Diabetes management! I recently attended a lecture on diabetes management. Here are the nuts and bolts…
There are three pillars of diabetes management… It’s best to max out #1 and #2 or you and your physician will need to travel down the road of #3.
#1. Diet. A key strategy is 45-60 grams of carbs per meal. Limit sweetened beverages and concentrated carbohydrates. Eat a “consistent carbohydrate diet.”
Mediterranean diet, DASH, plant based diets. To lose weight have a deficit of 500 to 750 kcal/day.
#2. Exercise. At least 150 minutes per week of moderate intensity aerobic, keeping heart rate at 50-70% of maximum heart rate. Strength training of 2-3 times per week is helpful for patients older than 50.Medications
Diabetes affects 8 different organ systems. For instance, pancreas is involved with insulin secretion and glucagon secretion, the brain is affected with appetite control, the kidney is affected by glucose reabsorption, the muscle has changes in glucose uptake.
The ADA has a new guideline December 2017 (see link at the bottom) which lets us know which medications to start depending on hemoglobin A1c. Metformin is the mainstay medication.
When should insulin be started? If the patient is on 3 oral medications at the maximum dose AND still not at HbA1c goal, the patient is due for insulin.
#3 Medications. And now the list of drug classes with their in-class medication names and the specifics.
Sulfonylureas. Decreases A1c by 1.5 % but it leads to progressive decline in beta-cell function. This has fallen out of favor due to this. Within 3 years more patients require second anti-diabetic medication.
Alpha-glucosidase inhibitors (brand names: Acarbose and Miglitol). Decreases A1c of 0.5 to 0.8%. This class of drug is not known to increase weight gain nor does it cause hypoglycemia. These medications help the patients decrease the speed of carbohydrate digestion. This may cause stomach cramping and feeling gassy.
Biguanides (metformin). This decreases GI glucose glucose absorption and reduces appetite and decreases liver glucose production. This helps bring the fasting glucose in the morning. Lowers A1c by 1.5% This is a safe drug for patients with good liver and kidney function. If patients get a CT scan, they should stop this medication 2 days before contrast use.
Meglitinides (brand names– Starlix and Prandin). Most physicians don’t use this drug class often. These medicines may cause hypoglycemia. May lower A1c by 1-1.5
Thiazolidinediones (TZD)–brand name: Actos and Avandia . Decrease A1c by 0.8 – 1%. Lower blood sugars without hypoglycemia. A few years ago, there was a bladder scare. This has been changed to show that bladder cancer patients were in smokers. This may increase central adiposity.
Dipeptidyl peptidase 4 inhibitors (DPP4s)–brand names: Januvia, Onglyza, Tradjenta. Lowers A1c from 0l.5 – 0.8%. Do not cause hypoglycemia often. Can be used in combination with other oral agents. May cause abdominal pain or headaches or sciatic nerve pain. Do not use this with GLP1 drugs. Tradjenta is dosed in one dose only and no adjustments are needed for renal failure patients.
Bile Acid Sequestrants (brand name: Welchol). Lowers A1c 0.5 – 0.6%. Lowers both A1c and LDL cholesterol.
Dopamine Agonist (brand name: Cycloset). Resets the biological clock and may. It does decrease A1c from 0.3 – 0.5%.
Sodium glucose Co-transporter 2 (SGLT2) brand names Invokana, Farxiga, Jardiance, Steglatro. Blocks the reabsorption of the glucose by the kidneys. Lowers A1c 0.7-1.0%. May also cause weight loss. There is a low risk of hypoglycemia. It may increase yeast infections in both women and uncircumcised males. SGLT2 may lead to reduction in bone formation. Invokana may increase rate of amputation. And, a rare side effect of this class of drug is Fournier’s gangrene. Jardiance may help decrease cardiovascular events.
Glucagon-like peptide-1 receptor agonist. GLP1 (Byetta and Victoza and Adlyxin and Bydureon and Trulicity and ozempic) is responsible for the incretin changes. It lowers A1c 0.6 – 1.4%. May cause nausea, vomiting, and a pounding temporal headaches. May cause weight loss and less chance of cardiovascular events. May use with metformin. Do not use with DPP4s. This may promote proliferation of beta cells and islet cells. Byetta is dosed twice a day. Victoza is dosed once a day. Adlyxin is new in 2016. Injection site may feel like a knot under the skin. This is normal and intended. Bydureon is dosed once a week. Trulicity is also dosed once a week. Ozempic was FDA approved in 2017 and is dosed once a week. This class is well tolerated.
Insulin. The goal is to start the patient on a therapeutic dose. 0.2 units/kg patient weight.
Rapid acting insulins work in 15 minutes and peak in 30-90 minutes and duration is 3-5 hours. This is matched with their food. Timing of insulin injection is important. Longer acting insuin (levemir and lantus) with onset 1-2 hours with peak at 3-9 hours with duration of up to 24 hours. Basaglar is biosimilar to lantus requires 25-50% more insulin than levemir and lantus. Toujeo is glargine U-300. Duration is 36 hours. Tresiba has a duration of 42 hours. This may be beneficial in patients who forget to take their daily insulin dose.
Have you heard about an inhaled insulin? It’s called Afrezza. This is not often prescribed, needs good lung functioning and can only be used in a nonsmoker.
Want to know more? The best overall look is the American Diabetes Association 2017 guidelines. https://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf
I am such a fan of direct medical care. Many of the 350 family medicine physicians that I trained in Kansas have opened direct medical care practices.
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Do you want to pay less for your medicine co-pays? Who doesn’t?! A recent JAMA article (see link below) looked at 9.5 million medication claims and found that nearly 23% of patients paid more through their insurance co-pays than the cost of those medications to insurers or to the pharmacy.
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