DISCLOSURES Gilead Sciences (Grant Recipient) Eli Lilly & Co - - PDF document

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Diabetes Management in the Safety Net: Making Sense of Medication Choices

UCSF CME: Medical Care of Vulnerable and Underserved Populations

March 1, 2019

Suneil K. Koliwad, MD, PhD Gerold Grodsky, PhD/JAB Chair in Diabetes Research Associate Professor of Medicine Diabetes Center University of California, San Francisco Division of Endocrinology San Francisco General Hospital

DISCLOSURES

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Gilead Sciences (Grant Recipient) Eli Lilly & Co (Grant Recipient) Suggestic (Equity; Consultant) Yes Health (Equity; Consultant) AMMA Therapeutics (Consultant)

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Overview

Environmental Factors- The dietary abyss Ethnicity- Putting trends into practice Medications- Oral Agents Insulin Self Care- To check, or not to check

Environmental Factors

”Anyone can out-eat their medications”

Ken Feingold, MD, PhD UCSF/VAMC

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Lifestyle Modification for Diabetes Risk Reduction

Lifestyle is a powerful “medicine”

The Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393.

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Relative Price Changes for Fresh Fruits and Vegetables, Sugars and Sweets, and Carbonated Drinks, 1978–2009

From: Bronwell KD, Frieden TR. Ounces of Prevention — The Public Policy Case for Taxes on Sugared Beverages. N Engl J Med. 2009 Apr 30;360(18):1805-8. Epub 2009 Apr 8.

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MISSION TENDERLOIN VISITACION VALLEY EXCELSIOR BAYVIEW

SODA EXPENDITURES Percent of Total Expenditures, National Rank by Tract (2011)

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Ethnicity

Diabetes Risk is Not Evenly Spread Across the Population

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O’Rahilly et al. Endocrinology, 2003

Leptin-deficient patients are severely obese but obesity can be reversed by leptin replacement

Locke, et al. 2015. Nature. 518(7538): 197-206. DEPICT analysis

GWAS Meta-Analysis: Heritable Component

• f BMI is Dominated by “Brain Genes”

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Obesity is Not a Highly Penetrant Diabetes Risk Factor

Kuhnen, et al., NEJM 2016

Two Individuals with POMC Mutations

Variable Patient 1 Patient 2 Glucose (mg/dl) 65 76 Insulin (mU/L) 26.7 9.8 Triglycerides (mg/dl) 99 63 HbA1C 5% 5.4%

Obesity and T2DM In the United States

Among people diagnosed with Type 2 diabetes, 55% are BMI ≥ 30 (obese), 30% are BMI ≥ 25 or ≤30 (overweight) 15 percent have a BMI ≤ 25 (classified as normal weight). ~70% of Overweight and Obese People do not develop T2DM

Adapted from: http://www.obesityinamerica.org/trends.html

BMI < 25 BMI > 25 or BMI < 30

15% 30% 55%

9 Obesity and T2DM In the United States

Among people diagnosed with Type 2 diabetes, 55% are BMI ≥ 30 (obese), 30% are BMI ≥ 25 or ≤30 (overweight) 15 percent have a BMI ≤ 25 (classified as normal weight). ~70% of Overweight and Obese People do not develop T2DM

Adapted from: http://www.obesityinamerica.org/trends.html

BMI < 25 BMI > 25 or BMI < 30

15% 30% 55%

Lotta, et al. Nature Genetics 49, 17–26 (2017); Involved Two Large Cohorts and a PFLD1 Cohort

DEPICT: Heritable Component of Insulin Resistance is Dominated by White AdiposeTissue and its Peripheral Storage Capacity

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What is the prevalence of type 2 diabetes?

• A. 10% of all diabetes in ages 5-18
• B. 5% of all diabetes in ages 5-18
• C. It is ethnicity dependent
• D. It can be greater than the prevalence of

type 1 diabetes

11 Understanding Ethnicity-Associated T2DM Risk: Clinical Impact

Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;

China and Japan : overweight BMI of 24, obesity BMI > 28. India: overweight BMI of 23, and obesity BMI > 27

http://screenat23.org

Ethnicity Impacts T2DM Risk

Nurse’s Health Study

Shai I et al. Diabetes Care 2006;29:1585-1590

12 Distribution of Diabetes Types by Age at Diagnosis and Race/Ethnicity

Case

55 yow w/ HTN, BMI 32, DM2 for 3 years. On metformin but in past year A1C has increased to 8.2%. What do you do next?

a) Encourage improved diet and exercise b) Start a sulfonylurea c) Start a TZD d) Start a DPPIV-inhibitor e) Start an SLGT-2 inhibitor f) Start a GLP-1 analogue g) Start insulin h) Start an α-glucosidase inhibitor, bromocriptine or colesevelam

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A1C Goal Efficacy Comorbidities Complications Patient Acceptance Adverse Effects Risks/Hypoglycemia Cost Cardiovascular Benefit/Harm

Case

55 yow w/ HTN, BMI 32, DM2 for 3 years. On metformin but in past year A1C has increased to 8.2%. What should her A1C target be?

a) < 6% b) < 6.5% c) < 7% d) 7-8% e) < 8%

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What I Know about Lowering Glucose in Diabetes

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What I Know about Lowering Glucose in Diabetes I THINK

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• 1. Lowering A1C prevents microvascular
• complications. The lower the better. The

earlier in the disease the better.

• 2. Lowering A1C early in the disease prevents

macrovascular complications many years later.

• 4. Aggressive A1C lowering results in more

hypoglycemia and the elderly are more prone to severe hypoglycemia.

• 3. The effects of improved glycemic control

early in the disease last decades after.

N Engl J Med 2005;353:2643-2653

DCCT/EDIC - Cumulative Incidence CVD Outcomes

42% reduction in CVD risk 57% reduction in risk of nonfatal MI, stroke or CVD death

7.2 v 9.1 % A1C 8.0 v 8.1 % A1C [----------------------------------------------] At 30 y Follow up 30% reduction in CVD risk 32% reduction in risk of nonfatal MI, stroke or CVD death

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UKPDS - HbA1c

Progression

Time from Randomization (years) 3 6 9 12 15

Conventional Intensive

Lancet, 1998; 352:837-853.

7% v 7.9% A1C

UKPDS - 20 y follow-up

Intensive Glucose Control

RR = 0.85* RR = 0.67*

NEJM, 2008; 359:1577-89.

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UKPDS - 20 y follow-up

Intensive Glucose Control

NEJM, 2008; 359:1577-89.

RR = 0.87* RR = 0.73*

Risk Factors for Mortality and CV Outcomes in DM2

• 271,174 patients with DM2 in Sweden
• Assessed 5 risk factors out of target range

– A1C > 7%, SBP > 140, smoking, LDL > 97 mg/dL, albuminuria – Explored CV outcomes and mortality

• Hazard Ratio for patients with all variables in

target range

– death 1.06 (1.00‐1.12) – acute MI 0.84 (0.75‐0.93) – stroke 0.95 (0.84‐1.07)

Rawshani et al. N Engl J Med 2018;379:633‐644.

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Which risk factor outside the target range was the strongest predictor of acute MI and stroke? a) elevated A1C b) elevated SBP c) smoking d) elevated LDL e) albuminuria

A B C D E

A Rawshani et al. N Engl J Med 2018;379:633‐644.

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Which risk factor outside the target range was the strongest predictor

• f death?

a) elevated A1C b) elevated SBP c) smoking d) elevated LDL e) albuminuria

A Rawshani et al. N Engl J Med 2018;379:633‐644.

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UKPDS ADVANCE ACCORD VADT

# subjects

4,209 11,140 10,251 1,791

Age (y)

54 66 62 60

BMI

28 28 32 31

CVD

7.5% 32% 35% 40%

Dx (y)

New 8 10 12

A1C %

7.1 7.5 8.3 9.4 Duration of Follow-up 10+10= 20 5.0 3.4+5.6= 9 5.6+4.4= 10

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Study Microvasc CVD Mortality

UKPDS

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DCCT / EDIC 

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ACCORD



      

ADVANCE

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   

VADT

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Long Term Follow‐up Initial Trial

Summary of Major Tight Control Trials

Modified from Kendall and Bergenstal

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Take Home Points

• Lowering A1C prevents microvascular complications.

The lower the better. The earlier in the disease the better.

• Lowering A1C early in the disease prevents

macrovascular complications many years later.

• Effects of early A1C lowering last decades after tight

control is done.

• Tight control late in T2DM in patients with established

CV disease

• Has more modest effects on microvascular disease
• Has unclear CV benefit

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Case

55 yow w/ HTN, BMI 32, DM2 for 3 years. On metformin but in past year A1C has increased to 8.2%. What should her A1C target be?

a) < 6% b) < 6.5% c) < 7% d) 7-8% e) < 8%

42 A B C D E

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Guidelines for Glycemic Targets

• American Association of Clinical

Endocrinologists

• American Diabetes Association
• VA/DOD
• NICE – UK
• American College of Physicians

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Glycemic targets

• < 7.0% for many adults
• < 6.5 % for selected patients if this can be achieved

without hypo or other adverse effects

• < 8% for patients with history of severe

hypoglycemia, limited life expectancy, advanced macro/microvascular disease, longstanding DM without attaining the goal

Diabetes Care 2018;41(Suppl. 1):S55–S64 | https://doi.org/10.2337/dc18-S006

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ACP Guidance for A1C Targets in DM2

• Clinicians should aim to achieve A1C of 7-8% in most

patients

• ACHIEVE - NOT “AIM TO ACHIEVE”
• Clinicians should consider cutting back on medical therapy

with A1C < 6.5%

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Qaseem et al for Guildine Committee, Ann Intern Med March, 2018

ACP Guidance for A1C Targets in DM2

• Clinicians should aim to achieve A1C of 7-8% in most

patients

• ACHIEVE - NOT “AIM TO ACHIEVE”
• Clinicians should consider cutting back on medical therapy

with A1C < 6.5%

• NOT FOR FOLKS ON METFORMIN/DRUGS WITHOUT

HYPOGLYCEMIA OR YOUNG FOLKS WITHOUT LOWS

• Life expectancy < 10 years (e.g. 80+, nursing home,

dementia, ESRD, COPD, CHF etc) goal is to minimize symptoms without A1C target

• – NEED AN A1C TO KNOW SE – Big difference between 8 and 12
• Personalize goals based on all those things we are talking

about

• YES!!!

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Qaseem et al for Guildine Committee, Ann Intern Med March, 2018

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A1C Target

55 yow w/ HTN, BMI 32, DM2 for 3

• years. On metformin but in past

year A1C has increased to 8.2%. What should her A1C target be?

a) < 6% b) < 6.5%

c)< 7%

d) 7-8% e) < 8%

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How? What of the multiple possible choices will you use to attempt to reach your desired A1c goal?

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Case

a) Encourage improved diet and exercise b) Start a sulphonylurea c) Start a TZD d) Start a DPPIV-inhibitor e) Start an SLGT-2 inhibitor f) Start a GLP-1 analogue g) Start insulin h) Start an α-glucosidase inhibitor, bromocriptine or colesevelam

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A1C Goal Efficacy

Comorbidities Contraindications Patient Acceptance Adverse Effects Risks/Hypoglycemia Cost Cardiovascular Benefit/Harm

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A1C Cost/mth

Sulfonylurea 1-2% $4-12 Metformin 1-2% $4 Pioglitazone 0.5-1.5% $9 GLP-1 Analog 0.5-1.5% $613-872 SGLT2 Inhibitors 0.5-1% $285-483 DPPIV Inhibitors 0.5-0.8% $208-447 Acarbose 0.5-0.8% $24

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Good Rx.com 12/8/2018

UCSF: Using the EMR to Assess T2DM Heterogeneity

Peterson, et al. Under Review

27 UCSF: Using the EMR to Assess T2DM Heterogeneity

Peterson, et al. Under Review

UCSF: Using the EMR to Assess T2DM Heterogeneity

Peterson, et al. Under Review

28 UCSF: Using the EMR to Assess T2DM Heterogeneity

Peterson, et al. Under Review

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Drugs with Poor A1C Effect

• DPPIV Inhibitors – Avoid with HIV
• α- glucosidase inhibitors (acarbose,miglitol)
• Colesevolam (Welchol)
• Bromocriptine (cycloset)

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SULFONYLUREAS INCREASE RISK OF CARDIOVASCULAR DISEASE.

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a)True b)False

A B

Sulfonylureas are very inexpensive

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Antonios Douros et al. BMJ 2018;362:bmj.k2693

Forest plot summarising the primary analysis and all sensitivity analyses

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77,138

Metformin Monotherapy Users

25,699

Adding or switching to SU

13,217

Adding SU

9,800

Switching to SU

0.5 2.5 4.5 6.5 8.5

Myocardial Infarction Adding SU Switching to SU Ischemic Stroke Adding SU Switching to SU CV Death Adding SU Switching to SU All Cause Mortality Adding SU Switching to SU

Adjusted HR (95% CI)

32 Adding a sulfonylurea to metformin does not increase the risk of cardiovascular disease but replacing metformin with a sulfonylurea does

MEDPAGE TODAY

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Agenda Against Inexpensive DM Meds

• Metformin

– Renal failure, CHF, GI SE

• SU

– Increased CV risk – Hypoglycemia

• Insulins

– Hypoglycemia UKPDS ADVANCE ACCORD VADT

# subjects

4,209 11,140 10,251 1,791

Age (y)

54 66 62 60

BMI

28 28 32 31

CVD

7.5% 32% 35% 40%

Dx (y)

New 8 10 12

A1C %

7.1 7.5 8.3 9.4 Duration of Follow-up 10+10= 20 5.0 3.4+5.6= 9 5.6+4.4= 10

66

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Liraglutide (Victoza GLP-1): CV outcomes

Marso SP et al. N Engl J Med 2016;375:311-322

CV Death HR 0.78*

Marso SP et al. N Engl J Med 2016;375:311-322

1° Outcome HR 0.87* Nonfatal Stroke, NS Nonfatal MI, NS

Marso SP et al. N Engl J Med 2016;375:311-322 Marso SP et al. N Engl J Med 2016;375:311-322

Liraglutide (Victoza): CV outcomes

Death HR 0.85* HF Hosp, NS

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GLP‐1 Agonists

GLP‐1 Agonists Trade Name Notable CV OUTCOMES Abliglutide Tanzeum Exenatide Byetta/Bydureon Dulaglutide Trulicity Liraglutide* Victoza FDA approved for CV outcomes* Semaglutide Ozempic Reduction in some CV outcomes

* FDA approved to reduce the risk of major adverse cardiovascular (CV) events, heart attack, stroke and CV death, in adults with type 2 diabetes and established CV disease. SGLT1

10%

Glucose

No Glucose S1 S3

Renal Handling of Glucose

SGLT2

90%

(GFR 150-180 L/day) x (glucose conc 90 mg/dL) =135-162 g/day filtered glucose

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Zinman B et al. N Engl J Med 2015;373:2117‐2128.

Empagliflozin (SGLT2): CV and Mortality Benefit

Death – HR 0.68* CV Death HR 0.62* Hosp HF – HR 0.65* Primary Outcome– HR 0.86*

SGLT2 Inhibitors

SGL2 Inhibitors Trade Name Notable CV Outcomes Canagliflozin Invokana Reduction in CV outcomes in secondary prevention Dapagliflozin Farxiga Study out 2019 Empagliflozin* Jardiance FDA approved for CV Indication* Ertuglifozin Steglatro Study ongoing

* FDA Approved to reduce the risk of cardiovascular death in adults with T2DM and established cardiovascular disease

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SGLT2 Inhibitors and Amputations

• Initial CANVA study with canagliflozin (Invokana)

showed an increase in lower extremity amputations.

• FDA added a black box warning for canagliflozin
• nly
• European Medicines Agency added a warning for

all drugs in the class

• Latest data suggests this is a class effect with HR

2.321

• Incidence rate 2.7 v 1.1 events per 1000 person

years1

1 Ueda et al, BMJ 2018; 363, epub November 2018

Summary

• The data on CVD and CHF outcomes for second

generation sulfonylureas are neutral/inconclusive.

• The SGLT-2 Inhibitors empagliflozin and canagliflozin

provide CV benefit in patients with established disease but come with an increased risk of amputation and DKA.

• The GLP-1 Analogues liraglutide and semaglutide

provide CV benefit in patients with established disease.

• Empagliflozin and liraglutide are FDA approved for CV

indications with established CV disease.

• Tight glucose early in the disease course provides CV

benefit.

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Case

55 yow with HTN, BMI 32, DM2 for 3 years. On metformin for several years but in past year A1C has increased to 8.2%. What do you do next?

a) Encourage improved diet and exercise b) Start a sulfonylurea c) Start a TZD d) Start a DPPIV-inhibitor e) Start an SLGT-2 inhibitor f) Start a GLP-1 analogue g) Start insulin h) Start an α-glucosidase inhibitor, bromocriptine or colesevelam

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Diabetes Care. Published online Oct 22, 2008

2008 ADA Type 2 Consensus Statement Diabetes Treatment Algorithm

An American Diabetes Association consensus statement represents the authors’ collective analysis, evaluation, and opinion at the time of publication and does not represent official association opinion.

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Less Well‐Validated Buffet for DM2

ADA Standards of Medical Care in Diabetes 2017

Liraglutide Empagliflozin

Diabetes Care 2018 Jan; 41(Supplement 1): S73-S8

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Case

55 yow with HTN, BMI 32, DM2 for 3 years. On metformin but in past year A1C has increased to 8.2%. What do you do next?

a) Encourage improved diet and exercise b) Start a sulfonylurea c) Start a TZD d) Start a DPPIV-inhibitor e) Start an SLGT-2 inhibitor f) Start a GLP-1 analogue g) Start insulin h) Start an α-glucosidase inhibitor, bromocriptine or colesevelam

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Case

55 yow HTN, BMI 32, DM2 for 3 years. On metformin but in past year A1C has increased to 8.2%. What do you do next?

a) Encourage improved diet and exercise b) Start a sulfonylurea c) Start a TZD d) Start a DPPIV-inhibitor e) Start an SLGT-2 inhibitor f) Start a GLP-1 analogue g) Start insulin h) Start an α-glucosidase inhibitor, bromocriptine or colesevelam

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Case

65 yow HTN, CAD s/p PTCA, CKD2, BMI 32, DM2 for 7 years. On metformin but in past year A1C has increased to 8.2%. What do you do next?

a) Encourage improved diet and exercise b) Start a sulfonylurea c) Start a TZD d) Start a DPPIV-inhibitor e) Start an SLGT-2 inhibitor f) Start a GLP-1 analogue g) Start insulin h) Start an α-glucosidase inhibitor, bromocriptine or colesevelam

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A1C Goal < ?%

Case

65 yow CAD s/p PTCA, CKD2, BMI 32, DM2 for 7

• years. On metformin but in past year A1C has

increased to 8.2%. What do you do next?

a) Encourage improved diet and exercise b) Start a sulfonylurea c) Start a TZD d) Start a DPPIV-inhibitor e) Start an SLGT-2 inhibitor f) Start a GLP-1 analogue g) Start insulin h) Start an α-glucosidase inhibitor, bromocriptine or colesevelam

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A1C Goal < ?%

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Case

55 yow homeless with ongoing meth use, HIV with poor ARV adherence (VL 32,860), HTN, BMI 32, DM2 for 3

• years. On metformin but in past year A1C has

increased to 8.2%. What do you do next?

a) Encourage improved diet and exercise b) Start a sulfonylurea c) Start a TZD d) Start a DPPIV-inhibitor e) Start an SLGT-2 inhibitor f) Start a GLP-1 analogue g) Start insulin h) Start an α-glucosidase inhibitor, bromocriptine or colesevelam

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Case

55 yow homeless with ongoing meth use, HIV with poor ARV adherence (VL 32,860), HTN, BMI 32, DM2 for 3 years. On metformin but in past year A1C has increased to 8.2%. What do you do next?

a) Encourage improved diet and exercise b) Start a sulfonylurea c) Start a TZD d) Start a DPPIV-inhibitor e) Start an SLGT-2 inhibitor f) Start a GLP-1 analogue g) Start insulin h) Start an α-glucosidase inhibitor, bromocriptine or colesevelam

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Do nothing! A1C Goal = Keep out of the hospital

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Case

55 yow homeless with ongoing meth use, HIV with poor ARV adherence (VL 32,860), HTN, BMI 32, DM2 for 3 years. On metformin but in past year A1C has increased to 11.2%. What do you do next?

a) Encourage improved diet and exercise b) Start a sulfonylurea c) Start a TZD d) Start a DPPIV-inhibitor e) Start an SLGT-2 inhibitor f) Start a GLP-1 analogue g) Start insulin h) Start an α-glucosidase inhibitor, bromocriptine or colesevelam

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A1C Goal = Keep out

• f the hospital &

symptom relief

Case

55 yow homeless with ongoing meth use, HIV with poor ARV adherence (VL 32,860), HTN, BMI 32, DM2 for 3 years. On metformin but in past year A1C has increased to 11.2%. What do you do next?

a) Encourage improved diet and exercise b) Start a sulfonylurea c) Start a TZD d) Start a DPPIV-inhibitor e) Start an SLGT-2 inhibitor f) Start a GLP-1 analogue g) Start insulin h) Start an α-glucosidase inhibitor, bromocriptine or colesevelam

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A1C Goal = Keep out

• f the hospital &

symptom relief

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Which Insulin would you start? a) Bedtime NPH b) Bedtime glargine c) Bedtime degludec d) Bedtime admelog e) I don’t even know what all these insulins are

A B C D E

Name Brand Name Status Manufacturer Cost glargine Lantus

• Sanofi. ‐ HSF

$278 glargine Basiglar Biosimilar Lilly ‐SFHP $235 glargine Lusduna Biosimilar Merck Not available glargine Toujeo U‐300 Sanofi $295 detemir Levemir Novo Nordisk $446 degludec Tresiba Novo Nordisk $490 NPH (vial) Humulin Lilly NPH (pen) Humulin Lilly $301 NPH (vial) Novolin Novo Nordisk $24 U-300 = 300 units per ml (normally 100 units per ml = U-100)

Good Rx.com 2018

45 Name Brand Name Status Manu‐ facturer Cost aspart Novolog Novo Nordisk $300‐ 560 glulisine Apidra Sanofi $423 lispro Humalog Lilly $178 ‐ $334 lispro (vial) Admelog Biosimilar/ Interchangeable Sanofi $470 R (vial) Humulin Lilly $99 R (pen) Humulin Lilly $578 R (pen) Kwikipen U‐500 Lilly ??

Good Rx.com 2018

Basal Insulins

Name Brand Name Cost per month glargine Lantus Basaglar $278 degludec Tresiba $490 NPH Novolin Humalin $24 Good Rx.com

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GLARGINE (LANTUS) VS. NPH

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a) Lowers A1C more b) Has less severe hypoglycemia c) Both lowers A1C more and has less severe hypoglycemia d) None of the above

A B C D

Cochraine Review

NPH versus Basal Analogues

• 6 studies comparing glargine to NPH
• 2 studies comparing detemir to NPH
• A1C and adverse effects did not differ in a clinically

relevant way.

• No difference for severe hypoglycemia
• Statistically significant lower rates of nocturnal

hypoglycemia with glargine/detemir in treat to target studies

• No effect on mortality, morbidity, QOL

Horvath et al, Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005613. DOI: 10.1002/14651858.CD005613.pub3

47 ED visits or Hospital Admissions for Hypoglycemia with Basal Insulin Analogs vs NPH in Type 2 Diabetes

• JAMA. 2018;320(1):53-62. doi:10.1001/jama.2018.7993

1.48 1.26 NPH Insulin Analogs

Reduction in A1C *

• JAMA. 2018;320(1):53-62. doi:10.1001/jama.2018.7993

48

Take Home Points

Basal Insulin in T2DM

• In randomized trials NPH results in more nocturnal

hypoglycemia with a strict treat to target morning glucose

• There is no data to suggest increased severe

hypoglycemia with NPH

• Basal analogues do not result in better A1C lowering
• r clinically significant reductions in hypoglycemia
• The cost of NPH is typically 10‐20 times less than

basal analogues

• JAMA. 2016;315(13):1400-1402. doi:10.1001/jama.2016.0126 and Endocrine News 2016

Viewpoint July 4, 2017

Human Insulin for Type 2 Diabetes

An Effective, Less-Expensive Option

Kasia J. Lipska, MD, MHS1; Irl B. Hirsch, MD2; Matthew C. Riddle, MD3

• JAMA. 2017;318(1):23-24. doi:10.1001/jama.2017.6939

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Diabetes Newsletter – email: Charlotte Kuo <Charlotte.Kuo@sfdph.org>

FBG > 130 after 6 wks? Or A1C > 7 after 12 wks?

Adapted from Upcoming Draft Insulin Guidelines; Courtesy Dr. Julie Kim, UCSF/ZSFG

Self Care- To Check or Not?

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Diabetes Resources in Sharepoint