Diabetes 3. Compare and contrast the ADA (American Diabetes - PDF document

August 2018 Jennifer D. Goldman, PharmD, CDE, BC-ADM, FCCP Professor of Pharmacy, MCPHS Unversity Learning Objectives 1. Review the epidemiology and global/US impact on morbidity, mortality and cost 2. Discuss the metabolic progression of diabetes and why to choose specific drug therapies for this pathophysiology Diabetes 3. Compare and contrast the ADA (American Diabetes Association) and the AACE/ACE (American Association of Clinical Endocrinologists and Is your formulary in line with guidelines? American College of Endocrinology) guidelines for the therapeutic management of hyperglycemia in patients with diabetes JENNIFER D. GOLDMAN, RPH, PHARMD, CDE, BC-ADM, FCCP PROFESSOR OF PHARMACY PRACTICE, MCPHS UNIVERSITY, BOSTON, MA 4. Identify and discuss the rationale for combination therapy for the CLINICAL PHARMACIST, WELL LIFE MEDICAL, PEABODY, MA treatment of T2DM 5. Utilizing a patient case, apply the guidelines to choose appropriate drug therapy for treatment Do you think your formulary matches the How much experience in the room? current guidelines? a.Yes a. < 10 years b. 11-19 years b.No c. 20-29 years d. 30+ years How many Americans develop diabetes What was the total cost of diabetes in every day (24 hours)? the US (2017) per day (24 hours)? a. 589 a. $27 million b.1200 b. $145 million c. 2450 c. $342 million d.3250 d. $578 million e. 4109 e. $896 million 1

August 2018 Jennifer D. Goldman, PharmD, CDE, BC-ADM, FCCP Professor of Pharmacy, MCPHS Unversity Many patients with diabetes remain above the What percentage of patients in the US do NOT achieve ADA-recommended A1C target recommended A1C goals despite initiation of diabetes A1C levels in US patients with diagnosed diabetes drug therapy? a. 8% Total US population with diabetes mellitus a b.17% 49% A1C >7% c. 37% d.49% 21% A1C >8% e. 72% a 2007-2010 US population. Data derived from the National Health and Nutrition Examination Survey (NHANES) and from the Behavioral Risk Factor Surveillance System (BRFSS). 1. Ali MK et al. N Engl J Med . 2013;368(17):1613-1624. 8 Type 2 diabetes is increasingly prevalent Increasing prevalence of diabetes • Globally , 387 million people are • At least 68% of people >65 years with living with diabetes diabetes die of heart disease 2 In 2015, 30.3 million people in the United States had diabetes Mortality risk associated with diabetes 3 Hazard ratio (95% CI) (diabetes (n=820,900) 3 By 2030, diabetes is predicted to vs no diabetes) 2 affect 1 in 3 adults – 55 million adults 1 Estimated total cost of Diagnosed diabetes in 2012 This will rise to 592 0 was $245 billion million by 2035 1 CV death All-cause mortality 1. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Estimates of diabetes and its burden in the United States. Available online: IDF DIABETES ATLAS 6TH EDITION 2014 HTTP://WWW.IDF.ORG/DIABETESATLAS; 2. CENTERS FOR DISEASE CONTROL AND PREVENTION 2011; 3. https://stacks.cdc.gov/view/cdc/46743. Accessed February 23, 2018. 2. Rowley WR, Bezold C, Arikan Y, et al. Diabetes 2030: Insights from yesterday, today, and SESHASAI ET AL. N ENGL J MED 2011;364:829-41 10 9 future trends. Popul Health Manag. 2017;20(1):6-12. 3. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36:1033-1046. Lowering your A1C by 1% lowers your risk of microvascular Complications of Diabetes – morbidity/morality complications (eyes, kidneys, nerves) by approximately 11 _____ % Stroke 2- to 4-fold increase in cardiovascular mortality a. 10% and stroke Diabetic Retinopathy Cardiovascular Leading cause of b.20% Disease blindness in adults 8/10 individuals with diabetes die from CVD c. 40% Diabetic Diabetic Neuropathy d.60% Nephropathy Leading cause of Leading cause of non-traumatic lower end-stage renal disease extremity amputations a. UKPDSG. Diabetes Res . 1990;13:1-11; b. Fong DS, et al. Diab Care. 2003;26(Suppl 1):S99-S102; c. HDS. J Hypertens . 1993;11:309-317; d. Molitch ME, et al. Diab Care . 2003;26(Suppl 1):S94-S98; e. Kannel WB, et al. Am Heart J. 1990;120:672-676; f. Haffner SM, et al. N Engl J Med . 1998;339:229-234; g. Diabetes organization website; h. Mayfield JA, et al. Diab Care . 12 2003;26(Suppl 1):S78-S79. 2

August 2018 Jennifer D. Goldman, PharmD, CDE, BC-ADM, FCCP Professor of Pharmacy, MCPHS Unversity Percent risk reduction of diabetes-related complications Patient Case- where do the guidelines fit? in patients with T2DM for each 1% decrease in A1C 48 year old male, new to practice (6/16), established with PCP, and referred to Pharmacy UKPDS 10-year follow-up showed a “legacy” effect: continued risk reduction for microvascular complications for medication management. Reports poor diet, but no complaints of fatigue, polyuria, and emergent risk reduction for myocardial infarction and death from any cause 2 polydipsia, no GI complaints. Study design: Prospective observational study of 4585 UKPDS patients with T2DM from 23 hospital-based clinics PMH: T2DM (2005), hypertension, hyperlipidemia, morbid obesity, vitamin D deficiency, in the United Kingdom. Total of 3642 patients were included in relative-risk analyses. Data adjusted for age, blood previous ETOH abuse (2014) pressure, gender, ethnic background, smoking, albuminuria, HDL, LDL, and triglycerides. SH: married, 3 children, one PharmD candidate, owner of liquor store and restaurant, past smoker 1 ½ packs per day, NKDA Medications: glipizide 15mg bid and metformin IR 1000mg bid Other: 43% 37% 21% 14% 14% atorvastatin 10mg qd, hctz 12.5mg qd , valsartan 320mg qd, aspirin 81mg qd P <0.0001 P <0.0001 P <0.0001 P <0.0001 P <0.0001 Pertinent labs/vitals: A1C 9.5%, 404lbs, BMI 63.3, BP 117/79 P79, CMP WNL, eGFR > 60, negative albuminuria, vitamin D 13, vitamin B12 254, FLP TC 124, TG 150, HDL 39, LDL AMPUTATION MICROVASCULAR DIABETES- MYOCARDIAL ALL-CAUSE OR PVD DEATH COMPLICATIONS RELATED INFARCTION MORTALITY 55, TSH wnl DEATH Stratton IM et al. BMJ . 2000;321(7258):405-412. Holman RR et al. N Engl J Med . 2008;359(15):1577-1589. According to the ADA guidelines which of the following According to the AACE guidelines which of the following agents should be added after metformin for most agents should be added after metformin for most patients? patients? a. Basal insulin (ie glargine/Lantus™) a. Basal insulin (ie glargine/Lantus™) b. Sulfonylurea (ie glipizide/Glucatrol™) b. Sulfonylurea (ie glipizide/Glucatrol™) c. GLP-1RA (ie liraglutide/Victoza™) c. GLP-1RA (ie liraglutide/Victoza™) d. DPP-4 inhibitor (ie sitagliptin/Januvia™) d. DPP-4 inhibitor (ie sitagliptin/Januvia™) e. Any of the above e. Any of the above 15 16 Approach to the Management of Hyperglycemia Glycemic Targets Recommended in Consensus-Based Guidelines: Nonpregnant Adults A1C more less Patient/Disease Features stringent 7% stringent Risk of hypoglycemia/drug adverse effects low high ADA AACE Parameter Disease Duration newly diagnosed long-standing A1C level <7.0% ≤6.5% Life expectancy short long Preprandial plasma Important comorbidities 70–130 mg/dL <110 mg/dL glucose (fasting) absent Few/mild severe Established vascular complications <180 mg/dL <140 mg/dL absent Few/mild severe Peak postprandial (2 h after start (2 h after start plasma glucose of meal) of meal) Patient attitude & expected treatment efforts highly motivated, adherent, excellent less motivated, nonadherent, poor self-care capabilities self-care capabilities *Appropriate for most, but should be tailored to patient circumstance. Resources & support system readily available limited Glycemic Targets: Standards of Medical Care in Diabetes - 2018 . Diabetes Care 2018; 41 (Suppl. 1): S55-S64 17 Glycemic Targets: Standards of Medical Care in Diabetes - 2018 . Diabetes Care 2018; 41 (Suppl. 1): S55-S64 3