Diabetes 2016: Strategies for achieving optimal diabetes control · 2017-10-20 · (B) No - adding Actos will get you sued when he develops bladder cancer for the 3rd time (C) YES

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PHASE Safety Net Community Benefit

Diabetes 2016: Strategies for achieving optimal diabetes control

Lisa Gilliam, MD, PhDClinical Leader

Diabetes ProgramKaiser Permanente Northern California

October 26, 2016

Dr. Lisa GilliamClinical Leader, Kaiser Permanente Northern California Diabetes Program

What is optimal diabetes control?

10 years ago

A1c < 7% for most

The lower, the better

One size fits all

Standards of Medical Care in Diabetes—2012

The ADA proposes optimal targets, but each target must be individualized to the needs of each patient and his or her disease factors

ACCORD

ADVANCE

VADT

What is optimal diabetes control in 2016?

Most people - A1c goal <7%

Lower targets (ex: <6.5%)

– Short duration of DM

– T2D treated with lifestyle or metformin only

– Long life expectance

– No significant CVD

– Only if this can be achieved without significant hypoglycemia or other adverse effects of treatment

Higher targets (ex: <8%)

– Severe hypoglycemia

– Limited life expectancy

– Advanced microvascular or macrovascular complications

– Extensive comorbid conditions

– Long-standing DM in whom general goal is difficult to attain

How does a health plan achieve optimal A1c control?

“Piling on”?

Kaiser Permanente Northern California:Leader in diabetes control

#9 in the US

for

A1c <8%

70% of DM patients have A1c under 8%

– Regional target = 73%

82% of DM patients have A1c under 9%

– Regional target = 86%

What has the KP NCal strategy been??

Dulaglutide inj (Trulicity)

NPH insulin

Glipizide (Glucotrol)

Glimiperide (Amaryl)

Pioglitazone (Actos)

Empagliflozin (Jardiance)

Dapagliflozin (Farxiga)

Canagloflozin (Invokana)

Linagliptin (Tradjenta)

Sitagliptin (Januvia)

Alogliptin (Nesina)

Saxagliptin (Onglyza) Exenatide ER inj (Bydureon)

Albiglutide inj (Tanzeum) Liraglutide inj (Victoza)

Exenatide inj (Byetta)

Metformin

Acarbose (Precose)

Regular insulin

Lispro (Humalog)

Glargine (Lantus)

What has the KP NCal strategy been??

Dulaglutide inj (Trulicity)

NPH insulin

Glipizide (Glucotrol)

Glimiperide (Amaryl)

Pioglitazone (Actos)

Empagliflozin (Jardiance)

Dapagliflozin (Farxiga)

Canagloflozin (Invokana)

Linagliptin (Tradjenta)

Sitagliptin (Januvia)

Alogliptin (Nesina)

Saxagliptin (Onglyza) Exenatide ER inj (Bydureon)

Albiglutide inj (Tanzeum) Liraglutide inj (Victoza)

Exenatide inj (Byetta)

Metformin

Acarbose (Precose)

Regular insulin

Lispro (Humalog)

Glargine (Lantus)

Key Factors in NCAL Performance

Technology Tools: PROMPT

Responsibility: Accountable Population Managers, or “APMs”

– PharmDs or RNXs – manage panels of patients with diabetes and other CV risk factors

Accountability: PROMPT Reporting

OK, so what medications

should I use??

Sulfonylureas

Glipizide (Glucotrol), Glimiperide (Amaryl) - $ ($100/yr)

Stimulates pancreatic beta cell insulin release

Advantages

• Oral

• Affordable

• Long clinical exp.

• microvascular risk

(UKPDS)

Disadvantages

• Hypoglycemia risk

• 1-3% risk for severe

hypoglycemia

• Weight gain (avg <5

kg)

• 1-2% A1c**

**expected decrease in A1c (%) with

MONOtherapy, actual A1c lowering when

used as 2nd or 3rd line agent will be less

Disadvantages

• Edema (25%)

• CHF

• <0.2% overall, 2-5% in high risk

• Contraindicated in III/IV CHF

• Weight gain (<5 kg)

• Fracture risk

• Bladder CA?-mixed data

• 0.5-1.4% A1c

Thiazolidinediones (TZD)

Pioglitazone (Actos) - $$ ($160/yr), Rosiglitazone (Avandia) - $$$$ ($3300/yr)

Activates PPAR gamma, insulin sensitivity

Advantages

• Oral

• Affordable

• No hypoglycemia

SGLT2 inhibitors

Empagliflozin (Jardiance), Dapagliflozin (Farxiga), Canagloflozin(Invokana) - $$$$ ($4700-4800/yr)

Blocks renal glucose reabsorption, promotes glucosuria

Advantages

• Oral

• Modest weight loss

• blood pressure

Disadvantages

• Not affordable

• GU infections (10%)

• UTI/urosepsis, pyelonephritis

• DKA

• Polyuria/hypotension/dizziness

• Fracture risk

• Contraindicated for GFR<30

• 0.5-0.7% A1c

DPP-4 Inhibitors

Linagliptin (Tradjenta), Sitagliptin (Januvia), Alogliptin* (Nesina), Saxagliptin (Onglyza) – $$$ ($1460/yr) - $$$$ ($4400/year)

Inhibits DPP-4 which GLP-1

GLP-1: food intake, gastric emptying

insulin release, post-prandial glucagon

Advantages

• Oral

• Weight neutral

• Generally few SEs

Disadvantages

• Not affordable

• Angioedema/urticaria

• ? Acute pancreatitis

• ? CHF hospitalizations

• 0.5-0.8% A1c

GLP-1 receptor agonists

Exenatide ER inj (Bydureon), Albiglutide inj (Tanzeum); Exenatide inj (Byetta), Liraglutide inj (Victoza), Dulaglutide inj (Trulicity) –$$$$$ ($5000-$9000/yr)

GLP-1: food intake, gastric emptying

insulin release, post-prandial glucagon

Advantages

• Modest weight loss

• Once weekly dosing

• Reduction in death from

CVD

Disadvantages

• Injected

• GI SE’s (N/V, diarrhea in 20-40%)

• ? Acute pancreatitis

• VERY expensive

• Contraindicated if FHx of MTC or

MEN2 (Exenatide ER)

• 0.5-1% A1c

Basal Insulin

– NPH (Humulin N) - $$ -(~$500/year)

– Analogs - Glargine (Lantus), Detemir (Levemir), Degludec (Tresiba) -$$$$ - $$$$$ ($3000-$9000/year)

Advantages

• Affordable (NPH vials)

• Unlimited efficacy

• Long clinical experience

• microvascular risk

(UKPDS)

Disadvantages

• Injected

• Hypoglycemia risk

• Weight gain (<5 kg)

How do we choose??

ADA Standards of Medical Care in Diabetes – 2016 Diabetes Care 39:1 (2016) p S54.

Kaiser National Adult Diabetes Guidelines2016

Case 1- what is the best choice for 3rd line agent?

“Tobacco Red” is a 48 year-old dye-worker with type 2 diabetes:

– Smokes 3 packs per day for the last 40 years

– He has beaten bladder cancer twice in last 10 years

– His current BMI is 55.3

– Last three quarterly A1C levels were:

7.5%

7.8%

8.1%

– Current meds:

Metformin XR 2 gm PO once daily

Glipizide 10 mg PO bid

Tobacco Red has been stable on this regimen for the last 3 years. At this point, the best course of action would be to...


(A) Nothing - 8.1% is not bad, and this guy is likely to die from bladder cancer

anyway.

(B) Add Pioglitazone (Actos), retest in 3 months

(C) Replace glipizide with bedtime NPH and titrate to a fasting glucose level <130. Retest in 3 months.

(D) Replace glipizide with a Liraglutide (Victoza), retest in 3 months.

(E) C or D

Hints:

– Current meds = Metformin 2000 mg qd, Glipizide 10 bid

– Considerations: Obesity (BMI 55), smoker


Answers:

(A) No - technically correct but politically incorrect.

(B) No - adding Actos will get you sued when he develops bladder cancer for the 3rd time

(C) YES - is correct and cost effective

(D) YES - is correct and Liraglutide (Victoza) have a weight negative effect, which this gentleman needs. It’s possible this might reduce his risk for CVD death. However, this option is less cost-effective.

(E) YES – either C or D is correct

Does Pioglitazone cause bladder cancer?

Dormandy, Lancet 2005: 366, 1279 - PROspective pioglitAzone Clinical Trial In macroVascular Events (PROactive) study – YES

– Erdmann, Diabetes Obes Metab 2014: 16, 63 – PROactive update – NO

Lewis, JAMA 2015: 314, 265 – Cohort and nested case-control study – NO

Tuccori, BMJ 2016; 352:i1541 – Cohort study – YES

AHRQ review (Diabetes Medications for Adults With Type 2 Diabetes: An Update, April 2016) - NO

– Used most rigorous evidence which evaluated people prospectively

Leader Trial - 2016 Liraglutide (Victoza) reduced death from CVD causes

Hazard ratio, 0.87; 95% CI, 0.78 to 0.97

2.3 kg more weight loss

~80% had established CVD

Unknowns:

– Helpful for primary prevention?

– Class effect? (Evaluation of Lixisenatide in Acute Coronary Syndrome (ELIXA) trial – no CVD benefit)

Case 2 - what is Terry’s next best course of action?

“Terry Treetrunklegs” is a 55 year-old lover of salt with type 2 diabetes who recently graduated to the 4th stage of CHF. She is quite proud of her accomplishment and feels a debt of gratitude to her hubby Jim, who makes her six nightly margaritas with salt at her favorite Mexican Restaurant. Her weight has increased by 5 lbs over the last 12 hours.

Terry has battled pancreatitis and won four different times.

Terry currently takes glipizide 10 mg PO bid

Her last three quarterly A1C values:

– 7.2%

– 7.8%

– 8.5%.


(A) Add metformin. Gradually titrate to 2,000 mg per day to avoid GI side effects. Retest in 3 months.

(B) Add Pioglitazone (Actos) 15 mg. Titrate dose up over the next 6 months based on quarterly A1C values.

(C) Increase glipizide to 20 mg PO BID and retest A1C in 3 months.

(D) Stop glipizide and start bedtime NPH. Titrate to fasting glucose <130. Recheck an A1C 3 months after achieving a fasting glucose <130.

(E) Add Exenatide (Byetta) to glipizide, retest in 3 months.

Hints:

– Current meds = Glipizide 10 bid

– Considerations: Stage IV CHF, h/o recurrent pancreatitis


Answers:

(A) NO - Metformin is contraindicated due to risk of lactic acidosis in acute CHF.

(B) No – Pioglitazone (Actos) contraindicated in CHF class 3 or higher.

(C) NO - This will be inadequate to reduce her A1C by the 1.5% needed to achieve goal.

(D) YES - Insulin is needed for this patient. Glipizide will be of little value once insulin is added, and it is an extra medication increasing the risk of polypharmacy effects.

(E) NO - This is a good way to get sued when Jim and his margaritas provoke pancreatitis bout #5.

Case 3 – Bernie’s next steps?

Bernie U. Rheinhard is a 57 year-old with type 2 diabetes whose last three hemoglobin A1C values were, in order, 7.9%, 8.5% and 8.9%.

Meds:

– Metformin 2,000 mg once daily

– Glipizide 10 mg twice daily

– She has a prescription for fluconazole 150 mg orally one time for yeast infections with 11 refills, because you are tired of her once monthly e-mail complaining of a new yeast infection.

Bernie is currently in your office because it "burns hard when she urines." Today is the fourth time she has been in your office with this complaint this year. While analyzing her urine results (nitrite positive), you recognize her A1C trend and decide to adjust her medication.


You decide to…

(A) Increase her glipizide to 20 mg orally twice daily

(B) Add canagliflozin (Invokana)

(C) Add pioglitazone (Actos)

(D) Add bedtime NPH insulin

(E) B or C


Answers:

(A) NO - technically, she needs a 2.0% reduction in her A1C to achieve goal. No oral hypoglycemic will get her there, and increasing the dosage of one she is already taking most certainly will not get her to goal.

(B) NO - this woman is a yeast producing factory who has had four UTIs in the last year. Canagliflozin will only cause more problems and cost a lot, without getting her to goal.

(C) NO - This is wrong for the same reason that (A) is wrong.

(D) YES - Insulin is the only medication likely to help her achieve the necessary A1C reduction. Cessation of glipizide is probably reasonable at this point.

(E) NO - neither (B) or (C) is correct.

Case 4 – Sugar’s second choice?

“Sugar T. Lowe” is a 77 yo lady with longstanding type 2 diabetes(>20 years) who has the local EMS team on her Christmas card list after several visits to the ED for hypoglycemia when she was previously taking glipizide. She also got to see her EMS friends recently after getting out of bed too quickly and conking her head on the nightstand, leading to unconsciousness.

Recent A1c 8.4%.

Meds:

– Metformin 1000 bid

– Donepezil (Aricept) for “senior moments” (she’s very forgetful these days)


(A) Add Canagloflozin (Invokana).

(B) Add Pioglitazone (Actos).

(C) Start bedtime NPH. Titrate to fasting glucose less than 130.

(D) Add Sitagliptin (Januvia).

(E) B or D

Hints:

– Current meds = Metformin 1000 mg bid

– Considerations: Hypoglycemia, longstanding DM, occasional dizziness, early dementia


Answers:

(A) NO - Canagloflozin (Invokana) would not be a good option in an elderly patient with dizziness/fall risk because it lowers BP.

(B) YES - Pioglitazone (Actos) would be a good option in this case, and is cost-effective. Target A1c in this lady would be <8% because of history of severe hypoglycemia and comorbid conditions (early dementia), and this target would probably be readily achieved by adding pioglitazone, while you would not increase her risk for hypoglycemia.

(C) NO – with history of severe hypoglycemia on glipizide, NPH would not be a great option for this lady.

(D) YES – Sitagliptin (Januvia) would be a good option for the same reasons listed above for Pioglitazone (Actos). However, this option is less cost-effective.

(E) YES - either (B) or (D) is correct.

Thank you!

The recording and slides will be emailed to all webinar participants and

participants of the PHASE program.

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Diabetes 2016: Strategies for achieving optimal diabetes control · 2017-10-20 · (B) No - adding Actos will get you sued when he develops bladder cancer for the 3rd time (C) YES