Tags: A1C, American Diabetes Association, Diabetes, DSME, insulin, kidneys, Medications
Eileen B. Wyner, NP
Bulfinch Medical Group
I recently reviewed updates to the American Diabetes Association’s (ADA) Standards of Care for 2017. In this post, I’ll review Section 8 of the standard that talks about different medications for treating diabetes. I will also discuss some of the newer medications used to treat diabetes.
Type 1 Diabetes is always treated with insulin, either through multiple injections or an insulin pump. Type 2 Diabetes can be treated with oral medications (pills by mouth), injections, or both. The ADA recommends that people with Type 2 diabetes start patients start with the pill metformin, as long as it safe for them to take it. Taking metformin for a long time may lead to not getting enough Vitamin B12, stomach symptoms, and can affect how well the kidneys work (your care team will monitor your kidneys to be sure they are working properly).
If someone is taking one oral medication at the highest possible dose but their A1C is still not at goal, providers should consider adding additional medications: another oral medication, long acting insulin (injection), or a non-insulin injectable medication called glucagon-like peptide 1 receptor agonists (GLP-1 receptor agonists).
Examples of GLP-receptor agonists are exenatide (Byetta), liraglutide (Victoza), and dulagultide (Trulicity). These medications cause food to move through the stomach slower so people feel full sooner. This leads to less glucagon (another hormone made by the pancreas) being released after meals and lowers appetite, which helps with weight loss. These medications need glucose to work, so there is little chance of hypoglycemia. Side effects include nausea, vomiting and acute pancreatitis. They may also cause medullary thyroid cancer in animals. It should be noted that these medications are expensive.
People with poorly controlled diabetes and atherosclerotic cardiovascular disease (ASCVD aka heart disease) may benefit from a new medication called empagliflozin (Jardiance), a type of medication called SGLT-2 inhibitor. These medications work by preventing the body from reabsorbing glucose. This lets more glucose leave the body through urine. People may have lower blood sugar values after eating and lose some weight. Studies show empagliflozin helped reduce deaths caused by heart attack, stroke, and cardiovascular disease. Empagliflozin is the only SGLT-2 inhibitor with these results, but other medications are being studied (liraglutide [Victoza] may have the same results, but other GLP-1 receptor agonists are not used this way). Potential side effects include hypoglycemia, low blood pressure, dizziness, urinary tract infection, needing to urinate a lot, and increased LDL and creatinine (a waste product filtered out by the kidneys). Again, these medications are very costly.
There are many medications available for the treatment of diabetes. These standards are general recommendations for medical care. Always discuss questions about your care plan with your healthcare provider.
Tags: American Diabetes Association, Diabetes, Diabetes management, DSME, standards of care
Eileen B. Wyner, NP
Bulfinch Medical Group
This week is part two of my review of the revisions to the 2017 American Diabetes Association Standards of Care (click here to review Part 1). First, a quick reminder that these are guidelines; always discuss questions about your personal health care plan with your health care provider.
Section 6: Glycemic Targets
The International Hypoglycemia Study Group has recommended that serious, clinically significant hypoglycemia be defined as a reading of less than 54 mg/dL. People who have experienced such measurements need to notify their health care providers immediately and be prescribed a glucagon emergency kit.
Hypoglycemia measuring less than 70 mg/dL is still treated by the rule of 15: 15 grams of fast acting carbohydrate with a blood sugar check in 15 minutes for an expected increase by at least 15 points. Repeat the process if the result doesn’t improve.
Section 7: Obesity Management for the Treatment of Type 2 Diabetes
The best blood sugar results occur with weight loss early in the management of Type 2 Diabetes, before beta cells begin to stop working. For this reason, metabolic surgery (formerly referred to as bariatric surgery) is now recommended for people with a BMI of 30 (or 27.5 for Asians with poorly controlled diabetes).
Section 9: Cardiovascular Disease and Risk Management
Any of the medications for managing high blood pressure can be used (except for beta blockers) as long as the person doesn’t have protein in the urine (albuminuria). One or more medications should be used at bedtime to improve blood pressure control.
The goal for blood pressure for pregnant women is 120-160/80-105. When prescribing medications, providers should consider both maintaining the health of the mother and avoiding harm to the baby.
There is a discussion of new medications and the potential benefits for people with diabetes and cardiovascular disease: empagliflozin (Jardiance) and liraglutide (Victoza).
Section 10: Microvascular Complications and Foot Care
There is an increased risk for retinopathy in pregnant women with Type 1 or Type 2 Diabetes. Thorough eye exams should be a part of preconception counseling as well as during pregnancy.
Anyone being treated for neuropathic pain should be evaluated for the addition of medication therapy with pregabalin (Lyrica) and duloxetine (Cymbalta). They should also be fitted for therapeutic footwear by a podiatrist.
Section 12: Children and Adolescents
Preconception counseling should begin in puberty to help to avoid the risk for birth defects in unplanned pregnancies.
When diabetic ketoacidosis appears in children, it is important to know if the child has Type 1 or Type 2 Diabetes as 6% of these cases are actually Type 2 Diabetes, not Type 1.
Section 13: Management of Diabetes in Pregnancy
Insulin is the preferred treatment for pregnant women. Oral medications may harm the baby.
Targets for blood sugar are the same for gestational diabetes as for preexisting diabetes.
Section 14: Diabetes Care in the Hospital
It’s now recommended to use basal and/or basal bolus insulin regimes (instead of sliding scale insulin alone) when patients are admitted to the hospital.
Tags: American Diabetes Association, care plan, Diabetes, Diabetes management, DSME
By Eileen B. Wyner, NP
Bulfinch Medical Group
The American Diabetes Association (ADA) publishes guidelines each January to educate professionals about the best clinical practice for people diabetes. I will review the standards that have had changes made in them for 2017. Section 8 (Pharmacologic Approaches to Glycemic Treatment) is a very important section with a great deal of information, so it will be covered in a separate post.
This year the Standards of Care have been updated to address psychosocial issues in all aspects of care. This includes the importance of assessing self-management capabilities, mental health status, and complications and comorbidities. These standards are meant to provide general treatment goals and are not meant to replace clinical judgment. This post is a brief overview of the changes to the standards; click here to access a full list and descriptions. Please remember, that these are in no way meant to replace the individual care that you are participating in with your health care team.
Section 2: Classification and Diagnosis of Diabetes
There is a new consensus on staging Type 1 Diabetes. Three stages have been identified:
- Stage 1 – no changes in the blood glucose values and no symptoms are present
- Stage 2 – some impaired fasting blood glucose and possibly some impaired glucose tolerance, too
- Stage 3 – the stage that most people are diagnosed. They may appear with dangerous hyperglycemia and have symptoms such as excessive thirst, hunger and urination
Investigators hope to use this staging system as a research road map to help better plan intervention strategies.
Dentists are also are important in identifying people with diabetes. One study shows 30% of people over 30 that are treated for periodontal disease have abnormal glucose levels. Educating dentists to refer these individuals to their health care providers for formal assessment will be helpful in identifying at-risk people sooner.
Birth weight of infants is no longer a risk factor for Type 2 Diabetes. Women who had gestational diabetes should have their fasting glucose test done 4 to 12 weeks after having their baby (instead of 6 to 12 weeks). The hope is that most women will have the test done before the 6 week checkup so they can discuss results and implications with their provider.
Section 3: Comprehensive Medical Evaluation and Assessment of Comorbidities
This is a new section highlighting screening for, and management of, comorbid conditions in people with diabetes. Assessment of sleep pattern and duration has been added as well as HIV, autoimmune diseases, depression and anxiety, and disordered eating patterns. Please refer to the full standards to see the entire list of conditions.
Section 4: Lifestyle Management
People following a flexible rapid acting insulin schedule should work closely with a registered dietician for education on counting fat and protein values as well as carbohydrates to be sure they are using correct insulin amounts.
Sitting is the new smoking! Stand up and move a little every 30 minutes. Aim for 150 minutes of exercise per week and try to do strength training 2 to 3 times a week. Balance and flexibility are priorities for older adults, and activities like yoga or Tai Chi are recommended. There is also a table providing information about situations that may require referral to a mental health professional.