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

8/30/19 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 outcomes u List and describe anti-diabetes medications with a focus on new u Oral medications u GLP-1 receptor agonists injectables u Insulins 1

8/30/19 § 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 7 th 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 Alabama u Ohio u Arkansas u Pennsylvania u Florida u South Carolina u Georgia u Tennessee u Kentucky u Texas u Louisiana u Virginia u Mississippi u West Virginia u North Carolina u Prevalence of diabetes (CDC) increased more than 100 percent in 18 states 2

8/30/19 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) 3

8/30/19 Weight management within primary care practices is the foundation of 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 (DPP 1 ) ● ≥ 175 min/wk (Look AHEAD 2 ) ► 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!! 4

8/30/19 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 5

8/30/19 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 6

8/30/19 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 Sodium-Glucose Co-Transporter Inhibitor (SGLT2) 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 Cons: u Effective in reducing HgbA1C 0.7-1% u Increased UTI’s / Genital Yeast Infections u Weight loss u Increased creatinine u Oral medication u Urinary increase u Decrease blood glucose and blood pressure u Cholesterol increase u Approved heart failure patients u Hypotension u Renal problems – avoid in Renal pts 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 7

8/30/19 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 8

8/30/19 Insulin Onset Peak Duration Lispro U-100 ≈ 15 min 1-2 hours 3-6 hours (Humalog) Rapid Insulins Lispro U-200 (Humalog ≈ 15 min 1-2 hours 3-6 hours 200) Aspart ≈ 15 min 1-2 hours 3-6 hours (Novolog) Glulisine ≈ 20 min 1-2 hours 3-6 hours (Apidra) Lispro < 15 min 1 hour 3-5 hours (Admelog) Aspart < 30 min 1 hour 5-7 hours (Fiasp) Insulin Varies with <15 mi ≈ 50 mi dose (Afrezz*) *Inhaled insulin Short-Acting Insulins Insulin Onset Peak Duration Regular U-100 (Novolin R, 30-60 min 2-4 hours 6-10 hours Humulin R) Humulin R 30-60 Up to 24 2-4 hours Regular U-500 minutes hours Intermediate-Acting Insulin Insulin Onset Peak Duration NPH (Novolin N, Humulin N, 2-4 hrs 4-8 hours 10-18 hours ReliOn) Insulin Onset Peak Duration Glargine Up to 24 U-100 1-2 hours Minimal hours Basal Insulins (Lantus) Glargine Up to 24 U-100 1-2 hours Minimal hours (Basaglar) No Up to Glargine U-300 6 hours significant 24-36 (Toujeo) peak hours Up to 24 Detemir 1-2 hours Minimal (Levemir) hours Degludec No U-100 & About 42 significant 1-4 hours U-200 hours peak (Tresiba) 9

8/30/19 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 10