DM Individualized Therapy Flashcards
What is the first line therapy for DM?
Metformin + Comprehensive lifestyle changes
- Metformin should be continued as long as possible
If A1c is elevated, may consider early combination therapy
If the patient has history of ASCVD, HF, or CKD,
What can we consider adding?
ASCVD:
- SGLT2i (Empa, Cana)
- GLP-1 agonist
HF:
- SGLT2i (Empa, Dapa)
- AVOID TZD
CKD:
- SGLT2i (Dapa) > GLP-1 agonist
If Metformin has been added but A1c is still above target goal, and pt needs to minimize hypoglycemia risk, what should we avoid?
*To reduce hypoglycemia risk, avoid those that secrete insulin:
- Insulin
- Sulfonylurea
Can consider:
- DPP4i
- GLP-1 agonist
- SGLT2i
- TZD
If Metformin has been added but A1c is still above target goal, and pt needs to lose weight, what can we add?
*Those that have weight loss benefits:
- GLP-1 agonist (reduce appetite, N/V, diarrhea)
- SGLT2i (diuresis)
The next best option is DPP4i which is weight neutral, but DO NOT use with GLP-1 agonist
The rest are a/w weight gain: SU, TZD, insulin
If Metformin has been added but A1c is still above target goal, and pt needs to be on additional drugs but has financial difficulties, what might we choose?
SUs > TZDs > DPP4i
Afterwards, then consider SGLT2i, insulin which are more expensive options
*Older drugs are cheaper
If greater glucose lowering is needed than can be obtained with oral agents, which injectable should be recommended first?
GLP-1 agonist (Liraglutide)
What are the considerations before deciding to add insulin into the therapy?
- Ongoing catabolism (weight loss) - possibly suspect delayed T1DM
- Symptoms of hyperglycemia
- A1c >10%
- Random BG >16.7mmol/L
[INSULIN INITIATION & TITRATION]
At what dose should insulin be initiated?
Initiate BASAL insulin or BEDTIME NPH insulin, at 10IU a day OR 0.1-0.2IU/kg a day
*Never start above 10IU
[INSULIN INITIATION & TITRATION]
Why might patients be less likely to initiate insulin with long-acting Glargine, Detemir, Degludec etc.?
More expensive, typically start with BEDTIME NPH <10units
[INSULIN INITIATION & TITRATION]
Why do we initiate with basal control?
Target FPG first, since high HbA1c is mainly contributed by FPG
[INSULIN INITIATION & TITRATION]
If A1c continues to be uncontrolled despite basal insulin initiation, how should we increase insulin dose to continue to act on FPG?
Increase insulin by 2 units every 3 days, until FPG is at goal (5.0-7.0mmol/L)
*Has to be consecutive 3 days
May increase up to 4 units every 3 days if FPG is consistently >10mmol/L
[INSULIN INITIATION & TITRATION]
If there is unexplained hypoglycemia and uncontrolled A1c after initiating basal insulin, how should we adjust insulin dose?
Decrease insulin dose by 10-20%
[INSULIN INITIATION & TITRATION]
Prandial coverage may be required if A1c is still above goal despite _________ OR ___________
- Basal dose >0.5IU/kg
- FPG at goal
[INSULIN INITIATION & TITRATION]
What should be done if A1c is still above goal despite basal dose >0.5IU/kg OR FPG at goal?
- Add prandial coverage (rapid/regular)
- 1 dose with largest meal
- 4 IU or 10% of basal
- If A1c <8.0%, decrease basal dose by 4IU or 10% (avoid hypoglycemia)
- *Consider pre-mixed to minimize number of injections - If on bedtime NPH,
- Split into two doses: 2/3 in morning, 1/3 in evening
[INSULIN INITIATION & TITRATION]
Why do we stop increasing basal insulin dose once >0.5 IU/kg?
What are the 3 unintended outcomes of overuse of basal insulin?
Overbasalization
- Basal insulin has ceiling effective dose => FPG reductions proportionally become smaller with increasing dose
- Overuse of basal insulin may cause unintended outcomes: weight gain, hypoglycemia, postprandial hyperglycemia
[INSULIN INITIATION & TITRATION]
Describe full-basal bolus regimen
One long-acting (basal) insulin (Glargine/Detemir)
Three rapid-acting/short-acting insulin (Aspart/Lispro/Glulisine/Regular), before each meal
[INSULIN INITIATION & TITRATION]
Describe twice-daily pre-mix regimen
Two pre-mix insulin (NPH + Regular/Rapid), take before meal
[INSULIN INITIATION & TITRATION]
Basal insulin usually constitutes ___% or more of the total daily insulin dose
50%
What is Somogyi Effect VS Dawn Phenomenon?
Both may be used to explain why there is high BG at dawn (early morning)
Somogyi Effect:
- BG drops sharply at night*
- Body responds by releasing glucagon, causing BG to rise in the morning
Dawn Phenomenon
- Release of cortisol in the morning cause BG levels to rise in the morning
- Cortisol => incr gluconeogenesis and dcr glycogen synthesis
What is a normal HbA1c drop across 3 months of DM therapy?
~1%
If drop by more than that, suggest there is hypoglycemia at some part of the day
=> If hypoglycemia at night, could be Somogyi Effect
If Somogyi Effect is suspected, whereby pt HbA1c drops more than expected but FPG still remains high, what should be done to insulin dose?
Stop increasing basal insulin dose despite the FPG (as pt would still have hypoglycemia symptoms at night)
Decrease dose instead
(recall if there is unexplained hypoglycemia we can decrease basal insulin dose by 10-20%)
[PREVENTION & MANAGEMENT OF COMPLICATIONS IN DM]
What might be done to prevent/manage DM complications?
+ General health maintenance
- Aspirin
- Smoking cessation
- Diet/exercise
- Blood pressure management
- Lipid profile management
- Metabolic syndrome - treat risk factors
- Complication prevention due to low immunity (influenza, pneumococcal vaccines)
- Skin care, foot care, eye care, dental and oral care
- Identification tags for children
[ROLE OF ASPIRIN IN DM]
What is the role of aspirin in secondary prevention of DM?
Aspirin SHOULD be used as secondary prevention in pt with diabetes + history of ASCVD (e.g., stroke, MI, HF)
*Clopidogrel 75mg/day if allergic to Aspirin
[ROLE OF ASPIRIN IN DM]
Which group of patients should Aspirin be considered for primary prevention?
What is the benefit?
Pt with diabetes who are at increased CVD risk (typically 50-70yo)
ASCVD risk factors include:
- LDL >= 2.6mmol/L
- High BP
- Smoking
- CKD
- Albuminuria
- Fam hist of premature ASCVD
Benefit: reduction in CV events, though it increases bleeding events
