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Diabetes - The Tools for Clinical Treatment

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Diabetes - The Tools for Clinical Treatment
Veronica Bandy, PharmD, MS, FCPhA, FCSHP, BCACP

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Diabetes - The Tools for Clinical Treatment

  1. 1. Diabetes – The Tools for Clinical TreatmentACPE# 0006-0000-19-003-L01-P Veronica T Bandy, PharmD, MS, FCPhA, FCSHP, BCACP Clinical Professor University of the Pacific
  2. 2. Conflict of Interest  I have no actual or potential conflict of interest in relation to this program/presentation.
  3. 3. Statement of Need  Overview of new drug therapies as it relates to diabetes
  4. 4. Course Objectives 1. Discuss current treatment guidelines for managing glycemic control in patients with diabetes 2. Describe adherence barriers to insulin therapy in the treatment of diabetes 3. Outline mechanism of action and efficacy of the various class of antihyperglycemic agents 4. Initiate and adjust insulin in appropriate patients who have not achieved glycemic control on non-insulin therapy 5. Summarize the economic, dietary and lifestyle considerations in patients with diabetes 6. Apply current treatment guidelines to patient case problems 7. Provide patient education and counseling points for selected diabetes regimens
  5. 5. Summary of New Guideline changes for 2018 ADA guideline  A new algorithm recommending antihypertensive treatment approach for adults with confirmed hypertension and diabetes with a blood pressure ≥140/90 mmHg  All patients with hypertension and diabetes monitor their blood pressure at home to compare with home and office measurements  Children less than 18 years of age who are overweight or obese and have one or more additional risk factors should be screened for prediabetes  Pharmacologic therapy for adults to decrease risk of hypoglycemia  Pregnant women with preexisting Type 1 or Type 2 diabetes consider daily low dose aspirin and beginning at end for first trimester  Increased awareness of social issues such as ability to afford medication, access to healthy foods and community support  Immunization recommendations for patients with diabetes updated to align with CDC
  6. 6. http://www.diabetes.org/assets/p dfs/at-risk/risk-test-paper- version.pdf Teaching Tool
  7. 7. Table 2.3 – Standards of Medical Care in Diabetes 2018 for adults  Consider testing for overweight or obese (BMI > 25 kg/m2 or > 23 kg/m2 Asian Americans)adults with one or more risk factors:  1st degree relative with DM  Ethnic high risk (African American, Latino, Native American, Asian American, Pacific Islander)  Hx CVD  Hypertension (> 140/90 mmHg or on tx HTN)  HDL <35 mg/dl &/or TG > 250 mg/dl  Women with diagnosis of PCOS  Physical inactivity  Conditions associated with insulin resistance ( severe obesity, acanthosis nigricans)  Test Yearly: patients classified with prediabetes [A1C> 5.7%, impaired fasting glucose (IFG) or impaired glucose tolerance (IGT)]  Test at least every 3 years: women diagnosed with gestational diabetes (GDM)  For all other patients, begin testing at age 45  Repeat testing every 3 years: if tests normal, consideration for more frequent testing depending on initial results or risk status https://diabetesed.net/wp- content/uploads/2017/12/2018-ADA-Standards-of- Care.pdf
  8. 8. Table 2.5 – Standards of Medical Care in Diabetes 2018  New criteria for assessment in children less than 18 years of age  Note: Type 2 prediabetes in asymptomatic children and adolescents in a clinical setting  Criteria  Overweight (BMI > 85th percentile for age & sex, weight for height > 85th percentile or weight >120% of ideal height  Plus 1 or more additional risk factors based on strength of association with DM as indicated by evidence grades  Maternal hx of DM or GDM during child’s gestationA  Family hx of DM (1st or 2nd degree relative)A  Race/Ethnicity (Native American, African American, Latino, Asian American, Pacific Islander)A  Sx of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, HTN, dyslipidemia, PCOS, or small for gestational age birth rate)
  9. 9. https://www.obesityaction.org/ get-educated/understanding- childhood-obesity/what-is- childhood-obesity/girls-bmi-for- age-percentile-chart/
  10. 10. BMI Charts (Girl and Boy) https://www.obesityaction.org/get-educated/understanding-childhood-obesity/what-is-childhood-obesity/girls-bmi-for-age-percentile- chart/ https://www.obesityaction.org/get-educated/understanding-childhood-obesity/what-is-childhood-obesity/boys-bmi-chart/
  11. 11. Barriers to Insulin Therapy Russell-Jones D, Pouwer F, Khunti K. Identification of barriers to insulin therapy and approaches to overcoming them. Diabetes Obes Metab. 2017;20(3):488-496. •Patient : DSME, mobile app intervention •Physician/System: training, nurse led management, specialist feedbackFear of Hypoglycemia •Patient: mobile app intervention, DSME, insulin with low risk of weight gainWeight Gain •Patient: mobile app interventions, pen devices, once daily dosing or flexible dosing •Physician: fixed ratio combos, simple titrationsBurdensome Regimes •Physician/System: nurse led management, communication between specialistsPoor Communication •Patient: improved communization to  fears Severe psychological insulin resistance •Patient: support from mental health care providerAnxiety and depression •System: nurse led management, specialist feedback Lack of time/resources for GPs
  12. 12. Barriers to Insulin Therapy When oral agents fail: practical barriers to starting insulin M Korytkowski1 *International Journal of Obesity (2002) 26, Suppl 3, S18–S24 Patient • Weight gain • Hypoglycemia • Painful injections • Needle anxiety • Lifestyle restrictions • Fear of stigma • Feelings of guilt/failure Healthcare Provider • Hypoglycemia/weight gain • Fear of patient compliance • Fear of patient anger • Fear of loosing/alienating patient • Oral agent failure anger/irritation • Lack of time/staff to teach insulin tx
  13. 13. Barriers to Insulin TherapyBarriers to Insulin Initiation. Andrew J. Karter, Usha Subramanian, Chandan Saha, Jesse C. Crosson, Melissa M.Parker, Bix E. Swain, Howard H. Moffet, David G. Marrero. Diabetes Care Apr 2010, 33 (4) 733-735; DOI: 10.2337/dc09-1184 http://care.diabetesjou rnals.org/content/33/4/ 733
  14. 14. Barriers to Insulin Therapy  Can be multifactorial  May be experienced my both the patient and the caregiver  Play a role in patient willingness to start insulin therapy
  15. 15. https://diabetesed.net/wp- content/uploads/2017/12/2018-ADA- Standards-of-Care.pdf Teaching Tool
  16. 16. New Drugs  Metformin combination agents  Dapagliflozin (Farxiga®)  Ertugliflozin (Steglatro®)  Ertugliflozin + sitagliptin (Steflujan®)  Insulin glargine + lixisenatide (Soliqua® 100/33)  Insulin degludec + liraglutide (XULTOPHY 100/3.6)  Saxagliptin (Onglyza®)  Semaglutide (Ozempic®)
  17. 17. Metformin (Glumetza®, Fortamet®, Riomet®, and Glucophage XR®)  MOA:  hepatic glucose production,  intestinal glucose absorption,  insulin sensitivity  Dose:  IR 500mg BID or 850 mg initially  ER: 500 to 1000mg daily initially  Max: 2000 – 2500 mg daily  A1C expectation:  1 to 2 %  Warning: not recommended to initiate eGFR 30-45ml/min/1.73m2  Counseling Tips  ER  possible “ghost shell”  With long term use vitamin B12 deficiency  SE: N/V/D, abdominal cramping, flatulence  Monitor renal function, B12, BG, A1C BBW:  risk lactic acidosis with dehydration, hypoxic states, > 65 years, IV radiocontrast dye, alcohol, hepatic or renal impairment
  18. 18. Metformin combinations + sulfonylurea Brand name Glipizide Metaglip Glyburide Glucovance +thiazolidinedione Pioglitazone Actosplus Met Rosiglitazone Avandamet + DPP-4 Inhibitor Alogliptin Kazano Linagliptin Jentadueto, Jentadueto XR Sitagliptin Janumet, Janumet XR Saxagliptin Kombiglyze XR +SGLT2 Inhibitor Brand Name Canagliflozin Invokamet, Invokamet XR Dapagliflozin Xigduo XR Empagliflozin Synjardy, Synjardy XR Ertugliflozin Segluromet + meglitinide Repaglinide PrandiMet
  19. 19. Meglitnides repaglinide (Prandin®), nateglinide (Starlix®)  MOA:  insulin secretion β cells ( ppbg)  Dose:  Repaglinide  A1C <8% 0.5mg AC TID  A1C > 8% 1-2 mg AC TID  Max: 16mg/daily  Nateglinide  60 -120mg AC TID  A1C expectation:  0.5 to 1.5 %  Warning: contraindicated in DKA or Type 1; repaglinide not given with gemfibrozil;  Counseling Tips  Can cause hypoglycemia  Alcohol can  risk  Repaglinide  Take 15 -30 minutes AC  Nateglinide  Take 1 – 30 minutes AC  SE: weight gain, upper respiratory tract infection, headache  Monitor AIC, BG
  20. 20. Sulfonylureas glipizide (Glucotrol®)  MOA:  insulin secretion β cells ( ppbg)  Dose:  IR: 5mg daily,  2.5 – 5 mg every few days  Max: 40 mg daily  XL: 5 mg daily  Max: 20 mg daily  A1C expectation:  1 to 2 %  Counseling Tips  Can cause hypoglycemia  Doses > 15 mg divide BID  SE: weight gain, nausea  IR take 30 minutes prior to meal  XL take with first meal of the day  XL may have “ghost shell”  Monitor AIC, BG
  21. 21. Sulfonylureas glimepride (Amaryl®)  MOA:  insulin secretion β cells ( ppbg)  Dose: 1 to 2 mg daily,  1 to 2 mg every 1 to 2 weeks  Max: 8 mg daily  A1C expectation:  1 to 2 %  Counseling Tips  Can cause hypoglycemia  SE: weight gain, nausea  Monitor AIC, BG
  22. 22. Sulfonylureas glyburide (Glynase®)  MOA:  insulin secretion β cells ( ppbg)  Dose: 2.5 to 5 mg daily,  by 2.5 mg weekly  Max: 20mg daily  A1C expectation:  0.5 to 1.5 %  Warning: caution in renal insufficiency as active metabolite cleared renal  Counseling Tips  Can cause hypoglycemia  Alcohol can  risk  SE: weight gain, nausea  Take with morning meal  Monitor AIC, BG
  23. 23. Thiazolidinediones pioglitazone (Actose®), rosiglitazone (Avandia®)  MOA:  periperial insulin sensitivity  Dose:  Actose: 15 – 30 mg daily  Max: 45 mg daily  Avandia: 4 – 8 mg daily  Max: 8mg daily  A1C expectation:  0.5 to 1.4 %  Contraindicated in NYHA Class III/IV  Counseling tips:  medguide required  Avandia avoidin patients with bladder cancer  Monitor for changes in cholesterol  Possible ovulation resumptionin premenopausal women  SE: peripheral edema, weight gain, myalgia  Monitor: s/sx HF, AIC, BG, LFTs  Counseling Tips 
  24. 24. Sodium Glucose Co-transporter Inhibitor canagliflozin (Invokana®)  MOA:  urinary glucose excretion,  plasma glucose concentration  Dose:100mg prior to 1st meal;  to 300mg daily  A1C expectation:  0.7 to 1%  Warning:  eGFR 45-59 mL/min/1.73m2: 100mg max  eGFR 30-44 mL/min/1.73m2 : not recom.  eGFR < 30 mL/min/1.73m2 : contraindicated  Counseling Tips  Medguide required  May cause hyperkalemia  Can increase risk of fractures  SE: weight loss, hypoglycemia,  urination, Mg/PO4  Monitor AIC, BG, renal fxn, LDL, volume status, BP
  25. 25. Sodium Glucose Co-transporter Inhibitor dapagliflozin (Farxiga®)  MOA:  urinary glucose excretion,  plasma glucose concentration  Dose: 5mg daily  Max: 10mg daily  A1C expectation:  0.7 to 1 %  Warning:  eGFR 30-59 mL/min/1.73m2 : not recom.  eGFR < 30 mL/min/1.73m2 : contraindicated  Counseling Tips  Medguide required  Can increase risk of bladder cancer  SE: weight loss, hypoglycemia,  urination, Mg/PO4  Monitor AIC, BG, renal fxn, LDL, volume status, BP
  26. 26. Sodium Glucose Co-transporter Inhibitor empagliflozin (Jardiance®)  MOA:  urinary glucose excretion,  plasma glucose concentration  Dose: 10 mg daily  Max: 25 mg daily  A1C expectation:  0.7 to 1 %  Warning:  eGFR 30-44 mL/min/1.73m2 : not recom.  eGFR < 30 mL/min/1.73m2 : contraindicated  Counseling Tips  Med guide required  SE: weight loss, hypoglycemia,  urination, Mg/PO4  Monitor AIC, BG, renal fxn, LDL, volume status, BP
  27. 27. Sodium Glucose Co-transporter Inhibitor ertugliflozin (Steglatro®)  MOA:  urinary glucose excretion,  plasma glucose concentration  Dose: 5 mg daily in AM  Max: 15 mg daily in AM  A1C expectation:  0.7 to 1 %  Warning:  eGFR initial between 30 to 60 mL/min/1.73m2 : do not initiate  < 30 mL/min/1.73m2 : not recommended  eGFR persists between 30 to 60 mL/min/1.73m2 : not recommended  Counseling Tips  Med guide required  Not recommended during 2nd & 3rd trimester of pregnancy  Not recommended during breastfeeding  SE: renal impairment, hypotension, ketoacidosis, limb amputation, genital mycotic infections,  LDL, urosepsis and pyelonephritis  Monitor AIC, BG, renal fxn initially and periodically, BP, LDL  Note; Ertugliflozin + sitagliptin (Stefluan®)
  28. 28. Kahoots #1
  29. 29. Dipeptidyl Peptidase 4 Inhibitor sitagliptin (Januvia®)  MOA:  insulin release β cells,  glucagon secretion   hepatic glucose production  Dose: 100mg daily  A1C expectation:  0.5 to 0.8 %  Warning:  CrCl 30-49 ml/min: 50mg daily  CrCl < 30 ml/min: 25mg daily  Possible acute pancretitis, severe joint pain, SJS rash  Counseling Tips  Medguide required   postprandial glucose  SE: UTIs, nasopharyngitis, peripheral edema, rash, upper respiratory tract infection  Monitor AIC, BG, renal function
  30. 30. Dipeptidyl Peptidase 4 Inhibitor saxagliptin (Onglyza®)  MOA:  insulin release β cells,  glucagon secretion   hepatic glucose production  Dose: 2.5 to 5 mg daily  A1C expectation:  0.5 to 0.8 %  Warning:  eGFR <45 mL/min/1.73m2 : 2.5 mg daily  Possible acute pancretitis, severe joint pain, SJS rash  Counseling Tips  Medguide required   postprandial glucose   risk of HF in patients with renal impairment or hx of HF  SE: UTIs, nasopharyngitis, peripheral edema, rash, upper respiratory tract infection  Monitor AIC, BG, renal function
  31. 31. Dipeptidyl Peptidase 4 Inhibitor linagliptin (Tradjenta®)  MOA:  insulin release β cells,  glucagon secretion   hepatic glucose production  Dose: 5mg daily  A1C expectation:  0.5 to 0.8 %  Warning:  Possible acute pancretitis, severe joint pain, SJS rash  Counseling Tips  Medguide required   postprandial glucose  No renal dose adjustment  SE: UTIs, nasopharyngitis, peripheral edema, rash, upper respiratory tract infection  Monitor AIC, BG,
  32. 32. Dipeptidyl Peptidase 4 Inhibitor alogliptin (Nesina®)  MOA:  insulin release β cells,  glucagon secretion   hepatic glucose production  Dose: 25 mg daily  A1C expectation:  0.5 to 0.8 %  Warning:  CrCl 30-49 ml/min: 12.5mg daily  CrCl < 30 ml/min: 6.25mg daily  Possible acute pancretitis, severe joint pain, SJS rash  hepatotoxicity  Counseling Tips  Medguide required   postprandial glucose  SE: UTIs, nasopharyngitis, peripheral edema, rash, upper respiratory tract infection  Monitor AIC, BG, renal function, liver function
  33. 33. Glucagon-like Peptide 1 Agonists Exenatide (Byetta®)  MOA:  glucose dependent insulin secretion,  glucagon secretion, slowed gastric emptying, improves satiety  Dose: 5mcg SC BID x 1 month, then 10 mcg SC BID  A1C expectation:  0.5 to 1.5 %  Warning:  Pancreatitis  Avoid in patients with severe GI disease  Counseling Tips   postprandial BG  Administer dose within 60 minutes of meals  Rotate injection sites  Do not store with pen needle attached  SE: NAUSEA, V/D/C, weight loss, injection site reaction  Medguide required  Monitor AIC, BG, renal function
  34. 34. Glucagon-like Peptide 1 Agonists liraglutide (Victoza®)  MOA:  glucose dependent insulin secretion,  glucagon secretion, slowed gastric emptying, improves satiety  Dose: 0.6mg daily x 1 week, 1.2mg SC daily  Max 1.8mg SC daily  A1C expectation:  0.5 to 1.5%  Warning:  Pancreatitis  Avoid in patients with severe GI disease  BBW: risk of thyroid C-cell carcinoma  Counseling Tips   postprandial BG  SE: NAUSEA, V/D/C, weight loss, injection site reaction  Rotate injection sites  Do not store with pen needle attached  Medguide required  Monitor AIC, BG, renal function
  35. 35. Glucagon-like Peptide 1 Agonists dulaglutide (Trulicity®)  MOA:  glucose dependent insulin secretion,  glucagon secretion, slowed gastric emptying, improves satiety  Dose: 0.75mg SC once WEEKLY  Max: 1.5mg SC once weekly  A1C expectation:  0.5 to 1.5 %  Warning:  Pancreatitis  Avoid in patients with severe GI disease  BBW: risk of thyroid C-cell carcinoma  Counseling Tips   postprandial BG  SE: NAUSEA, V/D/C, weight loss, injection site reaction, tachycardia, PR interval prolongation, 1st degree AV block  Rotate injection sites  Do not store with pen needle attached  Medguide required  Monitor AIC, BG, renal function
  36. 36. Glucagon-like Peptide 1 Agonists (albiglutide (Tanzeum®))  MOA:   Dose:  A1C expectation:  Warning:  Counseling Tips  Can cause  SE:  Monitor AIC, BG
  37. 37. Glucagon-like Peptide 1 Agonists lixisenatide (Adlyxin®)  MOA:  glucose dependent insulin secretion,  glucagon secretion, slowed gastric emptying, improves satiety  Dose: 10 mcg SC daily x 14 days, then  20 mcg daily  A1C expectation:  0.5 to 1.5 %  Warning:  Counseling Tips  Give dose within 60 minutes of meal   postprandial BG  Rotate injection sites  Do not store with pen needle attached  SE: NAUSEA, V/D/C, weight loss, injection site reaction  Medguide required  Monitor AIC, BG, renal function
  38. 38. Glucagon-like Peptide 1 Agonists Semaglutide (Ozempic®)  MOA:  glucose dependent insulin secretion,  glucagon secretion, slowed gastric emptying, improves satiety  Dose: 0.25 mg SC once weekly x 4 weeks, then  to 0.5 mg SC once weekly; may  to 1 mg SC weekly  A1C expectation:  0.5 to 1.5 %  Warning:   complications with diabetic retinopathy  BBW: risk of thyroid C-cell carcinoma  Counseling Tips  SE: NAUSEA, V/D/C, weight loss, injection site reaction  Rotate injection sites  Do not store with pen needle attached  Remove pen from refrigerator, let stand to room temperature 15 min  Medguide required  Monitor AIC, BG, renal function
  39. 39. Amlin analog Pramlintide (Symlin®)  MOA: slows gastric emptying, suppression glucagon secretion, increased satiety  Dose: 60 mcg/dose, then  120 mcg/dose after 3 days  A1C expectation:  0.5 to 1 %  Warning:  Hypoglycemia  Very important to decrease mealtime insulin by 50% if patient taking  Contraindicated in gastroparesis  Counseling Tips  Medguide required  Give SC prior to each meal > 30 gm carbohydrates or > 250 kcal  Decrease mealtime insulin  Administer oral medications at least 1 hour before or 2 hours after  SE: Nausea, vomiting, weight loss, headache, hypoglycemia  Monitor AIC, BG
  40. 40. Kahoots #2
  41. 41. Cases
  42. 42. Intermediate Acting Insulin (NPH)  Used in Type 2 DM when oral agents alone are unable to reach goal  100 units/ml  10ml vials available OTC  Counseling Tips  Remind patients of suspension  Storage  expiration
  43. 43. Long Acting Insulin  Used in Type 2 DM when oral agents alone are unable to reach goal  Detemir (Levemir, Levemir FlexTouch)  Glargine (Lantus, Lantus SoloStar, Basaglar, Toujeo Solostar)  Degludec (Tresiba Flextouch)  Counseling Tips  Do not mix with other insulins  Glargine as acidic pH  patients may complain of inject site stinging  Storage  expiration
  44. 44. Insulin glargine + lixisenatide (Soliqua 100/33)  MOA:  glucose dependent insulin secretion,  glucagon secretion, slowed gastric emptying, improves satiety + regulates glucose metabolism and  glucose uptake in muscles  Dose:  naïve or <30 units basal insulin  15 units SC once daily  Inadequate control 30-60 units basal insulin  30 units SC once daily  Titrate 2 to 4 units weekly based on BG until desired FBG level achieved  +2 units (2 units of insulin glargine and 0.66 mcg of lixisenatide) to +4 units (4 units insulin glargine and 1.32 mcg lixisenatide)  Warning:  Not recommended in patients with gastroparesis  Not studied in combo with prandial insulin  Not studied in patients with hx of pancreatitis  Not studied in children  Counseling Tips  SE: injection site reaction, hypoglycemia, nausea, nasopharyngitis, diarrhea, upper respiratory tract infection, weight gain and headache  D/C basal insulin &/or lixsenatide prior to use  Do not administer > 60 units  DDI: beta-blockers, clonidine, guanethidine, and reserpine (Hypoglycemia s/sx may be reduced). Take Ocs, acetaminophen and antibiotics at least 1 hour prior to injection  Monitor AIC, BG, s/sx pancreattis, sx thyroid tumor
  45. 45. Insulin degludec + liraglutide (Xultophy® 100/3.6)  MOA:  glucose dependent insulin secretion,  glucagon secretion, slowed gastric emptying, improves satiety + regulates glucose metabolism and  glucose uptake in muscles  Dose:  Naïve: 10 units SC once daily  Currently taking insulin or GLP-1; 16 units SC once daily  Titrate by 2 units every 3 to 4 days  + 2 units (2 units of insulin degludec and 0.072 mg of liraglutide)  Warning:  Not recommended in patients with gastroparesis  Not studied in combo with prandial insulin  Not studied in patients with hx of pancreatitis  Not studied in children  Counseling Tips  SE: injection site reaction, weight gain, stuffy or runny nose, sore throat, headache, nausea, diarrhea, increased blood levels of lipase, and upper respiratory tract infection  Do not administer more than 50 units daily  D/C basal insulin &/or lliraglutide prior to use  DDI: beta-blockers, clonidine, guanethidine, and reserpine (Hypoglycemia s/sx may be reduced).  Monitor AIC, BG, s/sx pancreattis, sx thyroid tumor, potassium
  46. 46. Rapid Acting Insulin  May be of use in patients who have one time of day with high post prandials  Aspart (Novolog, Novolog FlexPen)  Glulisine (Apidra, Apidra Solostar)  Lispro (Humalog,Humalog KwikPen)  Counseling Tips  Can cause hypocalcemia and hypokalemia  SE: weight gain, injection site reactions, peripheral edema  Monitor; weight, A1C, BG
  47. 47. Approach to starting and adjusting insulin in type 2 diabetes (17). American Diabetes Association Dia Care 2016;39:S52-S59 ©2016 by American Diabetes Association
  48. 48. Initiation of insulin in Patients with Type 2 diabetes  Initial dose: 0.1 to 0.2 units/kg/d (using ABW) or 10 units/d  Titration dose: increase by 10 – 15 % or 2 – 4 units once or twice weekly, until FBG goal achieved  What is the risk of hypoglycemia?  What is risk with adding to metformin regime?  What is risk to adding to other regimes?
  49. 49. Insulin Conversions  When converting from BID NPH  daily glargine  Use 80% TDD of NPH as initial dose of glargine  When converting from daily Toujeo  daily Lantus/Basaglar  Use 80% TDD Toujeo as initial dose of Lantus/Basaglar
  50. 50. Initiate and Adjust Insulin Therapy in Appropriate Patients  Include patient counseling  Pearls to insulin adjustment
  51. 51. Insulin Cases
  52. 52. Economic, dietary and lifestyle considerations  Inverse Association between Organic Food Purchase and Diabetes Mellitus in US Adults. Sun Y, Liu B, Du Y, Snetselaar LG, Sun Q, Hu FB, Bao W. Nutrients. 2018 Dec 3;10(12). pii: E1877. doi: 10.3390/nu10121877.  “Individuals who reported purchasing organic foods were less likely to have diabetes compared to those who did not report organic food purchase. After adjustment for age, gender, race/ethnicity, family history of diabetes, socioeconomic status, and dietary and lifestyle factors, the OR of diabetes associated with organic food purchase was 0.80 (95% CI 0.68–0.93). The association remained significant after additional adjustment for BMI with OR of 0.80 (0.69–0.94).”
  53. 53. Dietary considerations  Medical Nutrition Therapy (MNT) when delivered by a registered dietitian can lead to decreases of A1C by 0.3 – 2%  MNT to be considered as part of overall treatment plan
  54. 54. Dietary Considerations  Goals of Nutrition Therapy for Adults with Diabetes 1. Support and promote healthy eating patterns to improve overall health 1. Prevent or delay complications of diabetes 2. Achieve glycemic, lipid and blood pressure goals 3. Achieve and maintain weight goals 2. Address the nutrition needs on an individual basis including the assessment of health literacy, cultural preferences, access to healthy foods, barriers to change and willingness to change 3. Provide nonjudgmental messaging about food choices 4. Provision of tools that focus on healthy eating patterns rather than specific food items or nutrients
  55. 55. Dietary considerations  According to ADA guidelines “Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes. Therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals.”  Examples of diets that have shown positive results and examples of healthy eating include:  The Mediterranean  Dietary Approaches to Stop Hypertension (DASH)  Plant based diets  Sodium < 2300 mg/d
  56. 56. Summarize economic, dietary and lifestyle considerations  Economic factors plays a role in nutrition for patients with diabetes  Individualization should be taken into account  Health literacy and culture are also factors to recognize  Provide patients with tools
  57. 57. Kahoots #3

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