Type 2 Diabetes Treatment Intensification 1

Question 1

What kind of disease is Type 2 Diabetes

Answer 1

A Chronic Progressive Disease

Question 2

Mechanism behind why Type 2 Diabetes is a Progressive Disorder

Answer 2

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

Question 3

Education about the nature of Type 2 Diabetes

Answer 3

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

Question 4

Negative Images of Insulin

Answer 4

• Viewed as punishment for not controlling blood glucose
• Stigma: Using injections = illicit drug use
  Fear of hypoglycemia
  Weight gain

Question 5

Diabetes Canada Guidelines
- Follow Up

Answer 5

Review Annually
- Glycemic Control
- CV Status
- Renal Status

Assess
- Efficacy
- Side Effects
- Adherence

Reinforce
- Healthy Behaviour Interventions

Question 6

Diabetes Canada Guidelines
- Therapy Changes

Answer 6

Dose Adjustments, Substitutions, and/or Additions of antihyperglycemic medications should be done to:
- Maintain A1c
- Reach target within 3-6 months

Question 7

Diabetes Canada Guidelines
- Target not Achieved/Maintained
OR
- Individual’s Clinical Status Changes

Answer 7

Either:
- Reassess glycemic targets
- Add/Replace with other classes of agents (To reduce cardiorenal outcomes and/or improve glycemic control)

Question 8

Factors to consider when Intensifying Antihyperglycemic

Answer 8

• 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

Question 9

Factors to consider when Intensifying Antihyperglycemic
- High Risk of Cardio/Renal Events

Answer 9

Age > 60
2 or more CV risk factors
- Dyslipidemia, Hypertension, Smoking

Question 10

Factors to consider when Intensifying Antihyperglycemic
- Renal Function

Answer 10

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

Question 11

Factors to consider when Intensifying Antihyperglycemic
- Degree of Hyperglycemia

Answer 11

Increasing doses does not produce further blood glucose reduction

Question 12

Factors to consider when Intensifying Antihyperglycemic
- Side Effect (Risk of Hypoglycemia)

Answer 12

Insulin&raquo_space; Sulfonylurea > Meglitinides > DPP4i = GLP1ra = SGLT2i = TZD = Acarbose

Question 13

Factors to consider when Intensifying Antihyperglycemic
- Side Effect (Weight Gain)

Answer 13

Insulin&raquo_space;Sulfonylurea = Meglitinides = TZD

Question 14

Factors to consider when Intensifying Antihyperglycemic
- Side Effect (Weight Neutral)

Answer 14

DPP4i = Acarbose

Question 15

Factors to consider when Intensifying Antihyperglycemic
- Side Effect (Weight Loss)

Answer 15

GLP1ra = SGLT2i

Question 16

Factors to consider when Intensifying Antihyperglycemic
- Side Effect (Other)

Answer 16

Genital Mycotic Infection: SGLT2i
Fracture Risk: SGLT2i, TZD
Pancreatitis: DPP4i, GLP1ra

Question 17

Factors to consider when Intensifying Antihyperglycemic
- Costs

Answer 17

Insulin&raquo_space; GLP1 RA > DPP4i = SGLT2i = TZD > Acarbose = Meglitinides > Sulfonylureas

Question 18

Factors to consider when Intensifying Antihyperglycemic
- Patient Preference

Answer 18

Injections vs Oral

Question 19

Factors to consider when Intensifying Antihyperglycemic
- Ability to adhere to regimen

Question 20

Evidence on Microvascular Outcomes
- Effects of Intense Glycemic Control

Answer 20

Intense glycemic control increases hypoglycemia risk

Question 21

Evidence on Microvascular Outcomes
- Intense Glycemic Control reduces risk of

Answer 21

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

Question 22

Evidence on Macrovascular Outcomes
- Effects of Intense Glycemic Control

Answer 22

Fast and rapid achievement of target in people with established Type 2 Diabetes can kill people

Question 23

Evidence on Macrovascular Outcomes
- Intense Glycemic Control reduces risk of

Answer 23

• 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

Question 24

Most people with diabetes die from which?
- Microvascular or Macrovascular

Answer 24

Macrovascular

Question 25

Evidence on Insulin and Cardiovascular Risk Reduction

Answer 25

No effect on CV
- Insulin Glargine does not reduce or increase cardiovascular morbidity and/or mortality in people with high risk for vascular disease

Question 26

Evidence on Lifestyle Intervention and Cardiovascular Risk Reduction

Answer 26

No effect on CV

Question 27

Summary:
- Intensive Glycemic Control

Answer 27

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