Diabetes: Lecture 2 Flashcards
Goal of Diabetes Management?
Reduce morbidity and mortality
Prevent or slow progression of late complications
Keep BG lvl as close to normal as possible
Keep pt free of symptoms of hyper/hypo glycemia
Maximize pt contribution to their health
Trialnet.org
ppl with Type 1 diabetes enter this study or have relatives
intent to find how insulin production can be preserved
Prediabetes A1c?
Between 5.7% and 6.4%
Patients with A1c between 5.5% and 6%…..
increased risk of DM in 5 years between 9-25%
Patients with A1c between 6.0% and 6.4%….
Increased risk of DM in 5 years between 25-50%
Those with prediabetes should be informed about increased risk for….
DM, CVD and how to reduce risk
Treatments for Prediabetes?
Metformin = 31% reduction in risk after 3 years
Diet and Exercise change = 57% reduction risk after 3 years
Method for that group was weight loss of 7% and 30min/day exercise. Low fat/high fiber diet
Good points Metformin Pre-DM?
strong evidence
Demonstrated long-term safety
as effective as lifestyle with DMI > 35
Women with History of GDM, metformin + lifestyle reduced risk to 50%
Bad points Metformin Pre-DM?
less effective than lifestyle changes
not better than placebo of those 60+
Big diabetes study?
DPP
Overall, only med considered for pre-DM?
Metformin, shown to be best for variety of reasons
ADA pre-DM recommendations
Screen yearly
Treat other CVD risk factors
DPP = lifestyle modification…Weight loss/Physical activity
Metformin considered those at high risk
ADA risk factors to be considered high risk?
A1c of pre-DM
DMI >35
60yr old +
Women w/ H/o GDM
Foods that don’t raise blood glucose?
Fats and proteins
Carbs = raise BG
Lifestyle changes with Type 1?
Carb count to determine insulin dose, meal planning with insulin timing
eat at consistent times, synchronized with insulin
Lifestyle changes in Type 2?
Moderate weight loss = 7% Moderate caloric restriction Pay attention to carbs Increase fiber Reduce salt
Carb info
1 serving = 15 grams
Limit to 3(W)-4(M) servings of Carb per meal or 1-2 serving per snack
Perfect plate method
1/2 = Veggies 1/4 = carbs 1/4 = protein
If still hungry, go back for veggies/protein
Quick Nutrition counseling diabetes?
No sugar sweetened beverages No juice Severly limit deserts Cheat less often Plan meals
Physical Activity Recommendation
Children w/DM or Pre-DM = 60min/day
Adults = 150min/week
- all adults, esp those with DM, decrease sedentary behavior*
Drug Therapy Type 1
Insulin = mandatory
Oral agents and GLP-1 RA injectables no indicated
Pramlintide (Symlin) info
indicated for Type 1
Not often used, injected at every meal but not very effective in glucose lowering.
V expensive ~$2500 month
Biguanide
Metformin
SGLT2 inhibitors
Canagliflozin (Invokana)
Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)
GLP-1RA
Exenatide* (Byetta and Bydureon) Liraglutide*(Victoza) Dulaglutide* (Trulicity) Lixisenatide (Adlyxin) Semaglutide* (Ozempic (SC) and Rybelsus (PO))
Sulfonylureas
insulin secretagogues
Glyburide* (Diabeta, Glynase)
Glipizide* (Glucotrol)
Non-SU Secretagogues
Repaglinide* (Prandin)
DPP4 inhibitors
Sitagliptin* (Januvia)
Saxagliptan* (Onglyza)
Linagliptin* (Tradjenta)
TZDs *Thiazolidinediones
Pioglitazone (Actos)
General 1st line therapy for Type 2 DM?
generally includes metformin and comprehensive lifestyle modifications
Depends on comorbidities, pt centered treatment factors
Type 2 DM w/ ASCVD
GLP and/or SGLT2i
Type 2 DM w/ HF
SGLT2i
Type 2 DM w/ CKD
Elevated UACR = SGLT2i preferred or GLP
No elevated UACR = GLP and/or SGLT2i
Metformin MOA
Inhibits Hepatic Glucose Production
Major efect îs decrease hepatic glucose output, lowering fasting BG levels
Also increases insulin sensitive and better uptake in the muscle
Miscellaneous Metformin info
Multiple generic Comes in combo w/ a bunch of stuff Pills are big IR and ER formulations *Generally add agents too, not replace with BG uncontrolled*
Metformin Efficacy
Reduce A1c ~1%, - 1.5%
reduced risk of micro/macrovascular complications
Decrease weight
Dose not cause hypoglycemia as monotherapy
UKPDS
landmark trial used to establish goals
Metformin Adverse Effect
GI = diarrhea,cramping,bloating (start low dose taper up, take w/ food, switch to ER)
B12 deficiency
Lactic acidosis = V rare
When to not use Metformin?
Known Hypersensitivity
Alcohol Abuse = LFTs 3x ULN
Liver Dysfunction = LFTs 3x ULN
Stop for acute serious medical situations that req restrictions, start 2 day after
Sig renal disease
When undergoing iodinated contrast media
Dose adjustment recommendations Metformin
eGFR > 60 = OK
eGFR = 45-59 = continue using, reduce dose
eGFR = 30-44 = Don’t start, can continue reduce 50%
eGFR < 30 = Should DC
Metformin IR Dosing
BID = due to side effects
Usually 1000mg BID
Max dose IR = 2550mg/day, stop ~ 2000mg
If GI sx not tolerated, go to ER
Metformin ER Dosing
can be dosed once daily
max dose is 1500mg/day of the 750mg
Metformin Monitoring
Compliance
A1c, renal function, B12 check
SMBG readings
Low blood sugar not expected with monotherapy
Don’t take on empty stomach, w/ meals
GI SE can decrease or go away after few weeks.
GLP-1 RA with proven cv benefit
Liraglutide (Victoza)
Semaglutide (Ozempic)
Dulaglutide (Trulicity)
SGLT2i with proven Cv benefit
Empagliflozin (Jardiance)
Canagliflozin (Invokana)
