1. January 2013 Webinar: “Practical Ways to Help Get Our Diabetes Patients to Goal” Controlling the ABC’s Cases

2. Evidence Based Interventions that Reduce Morbidity and Mortality HbA1C < 7 BP < 140/90 LDL cholesterol < 100 (or <70 if CAD) Aspirin age > 50 men, 60 women with 1 risk factor ACE - age >55 Statin use - age >40 Yearly screen for nephropathy, feet, and eye exams

3. The ‘ABCs’ A 1C B P < 140/90 C holesterol (LDL<100, if CAD <70)

4. Improving Glucose Control

5. “But I Thought It Was Bad to Lower A1C Too Much..” All recent studies aimed at A1C = 6.5 or lower No evidence that A1C = 7 is bad Data says to reduce CVD It is not so much about glucose It’s the Blood Pressure and Cholesterol!

6. Really, Really Important Points: 1.Aggressive control early prevents complications 2.Because of the log-linear relationship between control and complications, absolute benefits are greatest at high HbA1c values (i.e. target A1C >9) 3.Pushing patients with advanced disease (particularly macrovascular complications) to ‘tight’ control that they cannot achieve probably increases mortality -Attention to hypoglycemia and particularly nocturnal hypoglycemia

7. Managing Glucose Goal A1C <7 Consider higher (8) if CAD, elderly, or hypoglycemia unawareness Focus on those at highest risk (i.e. A1C >9)

8. Sites of Drug ActionCarbohydrate DIGESTIVE ENZYMES Glucose Defective -cell secretion  -cell secretion Excessglucoseproduction Resistance to the action of insulin Reduced glucose uptake Excessivelipolysis Dinneen SF. Diabet Med. 1997; 14 (Suppl 3): S19-24. Sulfonlyureas Meglitinides Incretins Insulin Alpha-glucosidase Inhibitors, Incretins Metformin TZD Incretins TZD, Metformin

9. Points to Remember Each agent, except insulin, lowers A1C 1-2 If A1C >9, start two agents Follow SMBG, A1C, and Titrate!!!!!

11. Case 58 yo with Type 2 x 5 yrs A1C = 9.5 On metformin 1000 mg bid Glimepiride 4 mg qd What next?

12.  20  10 0102030 Natural History of Type 2 Diabetes Adapted from International Diabetes Center (IDC). Minneapolis, Minnesota. Years of Diabetes Relative  -Cell Function Plasma Glucose Insulin resistance Insulin secretion 126 mg/dL Fasting glucose Postmeal glucose

13. Type 2 Diabetes… A Progressive Disease Over time, most patients will need insulin to control glucose.

14. Reducing Clinical Inertia Eternal hope on lifestyle working Negotiate a deadline Escalating therapy more quickly Oral agents can be monthly Insulin can be weekly

15. Barriers to Starting Insulin Patient Barriers Guilt, failure Injection? Provider Barriers Who teaches? Consider pens Team Based Care to the rescue! Diabetes Educators?

16. Talking About Insulin “It seems like you have some concerns about insulin?” “What do you know about using insulin in DM?” Inevitable Simple Pens Can be daily at first No one needs to know Correct misconceptions

17. What To Do With Oral Agents Negotiate For weight- keep metformin For reducing need for second injection - insulin secretagouge For cost- stop orals

18. Correcting Fasting Hyperglycemia… 100 200 300 Normal A1C 5%–6% PG (mg/dL) 0800120018000800 Time of Day Uncontrolled A1C ~9% A1C ~6% Is Usually the First Task!! …then, Tackle Postprandial Hyperglycemia if A1C still >7%! “Controlled” A1C <7%

19. Titrating Glargine or Detemir Start 10 units 2 units q 3 days until FPG < 100 It’s that easy and it works!

20. 50 4:00 25 75 8:0012:0016:0020:0024:004:00 BreakfastLunchDinner Plasma Insulin ( U/mL) Insulin ( µU/mL) Time 8:00 Physiologic Serum Insulin Secretion Profile

21. How do you know they need another injection? FPG good but A1C not

22. 22

23. Case Type 2 DM x 6 y Glargine 60 units qhs FPG 90-110 A1C=8.5 Pt can measure qhs BG? Start 10 units rapid insulin pre-dinner If regular meals- 70/30 insulin 40 q Am, 30 q PM

24. Who Are Your High A1C Patients? Orals and need second oral? Need insulin? On insulin? There can be inertia at each level DEPRESSION? Adherence? Open-ended ended question: “Some people find it hard taking their insulin every day, how’s it going for you?”

25. BP CONTROL

26. BP Management <140/90 Multiple meds Don’t miss an opportunity to titrate Standing orders?

27. Medication Treatment Algorithm? Start with ACE or ARB and/or HCTZ Either one Best might be early combo since all will likely need it Third agent based on co-morbidity Beta blocker and/or Ca channel Add the 4 th and hopefully you’ve reached goal - if not call an expert +/- alpha blocker?

28. Tashko and Gabbay, Integrated Blood Pressure Control (2010)

29. Cholesterol LDL control <100 If CVD <70

30. Getting to Goal on LDL Most myalgia not from statins! Stop and observe Switch to another statin Mention stroke risk TITRATE

31. Evidence Based Interventions That Reduce Morbidity and Mortality HbA1C < 7 BP < 130/80 LDL cholesterol < 100 (or <70 if CAD) Aspirin age > 50 men, 60 women with 1 risk factor ACE -age >55 Statin use- age >40 Yearly screen for nephropathy, feet, and eye exams

32. QUESTIONS? Any Cases?