2. Learning Objectives
⦿Review the pathophysiology of
Diabetes and how it relates to therapy
⦿Summarize available treatment options
for diabetes mellitus
⦿Describe different methods of glucose
logging to meet the needs of patients
⦿Recall techniques to help patients be
more comfortable with injectable
therapy
7. Type 1 (Insulin dependent)
⦿Usually in young adults and adolescents
● Can present at any age
● Ketoacidosis is more common
⦿Total insulin deficiency which is often due to
beta cell destruction.
● immune mediated
○ macrophages and T lymphocytes with
autoantibodies to beta cell antigens
⦿Typical presentation: polyuria, polydipsia,
nausea, blurred vision due to hyperglycemia
8. Diabetic Ketoacidosis
⦿ Caused by increased fatty acid metabolism
and accumulation of ketoacids
⦿ Triggered by infections and problems with
insulin therapy
⦿ Can be fatal
⦿ Symptoms can develop quickly
● Polydipsia, SOB, confusion, fatigue, n/v,
frequent urination, fruity scented breath
⦿ Labs: hyperglycemia, anion gap acidosis,
ketonuria or ketonemia
⦿ Treatment: IV regular insulin, fluid
resuscitation
9. Type 2 (Non-insulin
dependent)
⦿Majority of diabetes cases (90-95%)
⦿Insulin resistance and progressively lowering
insulin secretion
● Insulin resistance often manifests as increased
lipolysis and free fatty acid production, increased
hepatic glucose production, and decreased
glucose uptake by skeletal muscle
⦿Abdominal obesity
⦿Co-morbidities often present
⦿Typical presentation: retinopathy, neuropathy,
nephropathy, obesity, HTN
10. Type 1 Vs Type 2
Type 1 Type 2
Etiology Autoimmune Insulin resistance
Age of Onset Younger Older
Family History Rare Common
Obesity Rare Common
Insulin Resistance No Yes
Ketosis Yes No
Genetic association
(HLA)
Yes No
Insulin presence within
the body
No Yes
Response to oral
agents
No Yes
15. Goals of Treatment
⦿Reduce the risk of microvascular
and macrovascular complications
⦿Ameliorate symptoms
⦿Reduce mortality
⦿Improve QOL
16. Treatment Options:
Metformin
⦿Gold standard
⦿Enhances insulin sensitivity of hepatic and
peripheral tissues
⦿BBW: Lactic acidosis
⦿Contraindicated if SCr ≥1.5 or ≥1.4 (f)
⦿Dosing
● IR: 500mg BID with food
● ER: 500mg 1 QD with evening meal
● Max: 2500mg daily
17. Treatment Options: Insulin
Secretagogues
⦿Stimulate insulin secretion from beta-cells
⦿Maximal glycemic control at 6 months
⦿Contraindicated in T1DM, DKA, concurrent used
with bosentan (glyburide) or gemfibrozil
(repaglinide)
⦿Dosing
● Glyburide 2.5-5 mg/day
● Glipizide 5 mg/day
● Glimepiride 1-2 mg/day
● Nateglinide 120 mg TID
● Repaglinide 0.5-2 mg before each meal dependent on
HbA1C
18. Treatment Options:
Thiazolidinediones (TZDs)
⦿Similar efficacy with glycemic control
⦿Pioglitazone reduces mortality, MI, and stroke
in high risk patients
⦿BBW: CHF
⦿Contraindicated in CHF and pulmonary
edema
⦿Dosing
● Pioglitazone 15 or 30 mg QD
● Rosiglitazone 4 mg/day
19. Treatment Options: Alpha-
GI
⦿Delays and reduces post-meal carbohydrate
absorption and postprandial blood glucose
⦿Contraindicated in IBD, intestinal obstruction,
malabsorption, cirrhosis, and CrCl< 25mL/min
or SCr>2mg/dL
⦿Dosing
● Arcarbose (Precose): 25mg with the first bite of
meal once a day then increase weekly to 2
times/day then 3 times/day
● Miglitol (Glyset): 25 mg with the first bite of
meal
21. Treatment Options: GLP-1
RA
⦿Increases insulin secretion, decreases
glucagon secretion and slows gastric
emptying
⦿BBW: Thyroid C-cell tumor risk (excludes
exenatide IR)
⦿Dosing
● Exenatide IR: 5 mcg SC BID x 1 month then 10
mcg SC BID (1 hour before meals)
● Exenatide ER: 2 mg SC Weekly
● Liraglutide: 0.6 mg SC QD x 1 week , then 1.2
mg SC QD
● Dulaglutide: 0.75 mg SC Weekly
22. Treatment Options: Amylin
Analogs
⦿Slows gastric emptying and suppresses
postprandial glucose
⦿BBW: Co-administration with insulin increases
the risk of hypoglycemia
⦿Contraindications: gastroparesis,
hypoglycemic unawareness
⦿Reduce mealtime insulin by 50%
⦿Dosing
● Type 1: Pramlintide 15 mcg before meals
● Type 2: Pramlintide 60 mcg before meals
23. Treatment Options: Bile
Acid Sequestrants
⦿Binds bile acids and decreases hepatic
glucose production
⦿Contraindicated with bowel obstruction,
triglycerides > 500 mg/dL, or history of
hypertriglyceridemia-induced pancreatitis
⦿Dosing
● Colesevelam (Welchol): 3 x 625 mg tabs twice
daily or 6 tabs daily with meals
● Suspension: 3.75 g/packet once daily with
largest meal
24. Treatment Options: DA
Agonists
⦿Activates the DA receptor and modulates
hypothalamic control of metabolism
● Does not increase plasma insulin, but rather it
decreases insulin resistance
⦿Contraindicated with lactation, syncopal
migraines, or hypersensitivity to ergot
derivatives or dopamine
⦿Dosing
● Bromocriptine (Cycloset): 0.8mg w/in 2 hours
of waking in the morning with food; titrate to
0.8 mg/week to a mean daily dose of 4.8 mg
every morning
25. Treatment Options: SGLT-2
inhibitors
⦿Lowers the renal threshold and reduces
reabsorption of glucose
⦿Contraindicated in CrCl <30mL/min, ESRD,
dialysis
⦿Glucosuria can increase risk of UTI and
urinary frequency, risk for ketoacidosis
⦿Dosing
● Canagliflozin 100 mg QD before breakfast
● Dapagliflozin 5 mg QAM
● Empagliflozin 10 mg QAM
28. Treatment Options: Side
Effects
Met GLP1
RA
SGLT
2i
DPP-
4i
AGi TZD SU/
Meg
Colsvl BCR Ins Praml
Hypo
mild-
sev
mod-
sev
Weight loss loss loss gain gain gain loss
Renal/
GU
GI mod mod mod mild mod
CHF mod
Bone Fracture
Risk
29. Guidelines: AACE v ADA
⦿There is extensive overlap between the two
⦿Key differences:
Biochemical Index ACE/AACE ADA
A1C ≤6.5% ≤7%
Preprandial plasma
glucose
70-130 mg/dL <110 mg/dL
Postprandial plasma
glucose
<180 mg/dL <140 mg/dL
32. Carb Counting
⦿Meal planning technique to manage blood
glucose levels
⦿Amount of carbohydrates consumed is
dependent on the individual
⦿ADA recommends starting at 45-60 grams of
carbohydrates at a meal
⦿Please see handouts for easy carb counting
for patients
33. Home Monitoring
⦿How to on testing blood sugars
⦿Different monitoring systems
⦿Frequency of monitoring
34. Smart Phone Apps
⦿Various ones available for free
● Glooko: for iPhone and Android
○ Sync and log blood sugar levels with
doctor’s devices. FDA approved as Class II
clinical device. The app is free, subscription
required
● Diabetes logbook: for iPhone and Android
○ Gamified logbook
● Diabetik: for iPhone
○ Simple basic design that allows users to set
medication and appointments reminders
based on preset information and location
35. Think, Pair, Share: Case 1
HL is a 56 y/o obese female with a
family history significant for diabetes and
presents for her annual physical exam.
A FPG is 170 mg/dL and she has no
concerns to discuss. How should HL be
managed?
A.Reassess in 1 year at her next physical
B.Obtain a f/u FPG in 1 week
C.Diagnose type 2 DM and discuss
dietary and lifestyle changes
36. Think, Pair, Share: Case 2
AR is a 46 y/o male newly diagnosed
with type 2 diabetes last month. He has
a BMI of 34kg/m2 and his most recent
A1C was 8.5% and has normal renal
function. His FPG readings ranged from
150-180 mg/dL despite his efforts to
implement dietary changes and starting
to exercise more frequently.
37. Think, Pair, Share: Case 2
Which option is best for AR?
A.Continue with diet and exercise for 1
year before trying pharmacologic
treatment
B.Start metformin 500 mg twice daily
titrating up to 2000 mg/day
C.Start basal insulin as his A1C indicates
need for insulin therapy
D.Start glyburide 10 mg twice daily
