Management Flashcards
Key point:
SGLT2 inhibitors (SGLT2i) + GLP1 receptor agonists (GLP1RA) are ‘new’ classes of glucose lowering medications
Likely represents greatest change to management of type 2 diabetes (T2D) in NZ for decades
Glucose lowering therapies for T2DM after Metformin
Pts with early onset II DM can have a more rapid increase in HbA1c levels, despite Rx, and are likely to require:
- more frequent dose increases,
- use of multiple oral medicines
- or earlier addition of insulin than older pts
Effective communication and engagement with patients and their whānau/family in regards to the importance of adhering to their medicines is of particular importance.
Reinforce that if they can gain control with assertive Rx and lifestyle, it may be possible to dial Rx back over time.
Shane* – age 46 – CVD risk assessment
+Weight: 100 kg
+BMI: 33 kg/m2
+BP: 146/90 mmHg
HbA1C 80
Have we established a diagnosis of T2DM?
Yes
Screen for diabetes in asymptomatic adults
- Men from age 45
- Women from 55
Māori, Pacific or Indo-Asian:
- Men from age 30
- Women from 40
+Follow up based on risk (prediabetes = annual)
Two abnormal tests (HbA1c or fasting) required to confirm the diagnosis either on same day or subsequent test without delay
Target HbA1c in most patients with diabetes is
< 53 mmol/mol
Lower target < 48 mmol/mol appropriate when risk of hypoglycaemia low and either:
- Young
- Considering pregnancy or pregnant
- Have diabetic microvascular complications (particularly retinopathy and nephropathy)
Higher target (e.g. 54 – 70 mol/mol) may be more appropriate when risks of hypoglycaemia likely outweigh benefits of tight glycaemic control
II DM management toolbox: from lifestyle to Insulin
Lifestyle interventions are crucial at all stages of management, reducing the need for pharmacological Rx and inducing remission in some people;
- help pts by providing regular advice, encouragement and referral to appropriate support programmes
At least 150 min/week of moderate intensity exercise – this may not be immediately achievable, but pts should have a plan to increase their level of physical activity to reach this goal
Weight loss should be encouraged at any stage to induce remission, slow progression, step down treatment intensity or delay the need to escalate Rx.
wt loss (5 – 10% of total body weight) in those who are overweight* – various dietary approaches are available; consider pt preference, tolerance, nutritional requirements, co-morbidities, cultural suitability and cost
Eating foods with a high fibre content, such as fruits, vegetables and whole grains, and avoiding sugar-sweetened beverages or foods with added sugars
Diabetes education and support is a critical aspect of lifestyle management,
- help them understand the need for making changes to their lifestyle and the role of medicines in diabetes management
- Losing weight, exercising and eating well can improve the body’s sensitivity to insulin and therefore this is something that the pt can do to reduce their need for medicines.
- In some patients, significant sustained lifestyle changes can normalise HbA1c levels and medicines may no longer be required.
Connect patients to services that can assist with lifestyle changes and provide support, includes
- referring pts to a dietitian,
- providing them with a Green Prescription to connect with a Green Prescription support person,
- or making pts aware of programmes offered by a local PHO, DHB (e.g. DESMOND) or Māori health provider.
- Diabetes New Zealand has branches throughout the country that provide a variety of services. For further information, see: www.diabetes.org.nz
Pharmacological treatment to reduce HbA1c levels
The overall aim of pharmacological Rx with glucose-lowering medicines is to help reduce HbA1c levels and the risk of complications
Hypoglycaemia is the main limiting adverse effect, and it can carry substantial risks, particularly in ps who are frail. It is associated with:
- an increased risk of falls and cognitive impairment,
- and may increase the risk of mortality
HbA1c targets and the choice of Rx should be individualised taking into account overall health status, co-morbidities and risks associated with hypoglycaemia; targets and management may need to change over time
Check HbA1c levels at least annually, but 3-6-monthly if required
A recommended approach to initiating glucose-lowering medicines is:
Initiate metformin at diagnosis; if HbA1c levels are > 64 mmol/mol, more intensive Rx may be required
Initiate metformin at or soon after diagnosis for all patients with type 2 diabetes (HbA1c ≥ 50 mmol/mol)
Consider initiating metformin in combination with lifestyle advice for patients with “pre-diabetes” (HbA1c 41 – 49 mmol/mol)
If Rx with metformin alone does not reduce HbA1c levels to the desired target, add empagliflozin,* dulaglutide,* vildagliptin, a sulfonylurea (glipizide or gliclazide) or pioglitazone
If further intensification is required, initiate insulin. Alternatively, combine three oral glucose-lowering medicines or two oral medicines and dulaglutide.
Prior to intensifying any pharmacological regimen, check the pt’s adherence to their existing medicine regimen and diet and physical activity approaches
If insulin is required, a basal insulin regimen is the preferred option in most clinical situations. Funded options are isophane insulin (usual first choice) and insulin glargine.
Approach to individualisation glycemic targets
Choosing a target: the first step
A HbA1c target should be individualised and determined by factors such as:
- the pt’s co-morbidities,
- potential duration of pt’s exposure to hyperglycaemia
- history of hypoglycaemia
- and overall health status
Reaching and maintaining target HbA1c levels can reduce a patient’s risk of microvascular complications, e.g. retinopathy, nephropathy, and neuropathy.
Reducing HbA1c in pts with particularly high levels, e.g. > 80 mmol/mol, to a more moderate level, e.g. < 65 mmol/mol, is thought to offer the greatest reductions in risk of microvascular complications.
Aiming for a very low target is not always best if the risks associated with reducing HbA1c levels, e.g. hypoglycaemia, outweigh the benefits.
Reducing HbA1c is also part of the multi-factorial risk reduction strategy to reduce macrovascular complications of diabetes. This includes:
- increasing physical activity
- smoking cessation
- managing hypertension
- dyslipidaemia
Patient characteristics to consider when selecting a HbA1c target
Target < 48 mmol/mol
Reasons for choosing target:
- Greatest reduction in risk of microvascular complications.
- Appropriate if can be achieved without adverse effects.
Characteristics of pts who may benefit from this target:
- Young, e.g. aged < 40 years
- Are at low risk of hypoglycaemia (i.e. not on insulin or a sulfonylurea)
- Considering pregnancy or are pregnant
- Have microvascular complications (particularly retinopathy and nephropathy)
Target < 53 mmol/mol
Reasons for choosing target:
- Reasonable balance between reduction in risk of microvascular complications with risks of treatment
Characteristics of pts who may benefit from this target:
- Most pts
Target 54 – 70 mmol/mol
Reasons for choosing target:
- Appropriate if benefits from treating to lower levels are outweighed by risk of hypoglycaemia
Characteristics of pts who may benefit from this target:
- Older pts at risk of falls and fractures
- Frailty
- Cognitive impairment
- Functionally dependent
- Hypoglycaemia experienced at lower targets
- Live alone and are at risk of severe hypoglycaemia
- Short life expectancy
- Already have advanced microvascular or macrovascular diabetes complications
- Require multiple medicines to achieve lower HbA1c targets and have complications caused by polypharmacy
Prescribing glucose-lowering medicines: choosing the right tools for the job
The pharmacological management typically follows a stepwise progression with lifestyle interventions, i.e. diet and exercise to induce weight loss, reinforced at each intensification step
The intensity of pharmacological Rx required to reduce and maintain HbA1c at target levels
- varies greatly between pts
- and also depends on the extent of lifestyle changes,
- the length of time they have had diabetes
- and their particular circumstances
- and preferences.
For pts with high HbA1c levels (> 64 mmol/mol) at diagnosis, initiating two medicines is recommended (e.g. metformin and vildagliptin).
For pts with very high HbA1c levels, e.g. > 80 – 90 mmol/mol, or significant symptoms of hyperglycaemia at diagnosis, initiation of insulin (in addition to metformin) is recommended.
- It is often possible to reduce insulin or remove it from the regimen once HbA1c stabilises
Metformin
remains first line agent for T2DM
Biguanide that:
- decreases peripheral insulin resistance and hepatic gluconeogenesis
- Reduces cardiovascular disease independent of glycaemic control
- Often leads to mild weight loss
Max dose 3 g/ day
Little therapeutic benefit and greater risk of adverse effects for doses > 2 g per day
Start at 250 - 500 mg od or bd and uptitrate weekly to 2 g/day or maximal tolerated dose with food
Starting low and slow typically avoids adverse effects, even in those previously ‘intolerant’
Stop Metformin in acute GI or dehydrating illness
Metformin
Reduce doses in renal impairment and contraindicated in renal, liver and heart failure:
- eGFR < 15 mL/min – metformin is contraindicated
- eGFR 15 – 29 mL/min – maximum daily dose 500 mg
- eGFR 30 – 59 mL/min – maximum daily dose 1000 mg
If worsening neuropathy on metformin then check serum vitamin B12 levels
Hypoglycaemia on metformin alone is extremely rare
If introduced to a regimen with insulin and/or sulfonylureas, then the dose of insulin and/or sulfonylureas may need to be reduced to prevent hypoglycaemia (particularly if the HbA1c is < 64 mmol/mol)
SGLT2i and GLP-1RA* special authority
