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Practical Considerations in Clinical Management

Practical Considerations in Clinical Management. Guideline-recommended glycemic targets in diabetes. *Plasma; † Blood ADA = American Diabetes Association ACE = American College of Endocrinology. ADA. Diabetes Care . 2007;30(suppl 1):S4-41. ACE. Endocr Pract . 2002;8(suppl 1):5-11.

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Practical Considerations in Clinical Management

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  1. Practical Considerations in Clinical Management

  2. Guideline-recommended glycemic targets in diabetes *Plasma; †Blood ADA = American Diabetes AssociationACE = American College of Endocrinology ADA. Diabetes Care. 2007;30(suppl 1):S4-41. ACE. Endocr Pract. 2002;8(suppl 1):5-11.

  3. Glucose dynamics: Basal and prandial 250 Postprandial hyperglycemia 200 Type 2diabetes Plasma glucose (mg/dL) 150 Basal hyperglycemia 100 50 Normal 0 0600 1200 1800 2400 0600 Time of day Riddle MC. Am J Med. 2004;116(suppl):3S-9.

  4. Relative contributions of postprandial glucose and FPG to A1C 100 80 60 Contribution (%) 40 20 0 <7.3 7.3–8.4 8.5–9.2 9.3–10.2 >10.2 A1C quintiles (%) Fasting plasma glucose Postprandial plasma glucose Monnier L et al. Diabetes Care. 2003;26:881-5.

  5. Glycemic control deteriorates with standard therapies N = 2220 with T2DM treated with SU + MET Pre-SU A1C levels (%) 100 ≥10 9.0-9.9 8.0-8.9 4.0-7.9 80 Patients withA1C ≥8% (%) 60 • ~85% of patients had A1C ≥8% after 4 years 40 20 0 0 1 2 3 4 Time from sulfonylurea initiation (years) SU = sulfonylurea, MET = metformin Cook MN et al. Diabetes Care. 2005;28:995-1000.

  6. A1C reduction with glucose-lowering medications *Monotherapy DPP = dipeptidyl peptidase; GLP = glucagon-like peptide Nathan DM. N Engl J Med. 2007;356:437-40.

  7. Oral diabetes agents Trujillo J. Formulary. 2006. Luna B, Feinglos MN. Am Fam Physician. 2001. Smyth S, Heron A. Nat Med. 2006.

  8. Incretin agents in glucose control GIP = gastric inhibitory peptide Trujillo J. Formulary. 2006;41:130-41.

  9. ADA: Managing hyperglycemia in T2DM Lifestyle intervention + metformin If A1C > goal Add basal insulin(most effective) Add sulfonylurea(least expensive) Add glitazone(no hypoglycemia) If A1C > goal If A1C > goal If A1C > goal Intensify insulin Add glitazone Add basal insulin Add sulfonylurea If A1C > goal If A1C > goal Add basal or intensify insulin Intensive insulin + metformin +/- glitazone ADA goal: A1C <7% Adapted from ADA. Diabetes Care. 2007;30(Suppl 1):S4-41.

  10. ACE road map to glycemic goals in T2DM: Treated patients A1C (%) Current therapy Intervention Mono- or combination therapy Initiate insulin therapy (basal-bolus) >8.5 • Monitor every2–3 months • Adjust treatment to meet ACE glycemic goals Combination therapy Maximize OAD combinations Maximize insulin therapy 6.5–8.5 Continue lifestyle modification Monotherapy Initiate combination therapy* Mono- or combination therapy Continue therapy oradjust as needed to meet ACE glycemic targets 6.0–6.5 *Add rapid-acting insulin analogs at any time to address persistent postprandial hyperglycemia ACE/AACE. www.aace.com.

  11. Treat-to-Target study: Basal insulin lowers FPG and A1C N = 756 previously treated with 1–2 OADs; Mean A1C 8.6% 9 200 8 FPG, mean(mg/dL) A1C,mean (%) 150 7 6 100 0 4 8 12 16 20 24 0 4 8 12 16 20 24 Weeks of treatment ~60% reached A1C ≤7% Insulin glargine NPH NPH = neutral protamine Hagedorn insulin Riddle MC et al. Diabetes Care. 2003;26:3080−6.

  12. Treat-to-Target: Nocturnal hypoglycemia vs glycemic control Riddle MC et al. Diabetes Care. 2003;26:3080―6.

  13. Fewer hypoglycemic episodes withinsulin analogue N = 371 with poorly controlled T2DM on SU + MET P < 0.0001 Hypoglycemic events, mean(per patient-years) P = 0.0009 P = 0.0449 Insulin glargine + OAD Premixed insulin* *30% regular/70% NPH insulin Janka HU et al. Diabetes Care. 2005;28:254-9.

  14. Insulin glargine + OAD effect on weight, A1C N = 12,216 with poorly controlled T2DM on OAD; 9-month outcomes BMI subgroup analysis  BMI (kg/m2) BMI (kg/m2) <25 25 to <30 30 to <35 ≥35 All A1C (%) -1.6 -1.6 -1.7 -1.8 -1.6  = change from baseline at 9 months Schrieber SA, Haak T. Diabetes Obes Metab. 2007;9:31-8.

  15. Glycemic control and weight change with detemir vs NPH insulin N = 475 with poorly controlled T2DM on OAD; add-on detemir or NPH 10 189 187 9 185 8 Body weight (lbs) A1C (%) 182 7 180 6 178 0 0 -2 0 4 8 12 16 20 24 -2 0 4 8 12 16 20 24 Study week Study week >70% achieved A1C ≤7% Mean weight gain (lbs) Detemir: 2.6; NPH: 6.2 (P < 0.001) Detemir NPH Hermansen K et al. Diabetes Care. 2006;29:1269-74.

  16. Add-on treatment with glargine vs rosiglitazone + SU/MET: A1C and FPG N = 217 with T2DM 7 8 9 10 11 0 200 -0.5 180 -1.0 † A1C,  from baseline(%) 160 † FPG, mean (mg/dL) -1.5 * * † -2.0 * † 140 * -2.5 120 -3.0 -3.5 100 0 4 8 12 16 20 24 Time (weeks) Insulin glargine Rosiglitazone *P < 0.05, †P = 0.001 between groups Rosenstock J et al. Diabetes Care. 2006;29:554-9.

  17. Glargine vs rosiglitazone added to SU + MET: Lipid effects N = 217 with T2DM HDL-C Total-C LDL-C TG 20 † 13.1 * 10.1 10 ‡ § 4.6 4.4 Change from baseline (%) 0 0 -1.4 -4.4 -10 -20 -19.0 Insulin glargine Rosiglitazone *P = 0.0001, †P = 0.0004, ‡P = 0.001, §P = 0.04 between groups Rosenstock J et al. Diabetes Care. 2006;29:554-9.

  18. Add-on Rx with glargine vs rosiglitazone + SU/MET: Comparative adverse effects N = 217 with T2DM *Plasma glucose <70 mg/dL Rosenstock J et al. Diabetes Care. 2006;29:554-9.

  19. Basal and bolus insulin pharmacodynamics Basal Bolus RHI = regular human insulin Flood TM. J Fam Practice. 2007;56(suppl):S1-12.

  20. Traditional thinking Atherogenic Fear of hypoglycemia Fear of weight gain Frequent injections Newer concepts Anti-atherogenic Less nocturnal hypoglycemia with steady-state once-daily basal insulins Weight neutral Long-acting basal insulins require fewer injections Dispelling misconceptions about insulin Dandona P et al. Am J Cardiol. 2007;99(suppl):15B-26. Stotland NL. Insulin. 2006;1:38-45.

  21. ACC/AHA secondary prevention guidelines: Diabetes management Class and level of evidence I IIa IIb III Initiate lifestyle and pharmacotherapy to achieve A1C <7% B Aggressively modify other CV risk factors (physical activity, weight, BP, cholesterol) B C Coordinate care with endocrinologist or PCP Smith SC et al. Circulation. 2006;113:2363-72.

  22. Discharge strategies for patients with hyperglycemia Lifestyle modification (nutrition and exercise) Insulin vs OAD for long-term management Patient educationeg, self-monitoring of glucose Continuity of carePCP ± Endocrinologist ACE/ADA. Diabetes Care. 2006;29:1955-62.

  23. Managing glucose in T2DM • Diabetes is a progressive disease • Most patients will require multiple therapies to achieve A1C goals • Utilize lifestyle intervention and metformin as initial treatment • Add medications rapidly and transition to new agents when A1C target is not achieved/sustained • Add insulin early in patients who do not meet A1C targets Nathan DM et al. Diabetologia. 2006;49:1711-21.

  24. Continuity of care for diabetes: It takes a health care team Patient Physician Diabeteseducator Eye doctor Dietician Exercise physiologist Podiatrist Social worker or psychologist ADA. www.diabetes.org.

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