Type 2 Diabetes Treatment Intensification 1 Flashcards
What kind of disease is Type 2 Diabetes
A Chronic Progressive Disease
Mechanism behind why Type 2 Diabetes is a Progressive Disorder
Steady decline in beta cell function
- Beta cell loss and hyperglycemia can occur several years before diagnosis
- Does not matter how intensive therapy is, there is always a loss of beta cells
Once someone has been diagnosed with diabetes it is likely they have already lost beta cell function
Education about the nature of Type 2 Diabetes
Regular monitoring of A1c even if it has been stable
Timely adjustments will be needed
- Dose increase
- Addition of antihyperglycemic agents
Insulin is always an option for treatment intensification but has negative connotations
Negative Images of Insulin
- Viewed as punishment for not controlling blood glucose
- Stigma: Using injections = illicit drug use
Fear of hypoglycemia
Weight gain
Diabetes Canada Guidelines
- Follow Up
Review Annually
- Glycemic Control
- CV Status
- Renal Status
Assess
- Efficacy
- Side Effects
- Adherence
Reinforce
- Healthy Behaviour Interventions
Diabetes Canada Guidelines
- Therapy Changes
Dose Adjustments, Substitutions, and/or Additions of antihyperglycemic medications should be done to:
- Maintain A1c
- Reach target within 3-6 months
Diabetes Canada Guidelines
- Target not Achieved/Maintained
OR
- Individual’s Clinical Status Changes
Either:
- Reassess glycemic targets
- Add/Replace with other classes of agents (To reduce cardiorenal outcomes and/or improve glycemic control)
Factors to consider when Intensifying Antihyperglycemic
- High Risk of Cardiovascular/Renal Events
- Renal Function
- Degree of Hyperglycemia
- Side Effects
–> Hypoglycemia risk
–> Weight gain - Costs and Coverage
- Patient Preference
- Ability to adhere to regimen
Factors to consider when Intensifying Antihyperglycemic
- High Risk of Cardio/Renal Events
Age > 60
2 or more CV risk factors
- Dyslipidemia, Hypertension, Smoking
Factors to consider when Intensifying Antihyperglycemic
- Renal Function
Greater than 60 = no wories
Less than 60: SGLTi loses effectivness when less than 45
- SU and TZD use with caution
- GLP1ra depends on agent
- DPP4i adjust dose
Factors to consider when Intensifying Antihyperglycemic
- Degree of Hyperglycemia
Increasing doses does not produce further blood glucose reduction
Factors to consider when Intensifying Antihyperglycemic
- Side Effect (Risk of Hypoglycemia)
Insulin»_space; Sulfonylurea > Meglitinides > DPP4i = GLP1ra = SGLT2i = TZD = Acarbose
Factors to consider when Intensifying Antihyperglycemic
- Side Effect (Weight Gain)
Insulin»_space;Sulfonylurea = Meglitinides = TZD
Factors to consider when Intensifying Antihyperglycemic
- Side Effect (Weight Neutral)
DPP4i = Acarbose
Factors to consider when Intensifying Antihyperglycemic
- Side Effect (Weight Loss)
GLP1ra = SGLT2i
Factors to consider when Intensifying Antihyperglycemic
- Side Effect (Other)
Genital Mycotic Infection: SGLT2i
Fracture Risk: SGLT2i, TZD
Pancreatitis: DPP4i, GLP1ra
Factors to consider when Intensifying Antihyperglycemic
- Costs
Insulin»_space; GLP1 RA > DPP4i = SGLT2i = TZD > Acarbose = Meglitinides > Sulfonylureas
Factors to consider when Intensifying Antihyperglycemic
- Patient Preference
Injections vs Oral
Factors to consider when Intensifying Antihyperglycemic
- Ability to adhere to regimen
Evidence on Microvascular Outcomes
- Effects of Intense Glycemic Control
Intense glycemic control increases hypoglycemia risk
Evidence on Microvascular Outcomes
- Intense Glycemic Control reduces risk of
Any microvascular event: Yes
Retinopathy: Probably
Nephropathy: Probably
Neuropathy: No
Even though there is little clinical trial evidence intense glycemic control makes sense pathologically at reducing microvascular outcomes
Evidence on Macrovascular Outcomes
- Effects of Intense Glycemic Control
Fast and rapid achievement of target in people with established Type 2 Diabetes can kill people
Evidence on Macrovascular Outcomes
- Intense Glycemic Control reduces risk of
- Major Adverse Cardiovascular Events: Yes
- All Cause Mortality: No (ACCORD reports significant risk increase)
- Cardiovascular Mortality: No (ACCORD reports significant risk increase)
- Myocardial Infarction: Maybe
- Stroke: No
- Heart Failure: No
Even though there is little clinical trial evidence intense glycemic control makes sense pathologically at reducing macrovascular outcomes
Most people with diabetes die from which?
- Microvascular or Macrovascular
Macrovascular
Evidence on Insulin and Cardiovascular Risk Reduction
No effect on CV
- Insulin Glargine does not reduce or increase cardiovascular morbidity and/or mortality in people with high risk for vascular disease
Evidence on Lifestyle Intervention and Cardiovascular Risk Reduction
No effect on CV
Summary:
- Intensive Glycemic Control
Only achieves modest reductions in risks of major diabetes-related events (CV disease, Kidney failure, blindness)
- Does not affect risks
- When looked at totality it does decrease risks
