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January 2013 Webinar: “Practical Ways to Help Get Our Diabetes Patients to Goal”

January 2013 Webinar: “Practical Ways to Help Get Our Diabetes Patients to Goal”. Controlling the ABC’s Cases. Evidence Based Interventions that Reduce Morbidity and Mortality. HbA1C < 7 BP < 140/90 LDL cholesterol < 100 (or <70 if CAD) Aspirin age > 50 men, 60 women with 1 risk factor

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January 2013 Webinar: “Practical Ways to Help Get Our Diabetes Patients to Goal”

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  1. January 2013 Webinar:“Practical Ways to Help Get Our Diabetes Patients to Goal” Controlling the ABC’s Cases

  2. Evidence Based Interventions that Reduce Morbidity and Mortality • HbA1C < 7 • BP < 140/90 • LDL cholesterol < 100 (or <70 if CAD) • Aspirin age > 50 men, 60 women with 1 risk factor • ACE - age >55 • Statin use - age >40 • Yearly screen for nephropathy, feet, and eye exams

  3. The ‘ABCs’ • A1C • BP < 140/90 • Cholesterol (LDL<100, if CAD <70)

  4. Improving Glucose Control

  5. “But I Thought It Was Bad to Lower A1C Too Much..” • All recent studies aimed at A1C = 6.5 or lower • No evidence that A1C = 7 is bad • Data says to reduce CVD • It is not so much about glucose • It’s the Blood Pressure and Cholesterol!

  6. Really, Really Important Points: • Aggressive control early prevents complications • Because of the log-linear relationship between control and complications, absolute benefits are greatest at high HbA1c values (i.e. target A1C >9) • Pushing patients with advanced disease (particularly macrovascular complications) to ‘tight’ control that they cannot achieve probably increases mortality -Attention to hypoglycemia and particularly nocturnal hypoglycemia

  7. Managing Glucose • Goal A1C <7 • Consider higher (8) if CAD, elderly, or hypoglycemia unawareness • Focus on those at highest risk (i.e. A1C >9)

  8. Sites of Drug Action Carbohydrate DIGESTIVE ENZYMES Alpha-glucosidase Inhibitors, Incretins Excessive lipolysis Glucose Sulfonlyureas Meglitinides Incretins Insulin Defective b-cell secretion Reduced glucose uptake Excess glucose production Metformin TZD Incretins Resistance to the action of insulin TZD, Metformin Dinneen SF. Diabet Med. 1997; 14 (Suppl 3): S19-24.

  9. Points to Remember • Each agent, except insulin, lowers A1C 1-2 • If A1C >9, start two agents • Follow SMBG, A1C, and Titrate!!!!!

  10. Case • 58 yo with Type 2 x 5 yrs • A1C = 9.5 • On metformin 1000 mg bid • Glimepiride 4 mg qd • What next?

  11. Natural History of Type 2 Diabetes Postmeal glucose Plasma Glucose Fasting glucose 126 mg/dL Insulin resistance Relative -Cell Function Insulin secretion 20 10 0 10 20 30 Years of Diabetes Adapted from International Diabetes Center (IDC). Minneapolis, Minnesota.

  12. Type 2 Diabetes… A Progressive Disease Over time, most patients will need insulin to control glucose.

  13. Reducing Clinical Inertia • Eternal hope on lifestyle working • Negotiate a deadline • Escalating therapy more quickly • Oral agents can be monthly • Insulin can be weekly

  14. Barriers to Starting Insulin • Patient Barriers • Guilt, failure • Injection? • Provider Barriers • Who teaches? • Consider pens • Team Based Care to the rescue! • Diabetes Educators?

  15. Talking About Insulin • “It seems like you have some concerns about insulin?” • “What do you know about using insulin in DM?” • Inevitable • Simple • Pens • Can be daily at first • No one needs to know • Correct misconceptions

  16. What To Do With Oral Agents • Negotiate • For weight- keep metformin • For reducing need for second injection - insulin secretagouge • For cost- stop orals

  17. Uncontrolled A1C ~9% Correcting Fasting Hyperglycemia… Is Usually the First Task!! 300 “Controlled” A1C <7% 200 PG (mg/dL) A1C ~6% 100 Normal A1C 5%–6% 0800 1200 1800 0800 Time of Day …then, Tackle Postprandial Hyperglycemia if A1C still >7%!

  18. Titrating Glargine or Detemir • Start 10 units • 2 units q 3 days until FPG < 100 • It’s that easy and it works!

  19. Physiologic Serum Insulin Secretion Profile 75 Breakfast Lunch Dinner 50 Plasma Insulin ( µU/mL) 25 4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00 Time

  20. How do you know they need another injection? FPG good but A1C not

  21. Case • Type 2 DM x 6 y • Glargine 60 units qhs • FPG 90-110 • A1C=8.5 • Pt can measure qhs BG? • Start 10 units rapid insulin pre-dinner • If regular meals- 70/30 insulin • 40 q Am, 30 q PM

  22. Who Are Your High A1C Patients? • Orals and need second oral? • Need insulin? • On insulin? • There can be inertia at each level • DEPRESSION? • Adherence? • Open-ended ended question: • “Some people find it hard taking their insulin every day, how’s it going for you?”

  23. BP CONTROL

  24. BP Management • <140/90 • Multiple meds • Don’t miss an opportunity to titrate • Standing orders?

  25. Medication Treatment Algorithm? • Start with ACE or ARB and/or HCTZ • Either one • Best might be early combo since all will likely need it • Third agent based on co-morbidity • Beta blocker and/or Ca channel • Add the 4th and hopefully you’ve reached goal - if not call an expert +/- alpha blocker?

  26. Tashko and Gabbay, Integrated Blood Pressure Control (2010)

  27. Cholesterol LDL control <100If CVD <70

  28. Getting to Goal on LDL • Most myalgia not from statins! • Stop and observe • Switch to another statin • Mention stroke risk • TITRATE

  29. Evidence Based Interventions That Reduce Morbidity and Mortality • HbA1C < 7 • BP < 130/80 • LDL cholesterol < 100 (or <70 if CAD) • Aspirin age > 50 men, 60 women with 1 risk factor • ACE -age >55 • Statin use- age >40 • Yearly screen for nephropathy, feet, and eye exams

  30. QUESTIONS? Any Cases?

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