Management of Diabetes: Non-Insulin Therapies 2024

Management of Diabetes: Non-Insulin Therapies Andrea Levin, PharmD, CPh, BCACP Assistant Professor, Nova Southeastern University College of Pharmacy 2024 Abbreviations ▪ Type 1 diabetes (T1DM) ▪ Type 2 diabetes (T2DM) ▪ American Diabetes Association (ADA) ▪ American Association of Clinical Endocrino...

Management of Diabetes: Non-Insulin Therapies Andrea Levin, PharmD, CPh, BCACP Assistant Professor, Nova Southeastern University College of Pharmacy 2024 Abbreviations ▪ Type 1 diabetes (T1DM) ▪ Type 2 diabetes (T2DM) ▪ American Diabetes Association (ADA) ▪ American Association of Clinical Endocrinologists (AACE) ▪ Hemoglobin A1c (HbA1c) ▪ Blood glucose (BG) ▪ Fasting plasma glucose (FPG) ▪ Fasting blood glucose (FBG) ▪ ▪ ▪ ▪ ▪ Postprandial blood glucose (PPG) Total daily dose (TDD) Contraindication (CI) Black box warning (BBW) Glucagon-like peptide 1 receptor agonists (GLP1 RA) ▪ Sodium glucose cotransporter 2 inhibitors (SGLT2i) ▪ Dipeptidyl peptidase 4 inhibitors (DPP4-i) Abbreviations ▪ Sulfonylureas (SU) ▪ Thiazolidinediones (TZDs) ▪ Meglitinides (Glinides) ▪ Alpha glucosidase inhibitors (AGi) ▪ Self Monitoring Blood Glucose (SMBG) ▪ Atherosclerotic cardiovascular disease (ASCVD) ▪ Heart failure (HF) ▪ Chronic kidney disease (CKD) T1DM vs. T2DM vs. Gestational DM T1DM T2DM Gestational DM ▪ 5% of DM cases ▪ Generally diagnosed in children, teens, or young adults ▪ Autoimmune ▪ 90-95% of DM cases ▪ Generally diagnosed >45 years of age ▪ Genetic component ▪ Diagnosed between weeks 24-28 of pregnancy ▪ Increased risk of GDM in: ▪ ▪ ▪ ▪ ▪ Age >25 y/o Non-white race Family history Personal history BMI >30 kg/m2 US Statistics ▪ 38.4 million individuals have diabetes (11.6%) ▪ Diagnosed: 29.7 million people, including 28.5 million adults ▪ Undiagnosed: 8.7 million people ▪ 97.6 million adults have prediabetes (38% of US population) ▪ 27.2 million people aged 65 years or older have prediabetes CDC Data and https://www.cdc.gov/diabetes/health-equity/diabetes-by-thenumbers.html. Accessed January 19, 2024 ADA Testing Criteria ▪ Consider testing in all adults who are overweight (BMI >25 kg/m2 or >23 kg/m2 in Asian Americans) with one or more additional risk factors: ▪ Physical inactivity ▪ First-degree relative with diabetes ▪ High-risk race/ethnicity (African American, Latino, Native American, Asian American, Pacific Islander) ▪ Hypertension (>140/90 mmHg or on antihypertensive medication) ▪ HDL cholesterol level 250 mg/dL ▪ Women with polycystic ovary syndrome ▪ HbA1c >5.7% , impaired glucose tolerance or impaired FBG on previous laboratory test ▪ Other manifestation associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) ▪ History of CVD ▪ Women delivering a baby >9 lbs or diagnosed with gestational diabetes ▪ HIV ▪ For all patients, testing should begin at 35 years of age. ▪ If results are normal, repeat at a minimum of 3-year intervals ▪ Perform yearly testing if results indicate prediabetes ADA Prediabetes vs. T2DM Prediabetes Classification ▪ FPG: 100-125 mg/dL OR ▪ HbA1c: 5.7-6.4% OR ▪ 2hr postprandial 75 gram oral glucose tolerance test: 140199 mg/dL T2DM Diagnosis* ▪ FPG: >126 mg/dL OR ▪ HbA1c: >6.5% OR ▪ Random BG: >200 mg/dL with symptoms of hyperglycemia OR ▪ 2hr postprandial 75 gram oral glucose tolerance test: >200 mg/dL Consider limitations of HbA1c *Two abnormal readings from the same sample to confirm diagnosis Goals*: ADA vs. AACE ADA HbA1c 15-20% SGLT2-i ▪ Decreases A1c by ~0.5-1% as monotherapy ▪ Canagliflozin (Invokana®) 100-300 mg before first main meal ▪ Dapagliflozin (Farxiga®) 5-10 mg daily in AM ▪ Empagliflozin (Jardiance®) 10-25 mg daily in AM ▪ Ertugliflozin (Steglatro®) 5-15 mg daily in AM ▪ All SGLT2i have GFR considerations for maximum doses and for initiation ▪ Contraindicated when GFR 300 mg/g SGLT2i (empagliflozin, canagliflozin, or dapagliflozin) If not at goal (utilize GLP 1 RA or SGLT2 i) semaglutide (sq) add-on in HFpEF? If not at goal (utilize GLP 1 RA) (liraglutide, semaglutide (sq), dulaglutide) Minimize Hypoglycemia without established ASCVD, CKD, or HF (+ metformin & lifestyle) DPP4i GLP1 RA SGLT2i TZD If not at goal If not at goal If not at goal If not at goal SGLT2i or TZD SGLT2i or TZD GLP1 RA or DPP4 or TZD SGLT2i or DPP4i or GLP1 RA If not at goal, can continue with additional agents as shown above If above agents have been utilized, consider SU or basal insulin **Do not combine DPP4i and GLP1 RA Minimize Weight Gain/Promote Weight Loss without established ASCVD, CKD, or HF (+ metformin & lifestyle) GLP 1 RA SGLT2i If not at goal If not at goal SGLT2i GLP1 RA If not at goal, or cannot tolerate the above agents, consider a DPP4i if not currently on a GLP1 RA Use caution with SU, TZD, Basal insulin Minimize Cost without established ASCVD, CKD, or HF (+ metformin & lifestyle) SU TZD If not at goal If not at goal TZD SU If above agents have been utilized, consider basal insulin, DPP4i OR SGLT2i with lowest cost Special Populations: Pregnancy Other Considerations ▪ Follow up ▪ HbA1c 2-4 times/year ▪ Q3 months if not controlled ▪ Q6 months if controlled ▪ Annual urinary albumin ▪ Dilated Eye Exam ▪ Annually ▪ Foot examination ▪ Every visit if at high risk for ulcerations ▪ Annual examination for everyone ▪ Dental ▪ At least every 6 months ▪ Immunizations ▪ Annual Influenza ▪ Pneumonia ▪ Prevnar 20 or ▪ Prevnar 15 followed by PPSV23 ▪ Hepatitis B series ▪ Other vaccine considerations based on age/comorbidities American Diabetes Association. Standards of medical care in diabetes-2019. Diabetes Care 2019; 42 Suppl 1. Summary ▪ Consider patient related factors in decision making ▪ Understand barriers to therapy ▪ Encourage goal setting ▪ Don’t forget about non-pharmacologic therapy References CDC Data and Statistics. http://www.cdc.gov/diabetes/data/index.html. Accessed Jan 19, 2024. International Diabetes Federation. IDF Diabetes Atlas, 10th edn. Brussels, Belgium: 2019. Available at: https://www.diabetesatlas.org Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2020. American Diabetes Association. Standards of medical care in diabetes-2024. Diabetes Care 2024; 47 Suppl 1. AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm 2020. Endocr Pract. 2020;26(1):91-120 Scirica BM, Bhatt DL, Braunwald E, et al. 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