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7/26/2019 Patient Case Discussion in Type 2 Diabetes
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Patient Case Discussioin Type 2 Diabetes
What Intensifcation Plan is Best?
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Outline
Introduction Diagnostic Criteria
Treatment Goals
Intensifcation Guidelines Changes in i!estyle and "#ercise$
Oral %gents$
Basal Insulin %nalogs$
Insulin Intensifcation
Case Presentations
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Introduction
Type 2 Diabetes &ellitus 'De!n??(
Important to stay ) step aheado! T2D&$
Intensi!ying antihyperglycemictherapy re*uires+
Guideline recommendations '%D%
, %%C"($ -a!e and e.ecti/e plans based on
indi/idual cases$
Intensifcation in order to meetcertain goal$
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Introduction
Diabetes is not a*uic1 f#$ egular !ollo34ups
needed$
Treatment adherence
is crucial$ Discuss goals o!treatment$
"ducate patients$
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Diagnostic criteria
6asting Plasma Glucose$ Impaired 6asting Glucose$
Impaired Glucose Tolerance$
Plasma Glucose$
Glycated 7emoglobin$
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Treatment Goals+ 9onpregnant %'Out Patient(
Parameter Treatment Goal
%)C ':(
Indi/iduali;e on the basis o! age$8 !or most Closer to normal !or healthy ess stringent !or @less healthyA
6PG 'mgd( ))
247our PPG 'mgd( )5
FPG = fasting plasma glucose; PPG = postprandial glucose.
Pro/ided target can be sa!ely achie/ed$
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Treatment Goals+ Pregnant Wome'Out Patient(
Condition Treatment Goal
Gestational diabetes mellitus (GDM)
Preprandial glucose< mgd =E8
)47our PPG< mgd =)5
247our PPG< mgd =)2
Preexisting T1D or T2D
Premeal< bedtime< and o/ernight glucose4EE
Pea1 PPG< mgd )4)2E
%)C =>$:
FPG = fasting plasma glucose; PPG = postprandial glucose.
Pro/ided target can be sa!ely achie/ed$
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Treatment Goals+ 9onpregnant %'In Patient(
Hospital Unit Treatment Goal
Intensive!riti!al !are
Glucose range< mgd )54)
General medi!ine and surger"# non$ICU
Premeal glucose< mgd )5
andom glucose< mgd )
ICU = intensive care unit.
Pro/ided target can be sa!ely achie/ed$
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Intensifcation Guidelines
Is a principle 3hichemphasi;e patient should betreated based on+
%ge
Degree o! complication
Other co4morbid conditions Intensifcati
on Therapy
i!estyleChange
and"#ercise
%Oral %gents
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Changes in i!estyle and "#ercis
i!estylemanagement is anintegral part o! T2D&management$
ealistic plan !or dietand physical acti/ityis necessary$
0
2
4
!
"0
"2
4.!
#.!
Intensive lifestyle
intervention*
(n=1079)
T2DMi
ncidence
per100person-years
Metfor"in
!#0 "$ %ID
(n=107&)
#!'
&1'
$Goal% #& reduction in 'aseline 'od( )eig*t t*roug* lo)+calorie, lo)+fat diet and -"0 min/)ee modera
PP, ia'etes Prevention Program; IG3, impaired glucose tolerance; 32, t(pe 2 dia'etes.
PP esearc* Group. N Engl J Med. 2002;54%565+405.
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Oral %gents
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Oral %gentsClass Primar" Me!%anism o& '!tion 'gent(s) 'vailable as
4Glucosidase
inhibitors
Delay carbohydrate
absorption !rom intestine
%carbose
&iglitol
Precose or gen
Glyset
%mylin analogue
Decrease glucagon secretion
-lo3 gastric emptying
Increase satiety
Pramlintide -ymlin
Biguanide
Decrease 7GP
Increase glucose upta1e in
muscle
&et!orminGlucophage orgeneric
Bile acidse*uestrant
Decrease 7GP?
Increase incretin le/els?Colese/elam WelChol
DPP45 inhibitors Increase glucose4dependent
insulin secretion
Decrease glucagon secretion
%logliptininagliptin-a#agliptin-itagliptin
9esinaTradHentaOngly;aanu/ia
Dopamine42agonist
%cti/ates dopaminergic
receptors
Bromocriptine
Cycloset
Glinides Increase insulin secretion9ateglinideepaglinide
-tarli# or generPrandin
"2
PP+4 = dipeptid(l peptidase; 7GP = *epatic glucose production.
Gar'er 89, et al. Endocr Pract. 20"5;"6:suppl 2%"+4!. In, et al. Diabetes Care. 20"2;5%"54+"5#6.
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Oral %gentsClass Primar" Me!%anism o& '!tion 'gent(s) 'vailable as
GP4) receptoragonists
Increase glucose4dependent
insulin secretion Decrease glucagon secretion
-lo3 gastric emptying
Increase satiety
%lbiglutide
Dulaglutide"#enatide"#enatide Jiraglutide
Tan;eum
TrulicityByettaBydureonKicto;a
-GT2 inhibitors Increase urinary e#cretion o!
glucose
CanagliLo;inDapagliLo;in"mpagliLo;in
In/o1ana6ar#igaardiance
-ul!onylureas Increase insulin secretion
GlimepirideGlipi;ideGlyburide
%maryl or geneGlucotrol orgeneric
Diaeta< Glyna
&icronase< orgeneric
Thia;olidinediones
Increase glucose upta1e in
muscle and !at
Decrease 7GP
Pioglita;oneosiglita;one
%ctos%/andia
"5
G?P+" = glucagon+lie peptide; 7GP = *epatic glucose production; G?32 = sodium glucose cotransporter 2.
Gar'er 89, et al. Endocr Pract. 20"5;"6:suppl 2%"+4!. In, et al. Diabetes Care. 20"2;5%"54+"5#6.
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Intensifcation Plan+ &ono< Dual< anTriple Therapy !or T2D&
"
8GI = +glucosidase in*i'itors; @C+A = 'romocriptine Buic release; Coles = colesevelam; PP4I = dipeptid(l peptidase 4 in*i'itors;G?P"8 = glucagon+lie peptide " receptor agonists; et = metformin; G?32I = sodium+glucose cotransporter 2 in*i'itors; U =sulfon(lureas; 3D = t*ia
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Basal Insulin %nalogs
DoesnRt ha/e to be permanent$ -a!e and e.ecti/e$
But o/erly aggressi/e hypoglycemia$
7ypoglycemia Cogniti/e , psychological changes$
%ccidents , !alls$ CK ".ects$
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Pharmaco1inetics o! Insulin'gent
+nset(%)
Pea, (%)Duration
(%)Considerations
-asal
9P7 245 54) )4)> Greater ris1 o! nocturnal hypoglyce
to insulin analogs
GlargineDetemir
S)45 9o pronouncedpea1
p to 25N ess nocturnal hypoglycemia comp
-asal$
Prandial
egular 48 =$8 S240 )2425 InHect 0 min be!ore a meal Indicated !or highly insulin res
indi/iduals se caution 3hen measuring d
inad/ertent o/erdose
Prandial
egular S$84) S240 p to &ust be inHected 0458 min be InHection 3ith or a!ter a meal c
ris1 !or hypoglycemia
%spartGlulisineisproInhaled insulin
$8 S$842$8 S048 Can be administered 4)8 min ess ris1 o! postprandial hypog
compared to regular insulin
$ >1*i'its a pea at *ig*er dosages.
E ose+dependent.
P7, eutral Protamine 7agedorn.og*issi > et al. Endocr Pract. 20"5;"6%2+5. 7umulin U+00 :concentrated insulin prescri'ing information. Indianapolis% ?ill( U8, ??C.
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Case Discussion )
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Case Discussion 2 54year old 7ispanic 3oman comes to her doctor
recommendations about her 3eight$ -he is married<
2 children in school and 3or1s !ull time as a boo11ee-he eats brea1!ast and dinner at home< and buys luat /arious locations$
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Case Discussion 0ohn is a 88 year4old Caucasian man 3ith diabet
and asthma$ 7e teaches math at a local high schoin 9e3 or1 City$ 7e 3as diagnosed 3ith typediabetes on blood tests per!ormed 3hen he appli!or li!e insurance at age 8)$ %t the time< he 3obese< 3eighing 22 pounds at 8 !eet< ) inch
height 'B&I U 0)$>($ With 7b%)c le/el o! F$2:$
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e!erences
Management of hyperglycemia in type 2 diabetepatient-centered approachV Diabetes care< /olum0854)0V -il/io "$In;ucchi
Patient case discussions in TD: what intensicatiis best?V&edscape educationV uingi 6$&eneghin
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