Diabetes

Overview
With Kahoot (so it won’t be so boring)
 CONTENTS OF THIS TRICK OR
TREAT BAG
Objectives:

● Identify Type 1 and Type 2 Diabetes, goals, and complications

● Distinguish between common diabetes drug classes
● Apply guidelines for diabetes treatment
● Evaluate different treatment options
● Design treatment plans
 TYPE 1 AND TYPE 2: THE
DIFFERENCE
Type 1 Diabetes
Autoimmune destruction of beta cells
“absolute” insulin deficiency
Most patients develop type 1 diabetes within the
first 20 years of life
Abrupt onset
Present with polydipsia, polyphagia, polyuria
20-40% present with DKA
 TYPE 1 AND TYPE 2: THE
DIFFERENCE

● Type 2 Diabetes
○ Gradual insulin resistance and deficiency
○ Developed over long period of time (>30 years
of age)
○ Gradual onset
■ Present without symptoms
■ Hyperosmolar hyperglycemic state
MICROVASCULAR COMPLICATIONS
Retinopathy
Most common

Diabetic kidney disease

Can progress to End Stage
Renal Disease (ESRD)

Peripheral neuropathy
Risk of foot infections and
amputations

Autonomic neuropathy
Erectile dysfunction,
gastroparesis
MACROVASCULAR COMPLICATIONS
Coronary Artery Disease
MI, stable angina

Cerebrovascular disease
Stroke, TIA

Peripheral artery
disease
Cardiovascular Disease in Diabetes

-with commentary
 Cardiovascular Disease in Diabetes

Hypertension Statin Therapy

Goal: <130/80 for most
Almost everyone with DM should
be on at least moderate intensity
Consider ACE/ARB for renal
statin
protection
For DM patients at high risk for
ASCVD, a high-intensity statin
should be considered
 Aspirin Therapy
Consider for primary prevention if patient has DM
plus at least one additional major risk factor (family
history of premature ASCVD, hypertension,
dyslipidemia, smoking, or chronic kidney
disease/albuminuria)

Use for secondary prevention in patients with DM and

ASCVD
Renal Disease in Diabetes
Diabetic Kidney Disease
Increased glomerular pressure leads to dysfunction
and protein “spilling”

Goal is to slow the progression of this damage

Normal: <30 mcg/mg
Microalbuminuria: 30-299 mcg/mg
Clinical albuminuria: >300 mcg/mg
Diabetic Kidney Disease
Guidelines
If albumin/Cr ratio: 30-299 → SSGLT2 or GLP1 or
both, use especially with ratio >300

Consider ACE/ARB in those with ratio 30-299,

strongly recommended in those with ratio >300
Some things from the guidelines
 Some things from the guidelines
What A1c goal to choose
It is usually < 7.0% except…

“Less stringent A1C goals (such as <8%

[64 mmol/mol]) may be appropriate for
patients with a history of severe
hypoglycemia, limited life expectancy,
advanced microvascular or
macrovascular complications, extensive
comorbid conditions, or long-standing
diabetes in whom the goal is difficult to
achieve…”

BG goals
• 80 – 130 mg/dL outpatient
• < 180 mg/dL inpatient
 What A1c goal would you use for
a patient with…..

CAD s/p 2 stents?

HTN, debilitating stroke?
Double BKA?
Dementia?
Impaired eyesight?
The drugs used in diabetes
 SGLT2-INHIBITORS

BENEFITS DISADVANTAGE
Reduced cardiovascular death and Increased urination, thirst
hospitalization in pts with Heart Dehydration, hypotension
Failure UTIs, fungal infection (jock itch)
Renal protective to Amputations?
prolong/prevent CKD Euglycemic ketoacidosis
Reduction in CVD events
No hypoglycemia
Weight loss

What I look for to start a SGLT2-I:

• DM with renal issues, HF issues, or CVD issues
• Ask if they have Hx of UTIs, fungal infxn, pancreatitis
 GLP1-AGONISTS

BENEFITS DISADVANTAGE
Reduce death in CVD Pancreatitis
Weight loss N/V/D
No hypoglycemia
Once weekly injections available
Long term beta cell function

What I look for to start a GLP1-A:

• DM with CVD issues, significant need for weight loss
• Ask if they have Hx of pancreatitis, thyroid turmors
 SULFONYLUREA

ADVANTAGE DISADVANTAGE
Cheap Hypoglycemia
Extensive track record of safety Weight gain
and effectiveness Tachyphylaxis to insulin secretion
effect
Pancreas burn out

What I look for to start a SU:

• IF cost is an issue
• Ask if they have Hx hypoglycemic events, or sulfa allergy
 TZDs

Advantages Disadvantages
Fat distribution Fluid retention
Increase insulin sensitivity DO NOT USE IN HF
Cheap Risk of fractures
Urinary bladder tumors?

What I look for to start a TZD:

• Not much….cost?
• Ask if they have Hx of HF
 DPP-4 Inhibitors

Advantages Disadvantages
Well tolerated Acute pancreatitis
Oral administration Risk of HF (saxa/alogliptin)
No hypoglycemia Modest lowering of A1c

What I look for to start a DPP-4:

• If an add on is needed
• Ask if they have Hx HF
DM2
What treatment to
use when
Knowing the medications and
guidelines
 Guideline Deetz

Consider initiating insulin if BG is >300 or A1c

>10%
Combination therapy can be considered in
patients with A1c 1.5-2.0% above goal
Initiate basal insulin first
When starting mealtime insulin, consider once
daily with biggest meal
Use a 10-15% increase or reduction of insulin
when adjusting dose.
 What would you do?

FBG Lunch Supper HS

You are seeing a patient for DM2 f/u. Day 1 145 154 169
Medications: Day 2 116 124 122
Insulin glargine 40 units at night Day 3 134 165 203
Day 4 121 127 134 165
Insulin aspart 10 units WM TID Day 5 92 145 164
Cetirizine 5mg daily Day 6 116 132 124
Day 7 138 167 192 212

Age: 54
PMH: UTIs
Pertinent labs: microalb/Cr ratio: 100.2
 What would you do?

A1c from 3 weeks ago: 7.8%. Goal A1c

You are seeing a patient for DM f/u.
is <7.0%
Medications:
Metformin 500mg BID
BG: 134-145-156-162-133-154
Alogliptin 25mg daily
Amlodipine 10mg daily

Age: 66
PMH includes HTN, HFrEF

Pertinent labs: Alb:Cr = 324,

BP: 126/76
 What would you do?

A1c from 2 months ago: 8.2%. Goal A1c

You are seeing a patient for DM f/u.
is <7.0%
Medications:
Metformin 500mg BID FBG Lunch Supper HS
Glargine 30 units daily Day 1 164
Aspart 8 units WM TID Day 2 234
Day 3
HCTZ/lisinopril 12.5mg/10mg
Day 4
Day 5 187
PMH includes HTN, HLD Day 6 123
Day 7
Pt is not motivated, doesn’t like
checking regularly
 What would you do?

A1c from 2 months ago: 8.1%. Goal A1c

You are seeing a patient for DM f/u.
is <7.0%
Medications:
Metformin 1000mg BID FBG Lunch Supper HS
Glargine 20 units daily Day 1 187 169
Aspart 8 units WM once Day 2 162 172
Carvedilol 6.25mg BID Day 3 143 178
Day 4 152 212
Day 5 133 173
PMH includes HTN, HLD, CAD s/p Day 6
CABG Day 7
 What would you do?

You are seeing a patient for DM f/u. A1c from 2 months ago: 8.1%. Goal A1c
Medications: is <7.0%
Metformin 1000mg BID
FBG Lunch Supper HS
Glargine 80 units daily Day 1 132 124 121
Aspart 20 units WM TID Day 2 122 133 124
Empagliflozin 10 mg Day 3 118 *141
Day 4 130 121 135 123
PMH includes HTN, HLD, Diabetic Day 5 98 114
Day 6
kidney disease, HF
Day 7

Today, complains of dry mouth, *Had 1/2 a honey bun

dizziness, and gets lightheaded
sometimes
THAT’S IT!
Happy October!