8/30/19 New & Old Medications & Healthier Lifestyles for - - PDF document

8/30/19 1 New & Old Medications & Healthier Lifestyles for Diabetes Management

Annette Hess, PhD, FNP-BC, CNS, COI Ida Moffett School of Nursing Samford University

Disclosure

u Annette Hess has nothing to disclose.

Objectives

u Review the Healthy People 2020 statement and

epidemiology of diabetes.

u Review the diagnostic criteria and glycemic control for

diabetes mellitus.

u Identify and discuss healthier lifestyles for healthier

• utcomes

u List and describe anti-diabetes medications with a focus

• n new

u Oral medications u GLP-1 receptor agonists injectables u Insulins

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§ Increase quality & years of healthy life § Eliminate health disparities

Diabetes Epidemic

Diabetes Mellitus

u Total: >30.3 million people have diabetes (9.4% of the US population) u 1 in 10 have diabetes & by 2025 1 in 5 will have DM u Diagnosed: 23.1 million people u Undiagnosed: 7.2 million people (23.8% of people are undiagnosed) u Prediabetes: 84.1 million u Total direct/indirect estimated cost in the US in 2012 was $245 billion

and In 2017 was $327 Billion

u 7th leading cause of death in the US u Diabetes kills one American every 3 minutes

Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2017.

Diabetes Belt

u Identified region of the US with Diabetes Escalating u 644 counties - located in the southern states of u Prevalence of diabetes (CDC) increased more than 100 percent in 18

states

u Alabama u Arkansas u Florida u Georgia u Kentucky u Louisiana u Mississippi u North Carolina u Ohio u Pennsylvania u South Carolina u Tennessee u Texas u Virginia u West Virginia

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Diabetes Belt

u Since 1996, this escalating growth of diabetes u Oklahoma u (increase of 226 percent) u Kentucky u (increase of 158 percent) u Georgia u (increase of 145 percent) u Alabama u (increase of 140 percent) u Washington u (increase of 135 percent) u West Virginia u (increase of 131 percent)

Diabetes vs Diabetic

u Diabetes affects individuals u Individuals can Control Diabetes or u Diabetes will control them u Individuals with diabetes are exactly this u NOT a DIABETIC (please do not label a patient)

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Weight management within primary care practices

is the foundation

• f prevention and management of chronic

diseases

(New Obesity Guidelines, 2014) Health is not merely the absence of disease; it it’s a a Lif Lifes estyle le Lifestyle Modification for Weight Control & Disease Prevention

► Reduce energy intake by 500-1,000 kcal/d

• Reduce portion size, fat, and sugar
• Meal replacements (CWL – Commercial Weight Loss))

► Exercise

• ≥150 min/wk (DPP1)
• ≥175 min/wk (Look AHEAD2)

► Set realistic goals for weight loss/behavior change

• 5% weight loss in 3 months and reassess
• When 5%-10% weight loss achieved, enter maintenance
• Close follow-up with patient: visits/phone
• Provide tips for weight loss from National Weight Control Registry
• If no weight loss in 3 months, modify plan to include pharmacotherapy

Healthy Nutrition

¨ Healthy Diet

¤ Achieve & maintain ideal body weight

n BMI (Body mass index) should be < 25 n If >25 = OVERWEIGHT

¤ Include your favorite foods ¤ Balance the number of calories eaten with activity ¤ Limit intake of fat, cholesterol, sugar, and salt ¤ Water intake 64 oz daily ¤ DO NOT SKIP MEALS ¤ Space eating throughout the day ¤ MODERATION is the KEY!!

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No single diet is right for everyone!

u Fruits and Vegetables u Whole grains - oats, fiber u Beans, peas, lentils, chickpeas u Walnuts, almonds, pistachios, peanuts – natural not dry roasted u Milk and milk products (low-fat) u Fish (salmon, herring, tuna, trout, mackerel) u Omega-3 fatty acids: oily fish, olive oil, canola oil, 1 gm of EPA + DHA daily

u AVOID: Red meats, butter, fried foods, cheese, saturated fats

Antidiabetes Medications

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Biguanides

u Decreases hepatic glucose production and intestinal glucose

absorption, increases insulin sensitivity:

u Example: metformin (Glucophage) u Start with 500 mg daily and advance to max of 1,000 mg BID u Pros:

u Effective in reducing HgbA1C 1-1.5% - Free at local drug store u Weight loss u Children age 6 y/o greater u Increased insulin sensitivity u GFR >30

u Cons:

u GI upset initially – (Metformin XL if necessary) u Lactic acidosis in presence of renal failure u Increased fertility

Sulfonylureas

u Oral med that stimulates insulin release from pancreatic B

cells:

u Example: glipizide (Glucotrol) / glyburide (Micronase) /

Glimepiride (Amaryl)

u Pros:

u Effective in reducing HgbA1C 1-1.5% u Cheap – Free or $4 at local drug store

u Cons:

u Moderate hypoglycemia risk (elderly – caution) u Some weight gain

Thiazolidinediones (TZDs)

u Helps insulin work better in muscle and fat cells. Lowers

glucose production in the liver.

u Example: pioglitazone (Actos) u Pros:

u Effective in reducing HgbA1C 1-1.5% u Lower risk of hypoglycemia than sulfonylureas u CV benefits – lowers triglycerides

u Cons:

u Some weight gain u Risk of edema and heart failure u Low cost u Black box warning: CHF

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DDP4 - Inhibitor

u Oral meds that work similarly to GLP-1 agonists. u Example: sitagliptin (Januvia 100 mg), saxagliptin

(Onglyza 2.5-5 mg), linagliptin, (Tradjenta 5 mg)

u Pros:

u Effective in reducing HgbA1C 0.5-1% u Low risk of hypoglycemia u Weight neutral u Few side effects u Few drug interactions

u Cons:

u More expensive

Block the action of a protein called sodium-glucose co-transporter 2 (SGLT2) in the kidney which reabsorbs glucose back into the body from the urine. Excess glucose excreted in the urine. Example: canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance), ertugliflozin (Steglatro)

u Pros: u Effective in reducing HgbA1C 0.7-1% u Weight loss u Oral medication u Decrease blood glucose and blood

pressure

u Approved heart failure patients u Cons: u Increased UTI’s / Genital Yeast

Infections

u Increased creatinine u Urinary increase u Cholesterol increase u Hypotension u Renal problems – avoid in Renal pts

Sodium-Glucose Co-Transporter Inhibitor (SGLT2)

GLP-1 Receptor Agonists

u Injectable meds that cause flucagon suppression and delays gastric emptying.

Example:

u Daily – exenatide (Byetta) bid, liraglutide (Victozia) qd u Weekly - exenatide XL (Bydureon), exendatide XR (Bydureon Bcise, dulaglutide

(Trulicity), semaglutide (Ozempic), albiglutide (Tanzeum)

u Liraglutide: Saxenda 0.6 mg – 3.0 mg – weight loss / appetite suppressant u Pros: u Effective in reducing HgbA1C 1-1.5% u Low risk of hypoglycemia u WEIGHT LOSS u Cons: u GI Side Effects u More expensive $$$ u Injection site reaction

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Combination Medications for Glucose Control

u Insulin glargine (Lantus) + Lixisenatide (Adlyxin) = Soliqua 100/33 u Insulin dedludec (Tresiba)=Liraglutide (Victozia)=Xultophy 100/3.6 u Metformin + Sitaligliptin = Janumet 50mg/1000mg starting dose

AACE Guidelines

Type 1 Diabetes: Insulin Therapy

u Types of insulin u Rapid-acting – lispro (Humalog), (Novolog-Medicaid

approved, Fiasp)*, glulisine (Apidra), Afrezza (inhaled)

u Short-acting (Regular)* u Intermediate-acting (NPH and Lente) u Long-acting (Lantus, Toujeo, Basaglar (Abasaglar),

Levemir, Tresiba)

u Administration u Age criteria for insulin pump: u Advantages & disadvantages of insulin pump

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Rapid Insulins

Lispro U-100 (Humalog)

≈15 min 1-2 hours 3-6 hours

Lispro U-200 (Humalog 200)

≈15 min 1-2 hours 3-6 hours

Aspart (Novolog)

≈15 min 1-2 hours 3-6 hours

Glulisine (Apidra)

≈20 min 1-2 hours 3-6 hours

Lispro (Admelog)

< 15 min 1 hour 3-5 hours

Aspart (Fiasp)

< 30 min 1 hour 5-7 hours

Insulin (Afrezz*)

<15 mi ≈50 mi Varies with dose

Insulin Onset Peak Duration

*Inhaled insulin

Short-Acting Insulins

Regular U-100 (Novolin R, Humulin R) 30-60 min 2-4 hours 6-10 hours Humulin R Regular U-500 30-60 minutes 2-4 hours Up to 24 hours

Insulin Onset Peak Duration

NPH (Novolin N, Humulin N, ReliOn) 2-4 hrs 4-8 hours 10-18 hours

Intermediate-Acting Insulin

Insulin Onset Peak Duration

Basal Insulins

Glargine U-100 (Lantus) 1-2 hours Minimal Up to 24 hours Glargine U-100 (Basaglar) 1-2 hours Minimal Up to 24 hours Glargine U-300 (Toujeo) 6 hours No significant peak Up to 24-36 hours Detemir (Levemir) 1-2 hours Minimal Up to 24 hours Degludec U-100 & U-200 (Tresiba) 1-4 hours No significant peak About 42 hours

Insulin Onset Peak Duration

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FYI Clinic Recommendations

u Long-acting insulin (Lantus) + Rapid acting insulin (Regular insulin) u Lantus and 70/30 insulin - NOT a recommended treatment strategy u Lantus is LONG acting for a maintenance blood glucose u Regular insulin is for meal coverage u Long-acting insulins should be a single injection and not a split dose

(am or qhs)

u Why ?

Insulin activation Insulin Pumps

u 6 Insulin pump companies u Animas u Insulet u Medtronic u Roche u Sooil u Tandem u 10 different types of insulin pumps u Continuous Glucose Monitors (CGM) u 6 types u Some Interactive with Insulin pump

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Health Goals (ADA, 2018)

u HGB A1C: u < 6.5% AACE u < 7.0 % ADA u Fasting Blood Glucose (FBG) 70-130 mg/dL u AACE < 100 mg/dL u ADA < 110 mg/dL u 2 hrs postprandial < 180mg/dL u Blood Pressure (BP) <130/80 mmHg u Total Cholesterol <200 u LDL <100 mg/dL u HDL > 40 mg/Dl for males u HDL > 50 mg/Dl for females u Triglycerides <150 mg/dL u Insulin 6.0 – 27.0 u Body Mass Index (BMI) < 25.0 u Waist Circumference u < 35 Women u < 40 Men u hsC-Reactive Protein: Risk for CV dz u Low risk: less than 1.0 mg/L u Average risk: 1.0 to 3.0 mg/L u High risk: above 3.0 mg/L

If you have questions, just ask! Thank You!