Transcript Slide Deck - Rational Prescribing

Last Modified September,
2015
In-Class Presentation:
Diabetes module
Funded by the Ministry of Health and Long Term Care and Sponsored by HealthForceOntario
Acknowledgements
Original materials developed by:
Lori MacCallum, BScPhm, PharmD
Onil Bhattacharyya, MD, PhD
Reviewed and revised by:
Rational Prescribing Management Team
The views expressed are those of the project team and do not
necessarily reflect those of the Agency.
Outline
• Activation Exercise
• Framework
• Case
– Diagnosis
– Guidelines
– Therapeutic Alternatives
– Prescription Writing
– Monitoring Plan
• Mini Cases
Activation Exercise:
Glucose Metabolism
Activation Exercise:
Glucose Metabolism
 Break off into small groups of 3-5 people
 List various drug classes and agents within each
class
 On the diagram, indicate if each class has a positive
(+) or negative (-) effect on the pathophysiology of
diabetes
 If you could design a new class of drug to treat DM,
describe what it would be and how it would work
 You have 10 minutes. Go!
Activation Exercise:
Answer
SGLT-2
inhibitor
Framework for Drug Prescribing
1. Identify the problem or diagnosis that requires
treatment
2. Identify all potentially effective treatment modalities
3. Select the best drug for the specific patient
– I Can PresCribE A Drug mnemonic.
I Can PresCribE A Drug
I
C
P
C
E
A
D
Indication
Contraindications
Precautions
Cost/Compliance
Effectiveness
Adverse Effects
Dose/Duration
Framework Continued
4. Write the prescription
5. Develop and follow a monitoring plan for the drug
Case
You are about to see
63 year old Jamie West
Jamie West- Medications
•
•
•
•
•
•
•
•
•
Metformin 1000 mg BID (with breakfast, supper)
Glyburide 10 mg BID (with breakfast, supper)
Telmisartan 80 mg QAM
Atenolol 25 mg QHS
ECASA 81 mg daily (with supper)
Coumadin® 2 mg daily (with supper)
Simvastatin 20 mg QHS
Glucosamine sulfate 500 mg TID with meals
Centrum Forte® 1 tab daily (with breakfast)
Jamie West’s Labs:1 month ago
• Hematology:
– Hb 126, WBC 6.7, Plt 375
• Chemistry:
– Na 137 [135-145], K 4.7 [3.5-5.0], Cl 100 [96-106], CO2 24
[22-30]
– SCr 123 [52-112], FBS 8.5 [4.0-6.0]
– HbA1c 0.089 [0.046-0.06]
– AST 23 [7-40], ALT 36 [10-45], ALP 94 [35-125] , GGT 61
[8-78]
– INR 2.4
STEP 1
Identify the problem or diagnosis
that requires treatment
Diabetes
• Diabetes affects 1.8 million Canadians
• 70% of deaths in diabetes are due to cardiovascular
disease (CVD)
• Multifactorial risk reduction (glycemia, blood pressure,
cholesterol) reduces risk of complications by ~50%*
• Glycemic control is important to reduce microvascular
complications
*STENO-2, Gaede P et al; N Engl J Med 2003; 348(5):383-393
Normal glucose metabolism
• Postprandial elevations in serum glucose stimulate insulin
synthesis and release from pancreatic beta cells
• Insulin binds to receptors in skeletal muscle, adipose
tissue and liver
• Insulin binding
• Inhibits glucose production in liver
• Suppresses lipolysis in adipose tissue
• Stimulates glucose uptake in muscle, fat
Diabetes: metabolic abnormality
• Decreased insulin secretion
• Increased resistance to insulin at tissues
– Muscle, liver, adipose
– Increase visceral adiposity, dyslipidemia, hypertension
– Lipolysis-  FFA impair beta cells, glucose uptake by
muscle
• Hyperglycemia further impairs above
Diagnosis of Diabetes
http://guidelines.diabetes.ca/
Metabolic Syndrome
National
Cholesterol
Education
Program
Adult
Treatment
Program
III criteria
Risk Factor
Defining Level
FBG
> 6.1 mmol/L
BP
> 130/85 mm Hg
TG
>1.7 mmol/L
HDL-C
Men
Women
<1.0 mmol/L
<1.3 mmol/L
Abdominal Obesity
Men
Women
Waist circumference
≥102 cm
≥ 88 cm
Targets in Diabetes
http://guidelines.diabetes.ca/
Targets in Diabetes (2)
• FBG/preprandial 4.0-7.0 mmol/L
• 2 hour post-prandial 5.0-10.0 mmol/L (5-8 if A1c targets
are not being met)
• BP ≤ 130/80 mmHg
• LDL ≤ 2 mmol/L and Total Chol/ HDL ≤ 4
Targets Among Frail Elderly
Parameter
Target
A1C
≤ 8.5%
FPG or
preprandial glucose
5.0-12.0 mmol/L
(depending on level of frailty)
Avoid Hypoglycemia
http://guidelines.diabetes.ca/
Clinical Pearls for Vascular Protection
http://guidelines.diabetes.ca/
STEP 2
Identify All Potentially Effective
Treatment Modalities
Non-Pharmacological Prevention of Progression to
Diabetes
• Weight loss
– 5% loss of body weight can reduce risk of progression
from IGT to diabetes by 58% at 4 years
– Study targeted weight loss with low-calorie, low fat,
low saturated fat, high fibre diet AND moderate
intensity phyisical activity of at least 150 minutes per
week
http://guidelines.diabetes.ca/
Non-Pharmacological Treatment of Type II DM
•
Exercise
– 150 minutes of moderate to vigorous aerobic activity a week over
minimum of 3 days/week (no >2 consecutive days without exercise)
– Resistance exercise 2-3X/week as well
– Consider baseline ECG +/- stress test prior to exercise especially for
sedentary
•
Diet
– Can reduce A1C by 1-2%
– Counseling by dietitian more effective
– Consistent CHO intake, spacing and regularity of meals important;
choosing lower glycemic intake foods; low saturated fat diet
•
Group self-management program
– Can reduce A1C by 1%
•
Bariatric surgery
– May be considered for appropriate patients when other interventions fail
•
Complementary/Alternative Medicine
– Some NHPs have shown lowering of A1c by 0.5% in trials lasting <3 mo
but most are single trials – more research is required
http://guidelines.diabetes.ca/
– Chromium – conflicting evidence
Carb Counting – the very basics
• Basic: Manage blood sugar and plan meals
• Carb counters available in books, websites, downloads
• 1 portion is 15 gram of carbohydrate
• DM patients need 50-55% of their kcal as low glycemic,
high fibre carb per day
• Advance: Look at meal, estimate the carbo count then
give short acting insulin by injection or pump
– Clinician prescribes a ratio of insulin to carb
– Eg: if ratio is 1:15 eating 45 gm of carb need 3 u insulin
• Consult diabetes education center or registered dietitian
Clinical Guidelines and Evidence
CDA Clinical Practice Guidelines
• Pharmacological treatment regimens should
consider
–
–
–
–
–
–
Degree of hyperglycemia
Effectiveness of agents
Contraindications
Risk of hypoglycemia
Presence of complications or comorbidities, and
Patient preferences
Therapeutic Options for Hyperglycemia
• Biguanides (e.g. metformin)
• Insulin secretagogues
– Sulfonylureas (e.g. glyburide, gliclazide), Meglitinides (e.g.
repaglinide, nateglinide)
• Insulin
• Dipeptidyl peptidase-4 Inhibitors (e.g. sitagliptin)
• Glucagon-Like Peptide-1 (GLP-1) agonists (e.g. liraglutide)
• Alpha-glucosidase inhibitors (e.g. acarbose)
• Thiazolidinediones (e.g. pioglitazone, rosiglitazone)
• Weight loss agents (e.g. orlistat)
• SGLT-2 inhibitors (e.g. canagliflozin)
Pharmacologic Treatment of Diabetes
• Metformin should be the initial drug used in most
patients
• Most drugs reduce A1C by 0.5-1.5% as monotherapy
• If A1C > 8.5%, consider starting more than one agent
with metformin or insulin
• Aim to achieve A1c targets w/in 3-6 months
• If not approaching targets by 2-3 months with lifestyle,
consider medication
• If considering insulin, start with an intermediate
(NPH) or long acting insulin analogue (glargine or
detemir) at bedtime
http://guidelines.diabetes.ca/
http://guidelines.diabetes.ca/
Therapeutic Controversies: Glycemic targets
• Does lowering A1C reduce cardiovascular disease and
mortality?
– Target of A1C ≤ 6% increased mortality in high risk (of
CV dz) patients (ACCORD trial)
– A1C ≤ 6.5% did not reduce CVD in two trials (VADT +
ADVANCE)
• But A1C ≤ 6.5% reduced nephropathy, though more
hypoglycemia
– Long term follow-up of patients with tight control after
diagnosis found reduction in mortality + CVD (UKPDS)
– Tighter control DOES lead to decreases in
microvascular complications but hypoglycemic events
increase
STEP 3
Select the best drug for the specific patient
Classes of antihyperglycemic drugs
Class
Selected Drugs
Biguanides
Metformin
Insulin
secretagogues
Glyburide
Gliclazide
Repaglinide
Insulin lispro
Insulin detemir
√
Sitagliptin
Saxagliptin
Linagliptin
Acarbose
√
Insulin
DPP-4
inhibitors
α-glucosidase
inhibitors
Thiazolidinediones
GLP-1
agonists
SGLT-2
inhibitors
Rosiglitazone
Pioglitazone
Liraglutide
Exanetide
Canagliflozin
Dapagliflozin
Empagliflozin
Increase Decrease
Insulin
Insulin
Resistance
√
Decrease
Hepatic
Glucose
Output
Delay
Decrease
absorption of
reabsorption
carbohydrates of glucose in
kidney
√
√
√
√
√
√
√
√
Efficacy of Alternatives
Agents/Class
Effect on
HbA1c
Major Clinical Trial Outcomes
Biguanides
↓ 1.0-1.5%
↓ microvascular complications
↓ macrovascular (in obese pts) UKPDS
↓ LDL Cochrane
GLP-1 agonist
↓ 1.0%
N/A
SGLT-2 inhibitors
↓ 0.7-1.0%
N/A
Sulfonylureas
↓ 0.8%
↓ microvascular complications UKPDS
TZDs
↓ 0.8%
↓ macrovascular (stroke and non-fatal MI
but ↑ CHF) PROactive (in patients with
existing CVD) ↑ HDL & LDL Cochrane
Meglitinides
↓ 0.7%
N/A
DPP-4 inhibitors
↓ 0.7%
N/A
Alpha glucosidase
inhibitor
↓ 0.6%
N/A
I Can PresCribE A Drug
I
C
P
C
E
A
D
Indication
Contraindications
Precautions
Cost/Compliance
Effectiveness
Adverse Effects
Dose/Duration
Therapeutic Alternatives:
Background
Biguanides e.g. metformin
Indication/ role:
• First line agent
• Reduces mortality and DM related end points (UKPDS)
Contraindications/ Precautions:
• Contraindicated: Severe renal impairment, liver disease
• Caution if CrCl < 60 ml/min (max dose 1000mg/day);
Avoid if CrCl <30 ml/min (CDA guidelines)
• Hold x 48 hrs for contrast dye
Biguanides
Adverse effects:
– Weight loss (~2.9 kg) –OFTEN A POSITIVE!
– Abdominal pain, nausea, diarrhea (5-20% initially)
– Vitamin B12/ folic deficiency
Dose:
• Metformin 250-500 mg to 1000 mg bid (max 2500mg/d)
• Metformin 850 mg tablets
• Metformin ER (Glumetza®) 1000-2000 mg q evening
• Metformin/rosiglitazone = Avandamet®
• Last three agents not covered by ODB
Insulin Secretagogues:
Sulfonylureas e.g. glyburide, gliclazide, glimepiride
Indication/ Role:
• Indicated as first line therapy due to ability to reduce
microvascular complications (UKPDS)
Contraindications:
• Severe renal, liver or thyroid impairment
– Low possibility of cross reaction with sulpha allergy
Sulfonylureas
Adverse effects:
• weight gain (2-3kg)/ hypoglycemia
Drug interactions:
– ETOH, sulfonamides, salicylates, warfarin (worsening
hypoglycemia)
– Steroids, OCP, niacin, thiazides, decongestants,
thyroid hormones (hyperglycemia)
Dose/ Administration:
• Most BS lowering effect achieved at 50-70% of max dose
• Glimepiride – not covered by ODB
Sulfonylureas
Clinical Pearls:
– Risk of hypoglycemia may be increased if:
• Elderly
• Renal impairment- glyburide is contraindicated in
patients with CKD (has active metabolites)
– gliclazide is less renally eliminated and has much shorter
half life so better choice in this population.
• Liver impairment
• Drug Interactions which may prolong duration of actionAlways Check!
Insulin Secretagogues:
Meglitinides e.g. repaglinide, nateglinide
Indication/ role:
• Good for postprandial hyperglycemia and erratic meal
schedule (e.g. Ramadan)
• Can be considered for patients with renal impairment and
hypoglycemia secondary to sulfonylureas
• Take 0-30 min before meals
Meglitinides
Contraindication/ precaution:
• Caution with adrenal / pituitary deficiency, elderly
(increased susceptibility to hypoglycemia)
Adverse effects:
• weight gain/ hypoglycemia
Drug interactions:
• Metabolized liver cytochrome P450 CYP 3A4
– Inhibited by ketoconazole, miconazole, erythromycin
(raise level, hypoglycemia)
– Induced by rifampin, barbiturates, carbamazepine
Dipeptidyl Peptidase-4 Inhibitors
e.g. sitagliptan, saxagliptin, linagliptin, alogliptin
Indication/ role:
• Add on therapy (No weight gain & minimal hypoglycemia)
– **Long term safety not yet established**
– Sitagliptin and Linagliptin has monotherapy indication
Contraindications:
• Saxagliptin is contraindicated in chronic kidney disease
Precautions:
• Acute pancreatitis has been reported. Use caution in patients
with risk factors for pancreatitis e.g. history of pancreatitis,
gallstones, alcoholism, or hypertriglyceridemia
DPP-4 Inhibitors
Adverse effects:
• Nasopharyngitis, headaches, nausea
• Excess of urinary tract infections versus comparators
• Can have hypersensitivity reactions (e.g. anaphylaxis, SJS)
Dose:
• Sitagliptin (Januvia®) 100 mg daily with or without food; 50 mg daily
for CrCl 30-50ml/min and 25 mg daily for CrCl <30 ml/min
• Saxagliptin (Onglyza®) 2.5 – 5 mg daily; 2.5 mg daily for CrCl
<50ml/min
• Linagliptin (Trajenta®) 5 mg daily
• Alogliptin (Nesina®) 25 mg daily; 12.5 mg daily for CrCl 30-50ml/min
and 6.25 mg daily for CrCl <30ml/min
• Cost: ~$3/pill (similar to TZDs); covered by ODB except alogliptin
Glucagon-like peptide-1 (GLP-1) agonist
e.g. liraglutide, exenatide
Indication/ role:
• Add on therapy to metformin or metformin + sulfonylurea
– **Long term safety not yet established**
Contraindications:
•
•
Liraglutide: - personal or family history of medullary thyroid
carcinoma or in patients with Multiple Endocrine Neoplasia
syndrome type 2
Exenatide - ESRD
Warnings and Precautions:
• Cardiovascular - Increase in HR, PR interval prolongation
• Avoid in moderate to severe renal and in hepatic insufficiency
Glucagon-like peptide-1 (GLP-1) agonist
Adverse effects:
• Dose-related GI effects (nausea, vomiting, diarrhea)
– More frequent in first few weeks; titrate dose
• Hypoglycemia is rare; increased risk when used with sulfonylurea
• Injection site reactions (2%) – bruising and pain
Dose:
• Liraglutide - 0.6 mg SC once daily x 1 week (at any time, independent
of meals); then increase to 1.2 mg once daily; can increase further to
1.8 mg/day for maximal effect
• Exenatide - 5 mcg SC bid (60 minutes prior to meals); can increase to
10 mcg SC bid after 1 month
• Cost ~ $5-7/day
Incretins: GLP-1 agonists vs. DPP-4 inhibitors
GLP – 1 receptor agonists
DPP-4 inhibitors
e.g. Liraglutide (Victoza)
e.g. Sitagliptin (Januvia)
Increases GLP-1 to supraphysiological levels
Modest increase in GLP-1 signal
Robust glucose lowering efficacy (HbA1c  0.8-1.5% - Moderate glucose lowering efficacy (HbA1c  0.7%)
liraglutide; 0.5-1.0% for exenatide) )
Weight reduction
Weight neutrality
Transient GI AE
Little potential for GI effects;
Main SE: increased HA, infection, dermatological effects
Improvement in CV parameters (BP, lipids, chol)
No marked effects on CV parameters
Hypoglycemic risk low
Hypoglycemic risk low
SC injection: 0.6, 1.2, 1.8 mg, independent of meals
Oral route: Saxagliptin 5mg daily, Sitagliptin 100mg daily
Cost: ~$150-230 per 30 days
Cost: ~ $85 per 30 days
Alpha Glucosidase Inhibitors
e.g. acarbose
Indication/ role:
• 2nd/ 3rd line agent (< 1% decrease in A1C)
Precaution:
• Caution if hypoglycemia develops when used in combo
treatment- treat with glucose
Adverse effects:
• flatulence, GI upset, diarrhea
Dose:
• TID with first bite of meals
• Limited Use code required in Ontario
Thiazolidinediones (TZDs)
e.g. rosiglitazone, pioglitazone
Indication/ role:
• Indicated as add-on therapy
Contraindication:
• All classes of heart failure
Thiazolidinediones (TZDs)
Adverse effects:
• Edema
• Weight gain (~3-5 kg)
• ALT elevations reported
• CV outcomes? (see next slide)
• Possible increase in fracture risk (in females)
Dose:
• Pioglitazone 15-45 mg daily
• Rosiglitazone 4-8 mg daily
• Onset ~ 2 weeks; max benefit 8-12 weeks
Thiazolidinediones (TZDs)
• Cardiovascular Risk:
– Meta-analyses small trials = increase risk with
rosiglitazone
– Larger trials couldn’t exclude risk (RECORD) or no
evidence harm/ benefit (BARI 2D)
Weight loss agents
Orlistat
Indication/ role:
• Use in combo with drugs, hypocaloric diet, exercise
Contraindication:
• Chronic malabsorption syndrome
Adverse effects:
• diarrhea, GI (oily stool, spotting)
Dose:
• Orlistat 120 mg po tid with each meal
• Supplement with fat soluble multivitamin
Sodium-Glucose Transporter 2 Inhibitors
(SGLT-2 inhibitors)
e.g. canagliflozin, dapagliflozin, empagliflozin
Indication/ role:
• Indicated as monotherapy or as add-on therapy
Contraindication:
• Moderate to severe renal impairment
Precautions:
• Rise in SCr, dehydration, postural hypotension,
hyperkalemia
Sodium-Glucose Transporter 2 Inhibitors
(SGLT-2 inhibitors)
e.g. canagliflozin, dapagliflozin, empagliflozin
Adverse effects:
• Genital fungal infections, UTIs, postural hypotension
Dose:
• Canagliflozin 100 mg po daily. May be increased to 300 mg
daily.
• Dapagliflozin 5 mg po daily. May be increased to 10 mg
daily.
• Empagliflozin 10 mg po daily. May be increased to 25 mg
daily
• Cost ~ $3/day
Insulin
Indication/ role:
• Symptomatic hyperglycemia, metabolic decompensation,
pregnancy
• Can be added when A1C ≥ 8.5%
• Greatest A1C reduction, no max dose
Adverse effects:
• weight gain, hypoglycemia
http://guidelines.diabetes.ca/
Serum Insulin Level
Human Basal: Humulin-N, Novolin ge NPH
Analogue Basal: Lantus, Levemir
Human Bolus: Humulin-R, Novolin ge Toronto
Analogue Bolus: Apidra, Humalog, NovoRapid
http://guidelines.diabetes.ca/
Human Premixed: Humulin 30/70, Novolin ge 30/70
Analogue Premixed: Humalog Mix25, NovoMix 30
http://guidelines.diabetes.ca/
http://ocfp.on.ca/docs/defaultsource/clinical-tools/insulin-titration--insulin-prescription-november-2014v4.pdf?sfvrsn=2
http://guidelines.diabetes.ca/BloodGluc
oseLowering/InsulinPrescriptionTool
Oral hypoglycemics-Combo
• Combination of submaximal doses of hypoglycemic
agents gains better control over max dose of a single
agent
• Good evidence with:
– Metformin PLUS sulfonylureas OR meglitinides OR
TZDs OR DPP-4 OR GLP-1 OR SGLT-2
• Some evidence for triple therapy:
– Metformin PLUS sulfonylurea PLUS DDP-4 or GLP-1 or
SGLT-2 - if close to target with 2 agents
– NOTE: Metformin PLUS sulfonylurea PLUS TZD not
recommended by product monograph
– Adding insulin is more effective at lowering A1c if
markedly elevated and is likely less expensive
Oral hypoglycemics with Insulin Combo
• Single injection of intermediate or long acting insulin at
bedtime with oral hypoglycemic helps gain control
– Biguanide + bedtime insulin=less wt gain
• When adding insulin stop TZD right away
– Then stop sulfonylurea when sugars controlled
– Can keep metformin permanently
• If unable to get sugars under control with both
insulin/oral hypoglycemic consider adding prandial
insulin or moving to a mixture of rapid/short acting and
NPH (i.e. 30/70) bid-tid
Selected Drug Costs
Selected Diabetic Agents
Starting Dose
Monthly Cost for Usual Doses
Glyburide
5mg po bid
$5 – 10
Gliclazide MR
30mg po qam
$15 – 20
Glimepiride
1mg po daily
$15 – 20
Repaglinide
0.5mg po tid
$20 – 30
Metformin
500mg po bid
$5 – 10
Pioglitazone
30mg po daily
$20 – 35
Acarbose
50mg po bid
$30 – 45
Sitagliptin
100mg po daily
~$100
Saxagliptin
5mg po daily
~$100
Liraglutide
1.2mg SC daily
~$250
Exanetide
10mcg SC daily
~$150
Canagliflozin
100mg po daily
~$100
Orlistat
120mg po tid
~$120
Insulin R
Per 10mL vial
~$20
Insulin Lispro (Humalog)
Per 10mL vial
~$25
Insulin NPH
Per 10mL vial
~$40
Insulin 30/70
Per 10mL vial
~$20
Insulin Glargine (Lantus)
Per 10mL vial
~$60
Insulin Detemir (Levemir)
For 3x5mL cartridges
~$100
Select the best drug
Exercise:
• Considering indications, contraindications,
precautions, cost/compliance, effectiveness and
adverse effects, what is the best alternative for
managing Jamie West at this time?
STEP 4
Write the prescription
For the alternative chosen write a
prescription
Can you spot the errors in this INITIAL Rx?
Northwest Family Health Centre
398 Oak Street, Maintown, ON
Patient Name: D.M.
Date: December 9, 2009
Rx:
Drug: Diabeta 10 mg OD
M: 100 tablets
Repeat:3
Dr. Smith
Include patient’s address
Use generic name when
possible
Initial dose of 2.5 or 5 mg
more appropriate
Use separate line to write
directions; include route
1 month supply
preferred for new meds
Prescriber’s name should
be printed and
registration # included
Step 5
Develop and Follow a Monitoring Plan
for the Drug
Monitoring
Agent
Parameter
Insulin, insulin secretagogues
Weight gain
Hypoglycemia- every patient taking one of these
agents should be counseled on how to recognize
symptoms and how to properly treat
Biguanides
GI upset, diarrhea; monitor Scr in case of need for
dosage adjustments
Alpha Glucosidase Inhibitors
GI upset, bloating
TZDs
Fluid retention, weight gain, shortness of breath,
AST
DPP-4 Inhibitor
Nasopharyngitis, headache
GLP-1 analogue
GI upset, injection site reactions
SGLT-2 inhibitors
Blood pressure, potassium, SCr
Monitoring
• Ensure patient education re. monitoring of diabetes to improve
compliance
–
–
–
–
–
–
–
–
–
Glucometer and bringing readings to appointments
HbA1c q 3 mos
Q 1-3 yrs lipids
Yearly urine albumin:creatinine
Cr/lytes?, LFTs? – depending on meds
ECG baseline and q 2 yrs for over 40 yo, HTN, proteinuria
Stress ECG if starting new exercise program and sedentary
Yearly eye checks
Yearly foot exams
Monitoring
Self Monitoring of Blood Glucose:
• Most patients with type 2 DM do not need routine SMBG
• Periodic testing for type 2 DM on oral agents:
•
– Acute illness
– Unstable BS levels requiring drug changes
– Risk of hypoglycemia from secretagogues
– On other meds that induced hyperglycemia
– Newly diagnosed (<6 months)
http://guidelines.diabetes.ca/CDACPG_resources/SMBG_HCP_Tool_l
c_final.pdf
Patient Education
Hypoglycemia identification and management
•
•
•
Important aspect of diabetes management, especially for those taking
insulin and/or sulfonylureas
Symptoms: trembling, palpitations, sweating, anxiety, hunger,
nausea, tingling, confusion, difficulty concentrating, weakness,
drowsiness, vision changes, difficulty speaking, headache, dizziness
Encourage to carry 15 g CHOfor treatment of mild-mod
hypoglycemia, eg.:
– 15 g glucose – glucose tablet
– 15 ml (3 tsp) / 3 pkt table sugar dissolved in water
– 175 ml (3/4 c) juice or regular soft drink
– 6 lifesavers
– 15 ml (1 tbsp) honey
Choosing a glucometer
• Blood sample
• Test time
• Alternate site
testing
• Calibration/
coding
• Size
Patient Information
General information provided by the Canadian Diabetes Association
http://www.diabetes.ca
For patients interested in learning more about controlling and managing diabetes
http://www.diabetesselfmanagement.com/
Website with general and in-depth information on diabetes
http://www.mayoclinic.com/health/diabetes/DS01121
Comprehensive website for patients with diabetes
http://www.dshs.state.tx.us/diabetes/patient.shtm
Website which helps promote lifestyle and behavioural changes
http://www.sparkpeople.com
Healthy Eating website (Ontario)
http://www.eatrightontario.ca/en/default.aspx
Mini Case 1 – Jamie’s cousin
•
•
•
•
•
•
•
49 year old male Type 2 DM
Shift worker at Loblaws stocking shelves – has benefits
12 hour shifts change every 7 days
A1C 7.8%
Metformin 1000 mg po bid; glyburide 10 mg po bid
Eats largest meal at 11 PM-12 AM
Often skips meals because sleeping or eats in middle of
the night
Mini Case 1: Discussion
• How would you manage this patient?
• What changes to his medications would you make?
• What factors need to be considered for shift workers?
Write a prescription
Mini Case 2
• 67 year old male with Type II DM x 10 years
• Metformin 1000mg po bid; glyburide 5mg po bid
• Recently diagnosed with hypertension with BP ranging
from 140/85mmHg to 160/95mmHg:
• Had been started on:
– Hydrochlorothiazide 12.5mg po daily
– Metoprolol 25mg po bid
• Patient’s glucose is now in the 15’s
Mini Case 2: Discussion
• How would you manage this patient?
• What changes to his medications would you make?
• Which, if any, antihypertensives have an effect on blood
sugar?
Write a prescription
Mini Case 3
• 59 year old RN working at local hospital
• A1c 0.072, eGFR 30 (stable in past year)
• Meds:
– Metformin 1000 mg bid
– Glyburide 5 mg bid
– ASA 81 mg OD
– Lipitor 20 mg OD
• Frequent lows, especially overnight
Mini Case 3: Discussion
• How would you manage this patient?
• What changes to his medications would you make?
• Consider factors which may lead to nocturnal
hypoglycemia?
Dosing in Renal Impairment
5 mg
5 mg
100 mg
5 mcg bid
10 mcg bid
http://guidelines.diabetes.ca/
Write a prescription
Mini Case 4
•
•
•
•
48 yo male with Type II DM x 6 years
Obese, BMI 35
A1c 0.078; Fasting glucose avg. 12
Diabetes meds:
– Metformin 1000 mg bid
– Diamicron MR (glicazide) 30 mg 4 tabs daily
– Actos (pioglitazone) 45 mg OD
• You have decided to start insulin
• What regimen will you give? Which medications do you
stop? Which do you keep?
Adding bedtime insulin
• Use basal insulin
– Intermedite (NPH) or long acting (detemir, glargine)
• Starting dose: 10 units s/c qhs
• Titrate by 1 unit per day until target FBS 4-7 mmol/L
• Elderly/ normal weight adults: consider lower starting
dose, slower titration, higher targets
• Need to monitor at least fasting glucose daily initially
• Reduce insulin dose for fasting hypoglycemia (not oral
hypoglycemics)
Write a prescription
Mini Case 5
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•
•
•
Type I DM x 5 years
8AM: Humulin 30/70 30 units
6PM: Humulin 30/70 20 units
Logbook fasting readings:
8 AM
12 PM
6 PM
10 PM
6.9
8.9
11.5
9.5
6.7
8.2
12.6
11.1
5.3
8.1
13.2
9.0
Mini Case 5 Discussion
• How would you manage this patient?
– Is there a trend?
– Which area do you want to target first?
• What changes to his medications would you make?
Adjusting Insulin
• Get overall impression of results; exclude rare outliers (one bad
reading where most at the same time are ok)
• Look for hypoglycemia (how often, time of day, what is recovery
blood sugar, over-treated?)
• Look at fasting levels (within target, too high or too low, how
much do they vary from the night before)
• Look at post meal levels (how much higher than pre-meal
result, within target, vary greatly depending on meal)
• Ask about meal times and any variations to routine
• Ask about timing of medication
Adjusting Insulin
• Adjust insulin dose based on time of peak activity of insulin
and the meal targeted
• Adjust only 1 component of a regimen at a time
Time of BS test
Target Insulin
Target Meal
Pre breakfast
Pre dinner/HS (NPH, glargine, detemir)
HS snack
Pre lunch
Pre breakfast (reg, aspart, lispro, glulisine) Breakfast or midmorning snack
Pre dinner
Pre breakfast (NPH, glargine, detemir) or
Pre lunch (reg, aspart, lispro, glulisine)
Lunch or afternoon
snack
Bedtime
Pre dinner (reg, aspart, lispro, glulisine)
Dinner
3 AM
Pre dinner/HS (NPH, glargine, detemir)
Dinner or bedtime
snack
Mini Case 6
• 8AM, 12PM and 6PM: Novorapid 8 units
• 10PM: Detemir 20 units
• Logbook fasting readings:
8 AM
12 PM
6 PM
10 PM
14.4
6.5
15.3
7.8
13.0
8.0
6.3
11.2
11.0
7.9
8.4
10.8
10.4
7.0
7.1
12.8
13.5
6.8
6.8
5.3
Mini Case 6 Discussion
• How would you manage this patient?
– Is there a trend?
– Which area do you want to target first?
• What changes to his medications would you make?
• Write a complete prescription
References
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•
Canadian Diabetes Association 2013 Clinical Practice
Guidelines + 2015 Updates
Available at:
http://guidelines.diabetes.ca
Additional Slides
Insulin and Cancer
Insulin and cancer
• 4 observational studies 2009 regarding association
between use of lantus (glargine) and cancer
– Breast cancer, all cancers
– Increasing dose confers increasing risk
• All studies reported some association between use of any
insulin and cancer risk
– more for Lantus in some studies
• Inconsistency of findings within and between the studies
– Smith U, Gale EM. Diabetologia. Online July 14, 2009
DM, insulin and cancer
• Type 2 DM associated with risk of certain cancers
– colon, pancreas and breast
• Mechanism likely hyperinsulinemia/insulin resistance
• Some insulins have higher affinity for IGF-1 receptor in
vitro
– Does insulin accelerate tumor growth???
– However no clear evidence that any insulin causes
cancer
• Metformin may be associated with lower rates of cancer
than insulin or sulfonylureas
What to tell patients about insulin and cancer
• Glucose control important
• If one needs to use insulin then use it
• Ensure patients are screened appropriately for cancer
– Mammograms, pap smears, colonoscopies etc
• Use metformin where possible -it may have some tumor
protective effect or neutralize the increased incidence of
cancer observed with insulin users
• Consider an alternate to glargine