Transcript Diabetes treatment

Diabetes Treatment
Practical Applications
Tim Drake PharmD
How to Adjust Therapy to Get
The Best Control
Intensive vs.. Conventional Insulin dosing
 Single vs.. Combination Oral Medications
 Fasting vs. Postprandial blood glucose
values
 Combination of Oral and Insulin
 American College of Endocrinologists vs.
American Diabetes Association Goals
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Blood Glucose Goals
ACE
ADA
A1C
 6.5
7
Fasting
<110
70-130
Post
prandial
Bedtime
<140
<180
110-150
A1C
A1C (%)
6
7
8
9
10
11
12
Mean Plasma
Glucose (mg/dl)
126
154
183
212
240
269
298
Fasting vs. Postprandial
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Fasting
 Reflects hepatic
glucose production
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Postprandial
hyperglycemia
 Carbohydrates in
meal
 Insulin deficiency
 Muscle sensitivity
 Incretin deficiency
 Glucagon increased
Fasting vs. Postprandial
Fasting values are more important with a
higher A1c
 Lower A1c values deal more with
postprandial values
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Effects on fasting or
postprandial?
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Fasting
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Metformin
TZD’s
Basal Insulin
Sulfonylureas
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Post-Prandial
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Exanatide
Sitigliptin
Nateglinide
Acarbose
Short-acting insulins
Miglitol
Repaglinide
Type 2 Case
JA is a 42 year old Hispanic male with
newly diagnosed type 2 diabetes. He also
has hypertension and hyperlipidemia.
 His mother and 2 sisters have diabetes.
Mother is on dialysis
 He is married and has 2 children. He works
as a restaurant manager
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Labs
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A1c = 9.8
Glucose = 238
Urinalysis =  glucose
SrCr = 0.8
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BMI = 33
LFTs = WNL
Eye exam = WNL
Foot exam = WNL
What Additional Information
Would You Want to Know?
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Dietary Information
Exercise Information
Current understanding of diabetes
Does he know how to self monitor?
Labs etc.
 Lipid profile
 Blood Pressure
 Albumin/creatinine ratio
JA was seen by the dietician, started walking 30 minutes
daily, but 2 weeks later, still has a fasting Blood Glucose
of 220.
What are the issues (good and bad) with
starting the following medications?
Glipizide 10 mg QD
 Metformin 500 mg BID
 Actos 30 mg QD
 Precose 25mg TID
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How would you counsel a patient or
monitor each one of the medications?
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Glipizide
 Sulfa allergy, do not skip meals, possible
hypoglycemia
Metformin
 Self limiting GI upset, SrCr, heart failure,
ALOH, surgery, potential CV benefit
Actos
 Edema, weight gain, possible HF symptoms,
caution use with insulin
Precose
 Timing with meals, GI side effects
JA is started on Metformin 500 mg BID and Actos 30mg QD
and titrated to the maximal effective dose. His A1c is still
7.5% after 3 months.
What would be the best to do for him?
Switch to glipizide ER 20mg daily
 Switch to Glucovance (metformin/glyburide
500mg/2.5mg) 2 tablets BID
 Add exenatide 5mcg SQ BID
 Add sitagliptin 100mg QD
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What if?
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What if JA was diagnosed with hepatitis and had
an elevated ALT of 150 (normal is 3-31)?
 Which anti-diabetic medications need to be
changed in the presence of liver dysfunction?
What if JA developed kidney failure and had a
SrCr of 2.6
 Which anti-diabetic medications need to be
changed in the presence of kidney failure?
Kidney Failure or Insufficiency
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Metformin
 Do not use with SrCr > 1.4 in women and 1.5 in
men
Glyburide
Miglitol
Acarbose
Exenatide
Sitagliptin
Liver Dysfunction
Glipizide, glyburide and glimepiride
 Nateglinide and repaglinide
 Metformin
 Rosiglitazone and pioglitazone
 DC if ALT is >3 times the ULN
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JA has been controlled with an A1c less than 7% on
metformin/glyburide 500/2.5mg 2 BID, and actos 30 mg daily
for the last 5 years. Recently his A1c has been creeping up. 1
year ago it was 6.5%, 6 months ago it was 6.9%, 3 months
ago – 7.3% and now it is 7.6%.
What would you recommend?
Lantus insulin 10 units QHS
 Add Avandia 4mg QD
 Add Precose 25mg TID
 Add glipizide 10 mg QD
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Insulin Management
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Basal Insulin
 Metobolic needs
 Keeps blood
glucose steady
 About 50% of
requirement
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Bolus Insulin
 Nutrition
 Correct highs
 About 50% of
requirement
Pattern Management
What is the target blood glucose level
 Get fasting blood glucose controlled first
 After fasting, then look at post-prandial and
others
 Only one change at a time
 Small problems = small changes
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JA has been on metformin/glyburide 500/2.5mg 2 BID, and
actos 30 mg daily with escalating A1c levels. He is placed
on Lantus 25 units SQ QHS
Titrate basal insulin 2 units every 2 days until
fasting blood glucose is at goal
Now JA is on 34 units of Lantus QHS plus oral
therapy. He comes in with these readings
Because of convenience, JA was switched to NPH/regular
insulin
He uses 24/6 units of NPH/regular at breakfast and 20/8 at
dinner
Breakfast 24/6
Dinner 25/8
Carbohydrate Counting
More precise matching of food and insulin
 More food choices
 Potential for increased blood glucose
control
 Fits insulin into the patient’s lifestyle
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Carbohydrate Exchange
or “15 grams of carbohydrate equal”
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1 slice of bread
6 crackers
½ cup of cereal or
grains
½ cup of juice
1 small piece of fruit
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¾ cup of yogurt
1 cup of milk
1 small cookie
1 Tbl jam or jelly
½ cup cooked veggies
1 cup raw veggies
Labeling
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Look at serving size
first
Count total
carbohydrates
If dietary fibers are 5
grams or more, deduct
from total
carbohydrate
Estimating CHO/insulin ratio
Usually 1 unit rapid acting insulin/15 grams
CHO
 Can vary from 1/(5-20)
 Lower insulin dose = higher ratio
 Lower body weight = higher ratio
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Estimating CHO/insulin ratio
Calculate patients daily insulin requirement
 450 divided by total daily insulin
requirement = ratio
 450/45 units = 10
 1 unit of insulin for every 10 grams CHO
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Insulin Sensitivity Factor
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1700 rule
Use for rapid acting insulin
1700/total daily insulin requirement = amount of
blood glucose lowering from 1 unit of rapid acting
insulin
1700/34 units = 50
 So for every 1 unit of insulin, you would expect
a 50 unit lowering of blood glucose
Fine Tuning
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Pick a meal for which you can easily keep a record
Record the CHO from that meal and keep the
CHO consistent for 7 days
Record the insulin used for that meal
Find 3 meals where the pre and post-prandial
levels were within goal
Divide the CHO by the insulin used to find your
new ratio
 45 grams CHO/ 3 units insulin = 15
Type 1 case
Ratio of 15:1
Breakfast: 4 units aspartamine insulin (60 grams CHO)
Lunch: 2 units aspartamine insulin (30 grams CHO)
Dinner: 5 units aspartamine insulin (60 grams CHO + 1
unit correction factor)
Takes 14 units of glargine at bedtime
Add correction back into lunch dosing
Decrease ratio for lunch
1:15 for breakfast
1:10 for lunch
1:15 for dinner
Patient Case
AS is a 37 y/o female with Diabetes
Mellitus Type 1 for >30years. She has been on
Multiple Dose Injection (MDI) therapy for
about 5 years. She is currently prescribed
glargine insulin (Lantus®) 15u at 10 PM and
glulisine Insulin before each meal. The before
meal Glulisine Insulin regimen is 4u before
breakfast, 4u before lunch, and 7u before
dinner. Her last A1C was 8.0 and BP110/75
mm Hg. The patient is complaining that her
blood glucose is inadequately controlled and
she is locked into eating a fixed amount for
each meal.
Patient Case
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What is recommended for her to help her
adjust her eating habits?
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What is her CHO/insulin ratio? About 1:15
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What is her insulin sensitivity factor?
 About 1:50
AS is taking glargine 10 units QHS and dosing glulisine
according to CHO counting with a ratio of 1:15. She has a
correction factor of about 1:50.
Morning
Lunch
Dinner
Before Bed
135
130
162 +1u
115
120
115
170 +1u
110
115
120
155 +1u
116
Why was the extra unit given at dinner?
 How should we adjust her schedule?
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What is the cost of therapy for
AS?
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How much glargine will she need per month?
450u or one vial (1000u) about $100
How much glulisine will she need each month?
Same, 450u at about $100
How many testing strips and lancets will she
need? About 150 so about $150
What other supplies or medications might she
need? Glucose monitor, syringes, etc.
What is the total cost of therapy just for the
diabetes? Like $400 per month
DCCT trial
Estimated that to use intense insulin
regimens on every type 1 patient and
advanced type 2 patients would cost 4
billion dollars
 Benefits seen would be net gains of 920,000
more years of sight, 691,000 more years of
free of end stage renal disease and 678,000
more years free from amputations.
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Self monitoring blood glucose
Is it worth it?
 Absolutely necessary for intense insulin
regimens and to avoid serious side effects
 For type 2 patients, it is not as crucial
 One study found an A1C lowering of 0.4%
while others showed no change
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Dawn Phenomenon
Associated with increased early morning
blood glucose and insulin requirements
 Comes from an increase in glucose
production
 Elevation in counter regulatory hormones
 Depends upon stress, illness, menses, BG
control
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Somogyi Effect
Rebound hyperglycemia
 First hypoglycemia followed by
hyperglycemia
 Difficult to distinguish from dawn
phenomenon
 Need a blood glucose reading from 2-3 am
to diagnose
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Immunizations
Annual influenza vaccine
 Pneumococcal vaccine
 Once for all patients with diabetes and
age 2 or older
 Repeat the vaccine after age 65 if they
have not received the vaccine in the last 5
years
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Adjusting A1C goals
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Older adults who are functional and cognitively
intact should have the same goals as younger
patients
For older adults who are not fully functional or
have cognitive disabilities, the goals can be
relaxed
Screening for complications should be
individualized
Hypertension should be treated in all patients
Anti-platelet and anti-lipid therapies should be
individualized
Adjusting A1C goals
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Even while relaxing A1C goals, care should
be taken to to avoid symptoms and acute
complications associated with
hyperglycemia or hypoglycemia