1. Clinical Update in Type 2 Diabetes A Case Discussion Dr. Yancey R. Holmes, MD, FACE Ohio Valley Endocrinology

2. Topics for Discussion Glycemic Targets Therapeutic Agents Case Discussion

3. Glycemic Targets American Diabetes Association American Association of Clinical Endocrinologists HbA1c Fasting glucose Post prandial glucose Hypoglycemia

4. Pharmacologic Agents Sulfonylureas and Meglitinides Metformin Alpha-glucosidase Inhibitors Thiazolidinediones Dipeptidyl Pepdidase-4 Inhibitors

5. Pharmacologic Agents Welchol Incretin Mimetic GLP-1 AgonistsGLP-1 Analogs Amylin Analogs

6. Pharmacologic Agents Human Insulin Regular NPH Analog Insulin Rapid Basal Mix

7. Special Considerations Heart Disease Renal Impairment Liver Disease Frailty Weight Gain

8. Case Discussion

9. Case 1 56 year old man referred by cardiologist Diabetes diagnosed during hospitalization for acute MI associated with pulmonary edema BMI 32 NYHA Class III functional status

10. Case 1 HbA1c 8.6% Serum creatinine 1.3 Discloses that he “ain’t takin’ no damn shots!”

11. Case 1 Discussion Drug naive patient with ischemic heart disease and systolic dysfunction Confrontational needle-phobe

12. Case 1 Metformin: Will it get to goal? Sulfonylurea: Hypoglycemia concerns? TZD’s: Fluid retention? DPP-4 Inhibitors?

13. Case 2a 42 year old woman referred by friend Strong family history. Symptoms of post prandial fatigue. Currently at her highest body weight. Exercise is infrequent

14. Case 2a BMI 36 HbA1c 7.8% Expresses a good understanding of recommended lifestyle changes.

15. Case 2a Metformin Sulfonylurea TZD DPP-4 Injections???

16. Case 2b After successful adoption of healthy lifestyle changes and metformin she maintains HbA1c less than 6.5% over the next three years She presents for follow up to discuss options to address weight gain and diabetes BMI 32

17. Case 2b 9 months ago HbA1c 7.3% Metformin was titrated to 1000 mg bid 6 months ago HbA1c 6.4% Back on track with exercise and associated 6 pound weight loss

18. Case 2b 3 months ago HbA1c 7.1% Recent job change, stressed out. Feels certain she can get back on track without additional medicaiton Now HbA1c 7.8% Weight is up 12 pounds from last visit Very frustrated with weight gain and constant hunger

19. Case 2b Metformin titration to 2500 mg? Addition of Sulfonylurea? Addition of TZD? Addition of DPP-4 Inhibitor? Addition of Basal Insulin Addition of a GLP-1 Agent

20. Case 3a 40 year old man currently on Metformin and SU maximal dose FBG 160-180 PPG 160-200 HbA1c 8.2% BMI 27

21. Case 3a Addition of third oral agent? Addition of GLP-1/Amylin Introduction of insulin? Human vs. Analog? What kind of dosing regimen?

22. Case 3b Addition of basal insulin helped maintain good glycemic control over the next 18 months Now HbA1c 7.8% FBG 100-140 PPG 180-220

23. Case 3b Oral agents? Mealtime insulin Mealtime amylin Should anything be discontinued?

24. Case 4a 38 year old man presents for assessment after family member tests a blood sugar of 400 He has already adopted many good dietary changes and saw the educator at the health department Blood sugars range from 180-250 HbA1c 9.8% BMI 31

25. Case 4a Metformin with continued lifestyle modification? Combination agent? Insulin? GLP-1/Amylin?

26. Case 4b After 5 years of maintaining HbA1c <7% on combination Metformin+TZD blood sugars are elevated HbA1c 8.2% 15 pound weight gain over past 3-6 months

27. Case 4b Third oral agent? Insulin? GLP-1/Amylin?

28. Case 5 60 year old woman with type 2 diabetes for 2 years treated with SU HbA1c has ranged from 8.2-6.8% over that time. Currently it is 7.5% Recent attempts to titrate SU have lead to frequent hypoglycemia, particularly with exercise She has been trying to exercise to stop her steady weight gain of 20 pounds over the past year

29. Case 5 Metformin? DPP-4? TZD? Insulin? GLP-1/Amylin?

30. Case 6 36 year old woman recently relocated to your area presents for first visit Diabetes diagnosed last year. Subacute onset of symptoms with passive 15 pound weight loss Started on Metformin and titrated to 1000 mg twice daily with good response

31. Case 6 Over past two months she has had recurrence of symptoms Blood sugars frequently in the 300+ range No change in routine Has experienced a 25 pound passive weight loss HbA1c now 10.5%

32. Case 6 Additional oral therapy? GLP-1/Amylin? What is her diagnosis?

33. Thank you