Diabetes in the 21 st Century 2010 Update

1. Diabetes in the 21st Century 2010 Update

2. American Diabetes Association 2010 Guidelines – Diagnostic Criteria • A1C > or = 6.5% is included as diagnostic criteria for diabetes. • A1C = 5.7- 6.4 – at increased risk for diabetes • Must be done by a lab method with appropriate certification and standardization. Point of care testing does not qualify.

3. American Diabetes Association 2010 Guidelines – Treatment Goals • A1C < 7% in general, non-pregnant adult population. • In select persons may target closer to normal - if can be achieved without significant risk of hypoglycemia or adverse events (i.e.: persons with diagnosis of short duration, long life expectancy, no history of CVD)

4. American Diabetes Association 2010 Guidelines – Treatment Goals • Conversely, less stringent goals may be appropriate for patients with history of hypoglycemia, limited life expectancy, advanced complications, extensive co-morbidities or difficult to control despite multiple modalities.

5. American Diabetes Association 2010 Guidelines – Dietary Guidelines • ADA comments that the use of glycemic index and glycemic load may add modest benefit for glycemic control over consideration of total carbohydrate alone. • Optimal mix of macronutrients remains unclear. Several studies have demonstrated some benefits of short term use of low carbohydrate diets (<130 Gm/day) with weight loss, improved HDL and triglycerides, or improved A1C, however long term metabolic effects remain unclear and monitoring is warranted.

6. American Diabetes Association 2010 Guidelines – Dietary Guidelines • Continued support of limiting intake of saturated fats to less than 7% total caloric intake and minimizing trans fats • Total caloric intake must be appropriate for the weight management goal

7. American Diabetes Association 2010 Guidelines - Exercise • 150 min per week of moderate intensity (or 75 min vigorous intensity) • In absence of contraindications, adding resistance training 3 times a week has been shown to reduce insulin resistance

8. Medication Update • Avandia remains in limelight. • Controversy regarding evidence of increased risk of cardiovascular morbidity and mortality. Are the risks greater than the benefits? • As of September 2010, FDA has determined to allow to remain on market with significant restrictions • Patients should be advised not to stop Avandia without consulting with their diabetes health care provider, but to discuss treatment changes as appropriate. • TZDs as a class are also noted to increase bone loss and risk of fracture.

9. Medication Update • Liraglutide (Victoza) – GLP1 receptor agonist • Similar effects, side effects and cautions as exenatide (Byetta) • Once a day subcutaneous dosing (start with 0.6 mg/day, increase to 1.2 mg/day after 1 week, can titrate up to 1.8 mg/day). Can be dosed at any time of day

10. Medication Update • GLP1 receptor agonists noted to have a risk of pancreatitis – screen for history of pancreatitis, gallstones, alcohol abuse or hypertriglyceridemia as contraindications. • Byetta has had post marketing reports of acute renal insufficiency and renal failure. Monitor kidney function at initiation and with dose increases.

11. Medication Update New DPP4 inhibitor • Saxagliptin (Onglyza) • Effects, side effects and cautions similar to sitagliptin (Januvia) • Dosing 2.5 – 5 mg PO QD

12. Resources: NMTOD Diabetes Compendium http://nmtod.com/diabetesresources.html American Diabetes Association (2010). Standards of medical care in diabetes – 2010. Diabetes Care, 33, s11-s61. Retrieved August 17, 2010 fromhttp://care.diabetesjournals.org/content/33/Supplement_1/S11.full.pdf+html.