Professional Documents
Culture Documents
in Type 2 Diabetes
What Intensification Plan is Best?
Outline
Introduction
Diagnostic Criteria
Treatment Goals
Intensification Guidelines
Changes in Lifestyle and Exercise.
Oral Agents.
Basal Insulin Analogs.
Insulin Intensification
Case Presentations
2
Introduction
Type 2 Diabetes Mellitus (Defn??)
Important to stay 1 step ahead
of T2DM.
Intensifying antihyperglycemic
therapy requires:
Guideline recommendations (ADA
& AACE).
Safe and effective plans based on
individual cases.
Introduction
Diabetes is not a
quick fix.
Regular follow-ups
needed.
Treatment adherence
is crucial.
Discuss goals of
treatment.
Educate patients.
Diagnostic criteria
Fasting Plasma Glucose.
Impaired Fasting Glucose.
Impaired Glucose Tolerance.
Plasma Glucose.
Glycated Hemoglobin.
A1C (%)
Treatment Goal
Individualize on the basis of age,
comorbidities, duration of disease, and
hypoglycemia risk:
In general, 6.5 for most*
Closer to normal for healthy
Less stringent for less healthy
FPG (mg/dL)
<110
<140
Treatment Goal
95*
140*
120*
60-99*
100-129*
6.0%*
Treatment Goal
Intensive/critical care
Glucose range, mg/dL
140-180*
<140*
<180*
Intensification Guidelines
Is a principle which
emphasize patient should be
treated based on:
Age
Degree of complication
Other co-morbid conditions
Oral Agents
Lifestyle
Change
and
Exercise
Intensificati
on Therapy
Basal
Insulin
Analogs
T2DM incidence
per 100 person-years
12
11
31%
10
8
6
58%
7.8
4.8
4
2
0
Intensive lifestyle
intervention*
(n=1079)
Metformin
850 mg BID
(n=1073)
Placebo
(n=1082)
*Goal: 7% reduction in baseline body weight through low-calorie, low-fat diet and 150 min/week moderate intensity exercise.
DPP, Diabetes Prevention Program; IGT, impaired glucose tolerance; T2D, type 2 diabetes.
DPP Research Group. N Engl J Med. 2002;346:393-403.
10 10
Oral Agents
11
Oral Agents
Class
-Glucosidase
inhibitors
Amylin analogue
Biguanide
Bile acid
sequestrant
Agent(s)
Acarbose
Miglitol
Available as
Precose or generic
Glyset
Pramlintide
Symlin
Metformin
Glucophage or
generic
Colesevelam
WelChol
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Bromocriptin
e
Nateglinide
Repaglinide
Nesina
Tradjenta
Onglyza
Januvia
DPP-4 inhibitors
Increase glucose-dependent
insulin secretion
Decrease glucagon secretion
Dopamine-2
agonist
Activates dopaminergic
receptors
Glinides
Cycloset
Starlix or generic
Prandin
12
Oral Agents
Class
GLP-1 receptor
agonists
SGLT2 inhibitors
Sulfonylureas
Thiazolidinedione
s
Agent(s)
Available as
Albiglutide
Dulaglutide
Exenatide
Exenatide XR
Liraglutide
Tanzeum
Trulicity
Byetta
Bydureon
Victoza
Canagliflozin
Dapagliflozin
Empagliflozin
Invokana
Farxiga
Jardiance
Glimepiride
Glipizide
Glyburide
Amaryl or generic
Glucotrol or
generic
Diaeta, Glynase,
Micronase, or
generic
Pioglitazone
Rosiglitazone
Actos
Avandia
GLP-1 = glucagon-like peptide; HGP = hepatic glucose production; SGLT2 = sodium glucose cotransporter 2.
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.
13
14
Dual therapy*
Triple therapy*
Metformin
GLP1RA
GLP1RA
GLP1RA
SGLT2I
SGLT2I
SGLT2I
DPP4I
TZD
DPP4I
TZD
Basal insulin
AGI
Basal insulin
DPP4I
TZD
Colesevelam
Colesevelam
SU/glinide
BCR-QR
BCR-QR
AGI
AGI
SU/glinide
SU/glinide
AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors;
GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU =
sulfonylureas; TZD = thiazolidinediones.
*Intensify therapy whenever A1C exceeds individualized target. Boldface denotes little or no risk of hypoglycemia or weight gain, few
adverse events, and/or the possibility of benefits beyond glucose-lowering.
15
Hypoglycemia
Cognitive & psychological changes.
Accidents & falls.
CV Effects.
16
Pharmacokinetics of Insulin
Onset
(h)
Peak (h)
Duration
(h)
NPH
2-4
4-10
10-16
Ba
sal Glargine
Detemir
~1-4
No pronounced
peak*
Up to 24
Ba Regular U-500
sal
Pr
an
dia
l
0.5
~2-3
12-24
Pr Regular
an
dia
l
Aspart
Glulisine
Lispro
Inhaled insulin
~0.5-1
~2-3
Up to 8
<0.5
~0.5-2.5
~3-5
Agent
Considerations
Greater risk of nocturnal hypoglycemia compared
to insulin analogs
Less nocturnal hypoglycemia compared to NPH
17
18
19
20
Case Discussion 1
21
Case Discussion 2
48-year old Hispanic woman comes to her doctor for
recommendations about her weight. She is married, has
2 children in school and works full time as a bookkeeper.
She eats breakfast and dinner at home, and buys lunch
at various locations.
22
Case Discussion 3
John is a 55 year-old Caucasian man with diabetes
and asthma. He teaches math at a local high school
in New York City. He was diagnosed with type 2
diabetes on blood tests performed when he applied
for life insurance at age 51. At the time, he was
obese, weighing 220 pounds at 5 feet, 10 inches
height (BMI = 31.6). With HbA1c level of 7.2%.
23
References
Management of hyperglycemia in type 2 diabetes: a
patient-centered approach; Diabetes care, volume
35,pg1364-1380; Silvio E.Inzucchi
Patient case discussions in TD: what intensification plan
is best?;Medscape education; Luingi F.Meneghini.
24
25