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You will be asked to complete a pre-assessment at the start of the program.

Before We Begin

Using the camera app on your smartphone or tablet, please complete the brief pre-assessment which can be accessed by scanning the QR code below

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By clicking the pre-assessment link provided by your chapter representatives. The data collected will be used in evaluating the program goals and objectives and to ensure we’ve provided a useful educational activity.

Sponsorship and Support

This educational activity is jointly provided by the North Carolina Academy of Family Physicians (NCAFP) and Spire Learning. This activity is supported by an educational grant from Novo Nordisk Inc.

Instructions to Receive Credit

To receive credit for your participation in this educational activity:

• Read the objectives and other introductory CME information
• Complete the preassessment prior to the start of the

activity

• Participate in the CV risk reduction in type 2 diabetes

presentation

• Complete the postassessment and evaluation at the

conclusion of the activity

Faculty and Disclosures (cont’d)

Faculty Educator: Jeffrey S. Freeman, DO, FACOI, FNLA

Professor of Internal Medicine Chairman, Division of Endocrinology Philadelphia College of Osteopathic Medicine Philadelphia, PA Endocrine Associates Crozer-Chester Medical Center Upland, PA

Disclosure Statement: Promotional Speaker: Amarin Corp; Novo Nordisk Inc; Zealand Pharm

Off-Label and Disclaimer Statements

If the faculty discuss off-label or investigational uses of products or devices, they will inform you that the use is off-label during the discussion. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. Further, participants should appraise the information presented critically and are encouraged to consult appropriate resources for any product or device mentioned in this program.

Learning Objectives

Upon completion of this activity, learners should be better able to:

• MANAGE CV risk factors in patients with diabetes according to

current clinical practice recommendations.

• INDIVIDUALIZE diabetes treatment based on comorbidities,

patient preferences, and CV risk reduction goals.

• EDUCATE patients/caregivers regarding CV risk, medication use

and adherence, and lifestyle management.

Why Are We Still Talking About Diabetes?

34.2 million

Americans

(9.4% of US population) have diabetes1

• 1. National Diabetes Statistics Report, 2020; Estimates of Diabetes and Its Burden in the United States. Available at: https://www.cdc.gov/diabetes/pdfs/data/statistics/national-

diabetes-statistics-report.pdf; 2. Davidson JA. Mayo Clin Proc. 2010;85(Suppl 12):S3-S4.

• f all diabetes management occurs

within the primary care setting2

88 million

Americans

(34.5% of US population) have prediabetes1

90%

Costs of Diabetes in the US

• ADA. The Cost of Diabetes. Available at: https://www.diabetes.org/resources/statistics/cost-

diabetes#targetText=The%20American%20Diabetes%20Association%20(Association,the%20cost%20was%20last%20examined.

Diagnosed diabetes costs America

$327 billion each year,

including $237 billion in direct medical costs and $90 billion in lost productivity. Healthcare costs for Americans with diabetes are 2.3x greater than those without diabetes:

$12,000/year for diabetes,

$4000/year without diabetes.

$1 in every $7

spent on health care in the US is used to treat diabetes and its complications. The largest components of medical expenditures include hospital inpatient care (30%),

prescription medications to treat diabetic complications (30%),

antidiabetic agents and supplies (15%), and physician office visits (13%).

Events per 10,000 overall adult population

Overall population Population with diabetes Overall population

Acute myocardial infarction Stroke

1990 1995 2000 2005 2010 10 2 4 6 8 150 125 25 100 75 50

Good News: Diabetes-Related Complications in the US

Gregg EW, et al. N Engl J Med. 2014;370(16):1514-1523.

Bad News: The Diabetes Epidemic

• 1. CDC. Long-term Trends in Diabetes; April 2017. Available at: https://www.cdc.gov/diabetes/statistics/slides/long_term_trends.pdf; 2. Boyle JP, et al. Popul Health Metr. 2010;8:29.

5 10 15 20 25 1 2 3 4 5 6 7 8

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Number and Percentage of US Population With Diagnosed Diabetes, 1980-20151

Percentage with diabetes Number with diabetes

Percentage Number (in millions)

By Year 2050, 1/3 of All Adults in the US Will Have Diabetes2

Type 2 Diabetes Mellitus

Mechanick JI, et al. Endocr Pract. 2018;24(11):995-1011.

Time: 30 Years Insulin Resistance Prediabetes Type 2 Diabetes Mellitus Vascular Complications

Consequences of Delayed Intervention

A1c, glycated hemoglobin; CVE, cardiovascular endpoint; HF, heart failure; IT, intensification of treatment; MI, myocardial infarction. Khunti K, et al. Prim Care Diabetes. 2017;11(1):3-12.

At 5.3 years (median follow-up), significantly increased risk of:

• MI 67% (CI 39%-101%)
• Stroke 51% (CI 25%-83%)
• HF 64% (CI 40%-91%)
• Composite CVE 62% (CI 46%-80%)

8.5 8.0 7.5 7.0 6.5 6 12 54 60 48 Months A1c, % Patients with A1c ≥7% not receiving IT within 1 year Patients with A1c <7% who received IT within 1 year of diagnosis

Bad glycemic “legacy” Drive risk for complications

Bill – 67 Years Old

BID, twice daily; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; LAD, left anterior descending; STEMI, ST-elevation myocardial infarction.

• Type 2 diabetes for 12 years
• Hyperlipidemia, hypertension, and

stage 3B CKD (eGFR=41 mL/min/1.73 m2)

• Had STEMI 2 years prior
• Drug-eluding stent placed in LAD artery
• Often fails to refill prescribed medications
• Medications

– Losartan 50 mg, atorvastatin 40 mg, metformin 500 mg BID, sitagliptin 100 mg, aspirin 81 mg, clopidogrel 75 mg

• Covered under Medicare

• Exercise

“Golf and walking my dog Lucky”

• Diet: Favorite restaurant is Golden
• Corral. “I get the senior discount”
• Employment: Trucking company

executive; frequent domestic travel

• Alcohol use: “Only when playing golf.

Don’t you?”

• Sleep schedule: “Four to 5 hours a
• night. I can’t make money when

I sleep.”

• Epworth score: 15 (sleepy)

Angiogram: 90% occlusion of LAD artery

Bill’s Social History

Bill’s Physical and Labs

Physical

• Blood pressure: 130/74 mm Hg
• BMI: 33 kg/m2
• Pertinent physical findings

– Peripheral sensory neuropathy with loss of vibratory sense and hot/cold sensation in both feet – Loss of ankle jerks bilaterally – 2+ pitting edema in ankles – Left carotid bruit

ACR, albumin to creatinine ratio; Apo-B, apolipoprotein B; BMI, body mass index; HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; HS-CRP, high-sensitivity C-reactive protein; LDL, low-density lipoprotein; TG, triglycerides.

Labs

HbA1c 8.4% (elevated) eGFR 41 mL/min/1.73 m2 (low) Vitamin B12 221 mg/dL (low) LDL 124 mg/dL (elevated) HDL 33 mg/dL (low) TG 224 mg/dL (elevated) HS-CRP 5.2 (elevated) Apo-B 112 (elevated)

Your Action Plan for Bill – Points to Consider

• How would you determine your

strategy for intensifying Bill’s therapy?

• How do you get Bill to commit to

his health and his care plan?

• What kind of glucose monitoring

would you recommend, if any?

What I Would Do

• Ask him what are his biggest concerns about

having diabetes

• Remind him that he is the “captain” of his

health care, whereas the clinician is the “coach”

• Do NOT scare him into believing he is going

to die if he doesn’t heed your professional advice

• Ask if he would consider wearing a flash

glucose sensor for 2 weeks so that his glycemic patterns can be evaluated and intensified

• After placing the sensor, have him return in

1 week to download the data

• Intensify therapy at 1 week and download

again after 7 days

Week 1 Week 2 (after medication change)

Glucose Monitoring

SMBG HbA1c CGM

CGM, continuous glucose monitoring; SMBG, self-monitored blood glucose.

1 Moment 3 Months Continuous

Hyperglycemic Hypoglycemic In Range

HbA1c=7% 100%

Patient A

HbA1c=7%

29% 8% 63%

Patient B

HbA1c=7%

58% 24% 18%

Patient C

HbA1c Only Provides a 90-Day Average

CGM: Targeting Priorities

• Identify and minimize hypoglycemic

events

– Target nocturnal hypoglycemia

• Reduce postprandial hyperglycemia
• Reduce glycemic variability, which

increases oxidative stress and risk of long-term complications

• Improve time in range (70-180 mg/dL)

– Every 10% increase in time in range = ~0.5%-0.8% HbA1c reduction – Each 5% increase is clinically beneficial

in Ranges section in the text for additional information regarding target goal setting in pediatric management).

T1DM, type 1 diabetes mellitus; TIR, time-in-range. Battelino T, et al. Diabetes Care. 2019;42:1593-1603.

<1% <4%c >70% >50% <25% <50%b <5% <10%

<1

T1DMa and T2DM Older or High-Risk Patients Target Target

>250 mg/dL >180 mg/dL Target Range 70-180 mg/dL <70 mg/dL <54 mg/dL >250 mg/dL >180 mg/dL Target Range 70-180 mg/dL <54 mg/dL

It’s More Than Glucose Control

Antiplatelet therapy Blood pressure Cholesterol Dietary Exercise Smoking cessation Regular examination of weight, eyes, mouth/teeth, feet, skin, kidneys Diabetes distress Quality of life Choose glucose- lowering medication shown to reduce cardiovascular risk (when possible)

There’s also… …and let’s not forget… Plus… And now…

AACE1 ADA2,3

HbA1c, % ≤6.5 ≤7.0 Fasting/premeal BG, mg/dL <110 80-130 Postprandial, mg/dL <140a <180b Blood pressure, mm Hg <130/80 <140/90 LDL, mg/dL <100 (<70) (<55)c Based on risk HDL, mg/dL >40 in men, >50 in women >40 in men, >50 in women Triglycerides, mg/dL <150 <150

Treatment Goals: More Than Just the Sugar

AACE, American Association of Clinical Endocrinologists; ADA, American Diabetes Association; BG, blood glucose.

• 1. Garber AJ, et al. Endocr Pract. 2020;26(1):107-239. 2. ADA. Diabetes Care. 2020;43:S66-S76. 3. ADA. Diabetes Care. 2020;43:S111-S134.

Overview of Lifestyle Recommendations for Diabetes

• Weight loss: 7% of baseline weight
• Exercise: 150 min/wk of moderate exercise
• Diet: No specific recommendations; refer to CDE or RD within

1 year of diagnosis

• Plant-based diet may be helpful in some patients
• Stop smoking and reduce alcohol consumption
• Promote glucose self monitoring

and utilize sensors when appropriate

CDE, certified diabetes educator; RD, registered dietitian.

• ADA. Diabetes Care. 2015;38:S31-S33. Knowler WC, et al. N Engl J Med. 2002;346(6):393-403.

% of patientsa achieving HbA1c <7% 2003-20061 2007-20101,2 2011-20142

56.8% 52.2% 50.9%

NHANES data 50 10 20 30 40 60 70 90 100 80

No improvement over the last decade!

Only About Half of Patients Achieve HbA1c <7%

NHANES, National Health and Nutrition Examination Survey.

• 1. Ali MK, et al. N Engl J Med. 2013;368(17):1613-1624. 2. Carls GS, et al. Diabetes Ther. 2017;8(4):863-873. 3. National Diabetes Statistics Report, 2020; Estimates of Diabetes

and Its Burden in the United States. Available at: https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed on July 27, 2020.

50.0%

2013-20163

Improving Adherence in Patients With Diabetes

Drugs don’t work if you don’t take them.

• C. Everett Koop, MD

“ ”

Consequences of Poor Medication Adherence

MMAS, Morisky Medication Adherence Scale.

• 1. DiBonaventura M, et al. Patient Prefer Adherence. 2014;8:873-882. 2. Currie CJ, et al. Diabetes Care. 2012;35(6):1279-1284.

↑ 0.21%

HbA1c

↑ 4.6%

Physician visits

↑ 20.4%

ER visits

↑ 20.9%

Hospital visits

1-point drop in self-reported medication adherence (MMAS) is associated with1:

Poor medication adherence Missed clinical appointments

1.6× all-cause

mortality2

Keys to Improving Adherence

• Explain the importance of diabetes intensification
• Use medications that minimize weight gain and

hypoglycemia

• Do the math

– What is the baseline HbA1c, and what interventions will be most successful at getting the patient to their metabolic targets?

• Always protect the heart and kidneys
• Consider positive nonglycemic effects of pharmacotherapy

– GLP-1 RAs may be neuroprotective – SGLT-2is are renal protective and may reduce CHF risk – TZDs reduce stroke risk – Metformin may reduce cancer risk and improve fertility in PCOS patients

• Engage and educate the family/caregiver

CHF, congestive heart failure; GLP-1 RA, glucagon-like peptide-1 receptor agonist; PCOS, polycystic ovarian syndrome; SGLT-2i, sodium-glucose transport protein 2 inhibitor; TZD, thiazolidinedione.

FDA Diabetes Mellitus Guidance − 2008

• CVOTs should include high-risk

patients

• Noninferiority design (show no harm

compared with placebo)

• Confirm that treatment with a

glucose-lowering drug does not result in unacceptable increase in CV risk

• CVOTs are usually event driven and

NOT focused on glycemic control, so a wide range of baseline A1Cs are allowed

CV, cardiovascular; CVOT, cardiovascular outcome trial. US FDA. http://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm071627.pdf. Image from: https://i.dailymail.co.uk/i/pix/2016/06/11/12/3526955300000578-3636565-A_guardsman_in_the_Household_Division_collapsed_pictured_during_-a-17_1465646069050.jpg.

The Value of CVOTs

• Trials include patients with high CV risk
• Trials will generate large volumes of

long-term data for analysis

– CV safety data are important for diabetes therapies – Long-term efficacy data from blinded randomized trials – Non-CV safety data – Identifying rare events

Hirshberg B, et al. Diabetes Care. 2013;36:S253-S258.

• Generalizability of results to all

populations may be limited

• Efficacy data may be of limited value

– Trials are not designed to document efficacy with treat-to-similar targets – Wide range of concomitant medications

• Development costs increase

– Larger and longer phase 3 programs – Reduced incentive for development of new drugs – Development limited to larger companies – LEADER CVOT cost: $46,000/patient (N=9340)

Pros Cons

ACS, acute coronary syndrome; MI, myocardial infarction; UA, unstable angina.

• 1. Sciria BM, et al. N Engl J Med. 2013;369(14):1317-1326. 2. White WB, et al. N Engl J Med. 2013;369(14):1327-1335. 3. Green JB, et al. N Engl J Med. 2015;16;373(3):232-242.
• 4. Pfeffer MA, et al. N Engl J Med. 2015;373(23):2247-2257.

Alogliptin (6.25, 12.5 or 25 mg/day*) + standard

• f care

T2D; HbA1c 6.5–11.0%; ACS within 15–90 days (n=5380) Placebo + standard of care Saxagliptin (2.5 or 5 mg/day**) + standard of care Placebo + standard of care T2D; HbA1c 6.5–12.0%; ≥40 years + CVD; ≥55 (men) or ≥60 (women) years + CV risk factors (n=16,492) Lixisenatide (10 or 20 mg/day†) + standard of care Placebo + standard of care T2D; HbA1c 5.5–11.0%; ACS within 180 days (n=6068) T2D; HbA1c 6.5–8.0%; ≥50 years; CVD history (n=14,671) Sitagliptin (100 or 50 mg/day***) + standard of care Placebo + standard of care

SAVOR-TIMI-53: Saxagliptin1 EXAMINE: Alogliptin2 TECOS: Sitagliptin3 ELIXA: Lixisenatide4

Time (days) Time (months) Time (months) Time (months) Patients with endpoint (%) Patients with endpoint (%) Patients with endpoint (%) Patients with endpoint (%)

EMPA-REG Trial Demonstrates Rapid Improvement in 3-Point MACE

N=7020 patients with T2DM at high risk of cardiovascular events. Adapted from: Zinman B, et al. N Engl J Med. 2015;373(22):2117-2128.

Patients with event, % Empagliflozin P=0.04 for superiority Hazard ratio, 0.86 (95.02% CI, 0.74-0.99) Placebo 20 15 5 10 0 0 12 6 18 24 30 36 42 48 Cumulative incidence of the primary outcomea Patients with event, % P<0.001 Hazard ratio, 0.62 (95% CI, 0.49-0.77) 9 3 6 0 0 12 6 18 24 30 36 42 48 Cumulative incidence of death from CV causes Patients with event, % P=0.002 Hazard ratio, 0.65 (95% CI, 0.50-0.85) 7 6 4 5 0 0 12 6 18 24 30 36 42 48 Month Hospitalization for heart failure 3 2 1

38%

risk reduction

14%

risk reduction

35%

risk reduction

Semaglutide Injection – SUSTAIN 6

• Rates of CV mortality and nonfatal MI are similar between groups, and rate of stroke is lower

in semaglutide group

• Rates of new or worsening nephropathy are lower in semaglutide group, but retinopathy

complications are higher

Marso SP, et al. N Engl J Med. 2016;375(19):1834-1844.

Weeks since randomization 5 10 15 20 16 32 48 64 80 96 109

HR: 0.74 (95% CI: 0.58-0.95) P<0.001 for noninferiority P=0.02 for superiority

Patients with event, %

CV Mortality, Nonfatal MI, or Nonfatal Stroke Semaglutide Placebo

Oral Semaglutide – PIONEER 6

• HR of death from any cause: 0.51 (95% CI: 0.31-0.84)
• No difference in rates of stroke or nonfatal MI between groups
• Gastrointestinal events leading to discontinuation were more common in oral

semaglutide group vs placebo

Weeks since randomization

HR: 0.79 (95% CI: 0.57-1.11) Oral semaglutide, 61 events Placebo, 76 events P<0.001 for noninferiority P=0.17 for superiority

Percentage of patients

Composite Primary Outcome

Placebo Oral semaglutide

10 9 8 7 6 5 4 3 2 1 9 18 27 36 45 54 63 72 83

Death From Cardiovascular Causes

HR: 0.49 (95% CI: 0.27-0.92) Oral semaglutide, 15 events Placebo, 30 events

Placebo Oral semaglutide

10 9 8 7 6 5 4 3 2 1 9 18 27 36 45 54 63 72 83 Weeks since randomization Percentage of patients

Husain M, et al. N Engl J Med. 2019;381(9):841-851.

Dulaglutide – REWIND

Gerstein HC, et al. Lancet. 2019;394(10193):121-130.

Cumulative risk, % HR 0.88 (95% CI: 0.79-0.99) P=0.026 N=9100 Composite Cardiovascular Outcome Dulaglutide Placebo Years since randomization 3 9 15 18 1 2 3 4 6 5 12 6

• 66 % were primary prevention and 34 % had established disease
• 12 % reduction in MACE vs PBO
• Renal function preservation

CANVAS2

HR: 0.67 (95% CI: 0.52-0.87)

Placebo Canagliflozin Patients with event, % Time since randomization (weeks)

EMPA-REG OUTCOME1

Patients with event, % Time since randomization (months)

Empagliflozin Placebo HR: 0.65 (95% CI: 0.50-0.85) P=0.002

Risk Reduction in HF and ASCVD Is Independent of Glycemic Improvement

ASCVD, atherosclerotic cardiovascular disease.

• 1. Zinman B, et al. N Engl J Med. 2015;373(22):2117-2128. 2. Neal B, et al. N Engl J Med. 2017;377(7):644-657. 3. Marso SP, et al. N Engl J Med. 2016;375(4):311-322.
• 4. Marso SP, et al. N Engl J Med. 2016;375(19):1834-1844.

HR: 1.11 (95% CI: 0.77-1.61) P=0.57

Placebo Semaglutide Patients with event, % Time since randomization (weeks)

SUSTAIN 64

Hospitalization for HF

LEADER3

Liraglutide Placebo HR: 0.87 (95% CI: 0.73-1.05) P=0.14 Patients with event, % Time since randomization (months)

Empagliflozin Canagliflozin Liraglutide Semaglutide

Dapagliflozin Reduces the Risk of CV Death and Hospitalization for Heart Failure

• 1. Wiviott SD, et al. N Engl J Med. 2019;380(4):347-357. 2. McMurray JJV, et al. N Engl J Med. 2019;381(21):1995-2008.

P<0.001 for noninferiority DECLARE TIMI-581 DAPA-HF2

Safety Considerations

• Black Box Warning –

thyroid C-cell tumors (liraglutide, dulaglutide, exenatide extended release)

• Gastrointestinal side

effects common (nausea, vomiting, diarrhea)

• Injection-site reactions
• Acute pancreatitis risk (?)

DPP-4i, dipeptidyl peptidase 4 inhibitor.

• ADA. Diabetes Care. 2020;43:S98-S110.
• Canagliflozin Black Box

Warning – risk of amputation

• Canagliflozin – risk of

bone fractures

• Diabetic ketoacidosis

(rare in T2D)

• Genitourinary infections
• Risk of volume depletion,

hypotension

• Increased LDL
• Risk of Fournier’s

gangrene

• Potential risk of acute

pancreatitis

• Joint pain

GLP-1 RA SGLT-2i DPP-4i

Your Action Plan for Bill – Points to Consider

• How would you intensify Bill’s

therapy?

• What side effects and other

patient-specific factors impact your recommendations?

…In With the New

• ADA. Diabetes Care.

2020;43:S98-S110.

Evidence Hierarchy Liraglutide > Semaglutide > Exenatide extended release Empagliflozin > Canagliflozin

Choosing Glucose-Lowering Medication in Patients With Established ASCVD

• ADA. Diabetes Care. 2020;43:S98-S110.

stronger for empagliflozin>canagliflozin. bBe aware that SGLT-2i vary by region and individual agent regarding indicated level of eGFR for initiation and continued use. cDegludec or U100 glargine has demonstrated CVD safety. dLow dose may be better tolerated though less well studied for CVD effects. eChoose later generation sulfonylurea with lower risk of hypoglycemia.

ASCVD predominates

If further intensification is required or patient is unable to tolerate GLP-1 RA and/or SGLT-2i, choose agents demonstrating CV safety

• Consider adding the other class (GLP-1 RA and/or SGLT-2i)

with proven CVD benefit

• DPP-4i if not on GLP-1 RA
• Basal insulinc
• TZDd
• Sulfonylureae

If HbA1c above target

GLP-1 RA with proven CVD benefita SGLT-2i with proven CVD benefita if eGFR adequateb Either/or

GLP-1 Receptor Agonists and Renal Outcomes

Diabetes is the primary cause of CKD and ESRD in the world

– Accounts for ~33% of patients initiating renal replacement therapy

• 1. Marso SP, et al. N Engl J Med. 2016;375(19):834-1844. 2. Mann JFE, et al. N Engl J Med. 2017;377(9):839-848. 3. Davies MJ, et al. Diabetes Care 2016;39(2):222-230.
• Semaglutide significantly decreased rates of new or worsening nephropathy compared to

placebo, largely due to a lower risk of new-onset macroalbuminuria

• New or worsening nephropathy (HR, 0.64; P=0.005)
• New-onset persistent macroalbuminuria (HR, 0.54; P=0.001)

SUSTAIN-61

• Liraglutide reduced the risk of the composite renal outcome (new-onset persistent

macroalbuminuria, persistent doubling of the serum creatinine level, ESRD, or death due to renal disease) compared to placebo

• Composite renal outcome (HR, 0.78; P=0.003)
• New-onset persistent albuminuria (HR, 0.74; P=0.004)
• Liraglutide did not affect eGFR after 26 weeks

LIRA-RENAL3 LEADER2

CREDENCE: Progression of Nephropathy (Primary and Secondary Endpoints)

Perkovic V, et al. N Engl J Med. 2019;380(24):2295-2306.

Back to Bill

• Hyperlipidemia, hypertension, and

stage 3B CKD (eGFR=41 mg/mL/1.73 m2)

• Had STEMI 2 years prior
• Medications

– Losartan 50 mg, atorvastatin 40 mg, metformin 500 mg BID, sitagliptin 100 mg, aspirin 81 mg, clopidogrel 75 mg

• Covered under Medicare

Pharmacologic

Bill’s Treatment Intensification – What I Would Do

• Metformin 500 mg BID with meals
• Semaglutide .25 mg weekly titrating to

1.0 mg/week in 8 weeks (CV and renal secondary prevention)

• High-intensity statin: atorvastatin 80 mg,

consider adding a PCSK9 if not at target in 6 weeks

• Continue aspirin 81 mg/day and

clopidogrel 75 mg/day

• Consider adding canagliflozin 100 mg/day

for renal and CV protection

• Stop sitagliptin
• Encourage use of flash glucose monitoring
• Stop alcohol
• Walk 30 minutes/day, 5 days per week
• Teach proper injection technique and watch for nonadherence
• Encourage appropriate sleep hygiene (needs 6-8 hours of

sleep/night)

• Discuss anticipated side effects of medications, as well as any
• ff-label uses (canagliflozin for renal protection and

semaglutide for CV and renal risk reduction)

• Discuss appropriate timing of all meds
• Provide a written list of all meds, which includes drug name,

dose, timing, and reason for using the medication

• If patient does not ask any questions, ask one on

his/her behalf

• CDE referral as mandated by the ADA
• Always find something praiseworthy at each subsequent visit!

Behavioral

Conclusions

• The landscape of diabetes management has changed from a

glucocentric approach to one targeting customized patient metabolic targets

• Clinicians should intensify their management of diabetes based on

the presence of coronary artery disease, heart failure, diabetic kidney disease, obesity, hypoglycemia risk, and financial concerns

• GLP-1 RAs (liraglutide, semaglutide, and dulaglutide) reduce 3-point

MACE and should be considered first therapies for patients with CAD

• SGLT-2is reduce risk of CAD and CHF; some in class appear to slow

progression of diabetic kidney disease

• Adherence for oral and injectable drugs is low for ALL chronic

diseases

CAD, coronary artery disease.

Managing Diabetes Patients With COVID-19

• We do NOT want our patients to be hospitalized!
• Avoid dehydration if febrile. Fever results in anorexia and

dehydration which can progress to DKA

• Hypoglycemia is commonly seen in COVID-19 pts!
• Monitor, monitor, SENSOR!
• STOP SGLT-2i at the first signs of symptoms (avoid DKA)
• Patients who refuse to D/C SGLT-2i should check

ketones daily

• Prescribe antiemetics
• May need to REDUCE doses of insulin or GLP-1 RA
• Prepare a hospital kit

– BG meters or sensors (nurses may not monitor) – Bring charger cables for iPhones and any equipment needed for monitoring – Bring all meds to hospital

BG, blood glucose; D/C, discontinue; DKA, diabetic ketoacidosis. Peters AL. ‘Everyone With Diabetes’ Must Prepare for COVID-19. March 11, 2020. Available at: https://www.medscape.com/viewarticle/926418.

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