
Insulin secretion
![Page 13: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/13.jpg)
Kinetics: Meglitinides vs. Sulfonylureas
13
What if the patient skips meals?
![Page 14: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/14.jpg)
Thiazolidinediones (TZD's)
• Example:• Pioglitazone
• A1C Effect: 1 to 2%• Upsides:
• (1) Generic pill (2) No hypoglycemia (3) Stroke reduction (4) Durability – possibly beta cell sparing
• Side Effects, Limiting Factors:• (1) Edema (2) Weight gain (5kg) (3) Fracture risk in females (4) Bladder cancer (5) Symptomatic heart failure – black box warning
14Dormandy JA et al. Lancet 2005Kahn SE, et al. NEJM 2006
![Page 15: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/15.jpg)
Type 2 Diabetes Mellitus: Second-Line Medication Choice…
• The choice for second-line therapy is not straight forward and based on multiple factors…
•Change in A1C (efficacy)
•Cost
•Hypoglycemia risk
•Side effects
•Weight Change
•Cardiovascular disease
15ADA Guidelines. Diabetes Care. 2021
![Page 16: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/16.jpg)
DPP-4 Inhibitors
• Examples: • Sitagliptin (Januvia)
• Saxagliptin (Onglyza)
• Linagliptin (Tradjenta)
• Alogliptin (Nesina)
• A1C Effect: 0.5 to 0.9%• Upsides: (1) PO Route (2) well-tolerated
(3) No Hypoglycemia (4) No weight gain
• Side effects, Limiting Factors: (1) Cost (2) Modest A1C benefit, (3) CHF in saxa- and alogliptin (4) Low likelihood of pancreatitis (5) Joint pains (6) No positive or negative cardiovascular impact
16
Increase insulin secretion;Decrease glucagon
![Page 17: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/17.jpg)
Type 2 Diabetes Mellitus: Second-Line Medication Choice…
The choice for second-line therapy is not straight forward and based on multiple factors…
•Change in A1C (efficacy)
•Cost
•Hypoglycemia risk
•Side effects
•Weight Change
•Cardiovascular disease
17ADA Guidelines. Diabetes Care. 2021
![Page 18: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/18.jpg)
GLP-1 Receptor Agonists• Examples:
• Exenatide (Byetta / Bydureon)
• Liraglutide (Victoza)
• Lixisenatide (Adlyxin)
• Dulaglutide (Trulicity)
• Semaglutide (Ozempic SQ & Rybelsus PO)
• A1C Effect: - 0.5 to 1.5%• Upsides: (1) Weight loss (2) Cardiovascular outcomes (3)
Minimal Hypoglycemia
• Side effects, Limiting Factors: (1) Cost (2) Gastrointestinal side effects (nausea 39%, diarrhea 21%, vomiting 16%) (3) Thyroid c-cell tumors unlikely
18
Increase insulin secretion;Decrease glucagon;Increase satietySlow gastric emptying
![Page 19: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/19.jpg)
SGLT-2 Inhibitors• Examples:
• Dapagliflozin (Farxiga)
• Canagliflozin (Invokana)
• Empagliflozin (Jardiance)
• Ertugliflozin (Steglatro)
• A1C Effect: - 0.5 to 1%• Upsides: (1) Weight loss (1 to 2 kg) (2) Cardio-renal outcomes
(3) PO route (4) Minimal hypoglycemia
• Side effects, Limiting Factors: (1) Euglycemic DKA (<1%) - HOLD
3-4 days prior to procedure (2) Genitourinary infections – Fournier’s Gangrene (3) Cost (4) Limitations in GFR levels to start medications (5) Lower extremity amputation – Black box warning removed in 2020 (6) Dehydration – Caution with diuretics
19
Reduce Glucose Reabsorption
![Page 20: Type 2 Diabetes Mellitus Care Guidelines – Updates in ...](https://reader033.fdocuments.us/reader033/viewer/2022042013/6255874473e0a160cc7eb9b6/html5/thumbnails/20.jpg)
Type 2 Diabetes Management: Take Home Points
• Set an A1C target• DM education is key!• Start with Metformin
• Consider Extended Release
• Second-line therapy choice is based on multiple factors
• Cost• Side effects• Weight gain / weight loss• Hypoglycemia risk• Cardiovascular (and renal) impact
20