January 2013 Webinar:“Practical Ways to Help Get Our Diabetes Patients to Goal”

• Controlling the ABC’s• Cases

Evidence Based Interventions that Reduce Morbidity and Mortality• HbA1C < 7• BP < 140/90• LDL cholesterol < 100 (or <70 if CAD) • Aspirin age > 50 men, 60 women with 1 risk

factor• ACE - age >55• Statin use - age >40• Yearly screen for nephropathy, feet, and eye

exams

The ‘ABCs’

•A1C

•BP < 140/90

•Cholesterol (LDL<100, if CAD <70)

Improving Glucose Control

“But I Thought It Was Bad to Lower A1C Too Much..”• All recent studies aimed at A1C = 6.5 or lower• No evidence that A1C = 7 is bad• Data says to reduce CVD

• It is not so much about glucose• It’s the Blood Pressure and Cholesterol!

Really, Really Important Points:1. Aggressive control early prevents complications2. Because of the log-linear relationship between

control and complications, absolute benefits are greatest at high HbA1c values (i.e. target A1C >9)

3. Pushing patients with advanced disease (particularly macrovascular complications) to ‘tight’ control that they cannot achieve probably increases mortality

-Attention to hypoglycemia and particularly nocturnal hypoglycemia

Managing Glucose

• Goal A1C <7• Consider higher (8) if CAD, elderly, or

hypoglycemia unawareness• Focus on those at highest risk (i.e. A1C >9)

Sites of Drug Action

CarbohydrateDIGESTIVE ENZYMES

Glucose

Defectiveb-cell secretion

Excessglucoseproduction

Resistance to the action of insulin

Reduced glucoseuptake

Excessivelipolysis

Dinneen SF. Diabet Med. 1997; 14 (Suppl 3): S19-24.

Sulfonlyureas MeglitinidesIncretinsInsulin

Alpha-glucosidaseInhibitors, Incretins

MetforminTZDIncretins TZD, Metformin

Points to Remember

• Each agent, except insulin, lowers A1C 1-2• If A1C >9, start two agents• Follow SMBG, A1C, and Titrate!!!!!

Case

• 58 yo with Type 2 x 5 yrs• A1C = 9.5• On metformin 1000 mg bid• Glimepiride 4 mg qd

• What next?

20 10 0 10 20 30

Natural History of Type 2 Diabetes

Adapted from International Diabetes Center (IDC). Minneapolis, Minnesota.

Years of Diabetes

Relative -Cell Function

PlasmaGlucose

Insulin resistance

Insulin secretion

126 mg/dL Fasting glucose

Postmeal glucose

Type 2 Diabetes… A Progressive Disease

Over time, most patients will need

insulin to control glucose.

Reducing Clinical Inertia

• Eternal hope on lifestyle working• Negotiate a deadline

• Escalating therapy more quickly• Oral agents can be monthly• Insulin can be weekly

Barriers to Starting Insulin

• Patient Barriers• Guilt, failure• Injection?

• Provider Barriers• Who teaches?• Consider pens

• Team Based Care to the rescue!• Diabetes Educators?

Talking About Insulin

• “It seems like you have some concerns about insulin?”

• “What do you know about using insulin in DM?”• Inevitable • Simple• Pens• Can be daily at first• No one needs to know • Correct misconceptions

What To Do With Oral Agents

• Negotiate• For weight- keep metformin• For reducing need for second injection - insulin

secretagouge• For cost- stop orals

Correcting Fasting Hyperglycemia…

100

200

300

Normal A1C 5%–6%

PG

(m

g/d

L)

0800 1200 1800 0800

Time of Day

Uncontrolled A1C ~9%

A1C ~6%

Is Usually the First Task!!

…then, Tackle Postprandial Hyperglycemia if A1C still >7%!

“Controlled” A1C <7%

Titrating Glargine or Detemir

• Start 10 units• 2 units q 3 days until FPG < 100• It’s that easy and it works!

50

4:00

25

75

8:00 12:00 16:00 20:00 24:00 4:00

Breakfast Lunch Dinner

PlasmaInsulin ( µU/mL)

Time8:00

Physiologic Serum Insulin Secretion Profile

How do you know they need another

injection?FPG good but A1C not

22

Case

• Type 2 DM x 6 y• Glargine 60 units qhs• FPG 90-110• A1C=8.5• Pt can measure qhs BG?

• Start 10 units rapid insulin pre-dinner• If regular meals- 70/30 insulin

• 40 q Am, 30 q PM

Who Are Your High A1C Patients?

• Orals and need second oral?• Need insulin?• On insulin?• There can be inertia at each level• DEPRESSION?• Adherence?

• Open-ended ended question:• “Some people find it hard taking their insulin

every day, how’s it going for you?”

BP CONTROL

BP Management

• <140/90• Multiple meds • Don’t miss an opportunity to titrate• Standing orders?

Medication Treatment Algorithm?

• Start with ACE or ARB and/or HCTZ• Either one

• Best might be early combo since all will likely need it

• Third agent based on co-morbidity• Beta blocker and/or Ca channel

• Add the 4th and hopefully you’ve reached goal - if not call an expert +/- alpha blocker?

Tashko and Gabbay, Integrated Blood Pressure Control (2010)

Cholesterol LDL control <100If CVD <70

Getting to Goal on LDL

• Most myalgia not from statins!• Stop and observe• Switch to another statin• Mention stroke risk• TITRATE

Evidence Based Interventions That Reduce Morbidity and Mortality• HbA1C < 7• BP < 130/80• LDL cholesterol < 100 (or <70 if CAD) • Aspirin age > 50 men, 60 women with 1 risk

factor• ACE -age >55• Statin use- age >40• Yearly screen for nephropathy, feet, and eye

exams

QUESTIONS?

Any Cases?