What individual patient characteristics should be considered in determining the treatment goals?
Duration of time since DM onset (6 months ago), life expectancy and Age (45 yrs.), Comorbidities (bipolar, HTN, dyslipidemia, obesity), Renal functions (microalbuminuria), Presence of CVD (No CVD, 10-year ASCVD risk 3.9%), history and risk of hypoglycemia, income / ability to pay for medications (sales associate), level of motivation and compliance, Past glycemic control (poor), diet (poor), exercise (little to none), risk of developing complications, difficulty achieving goal
What nonpharmacologic interventions should be recommended for this patient’s drug therapy problems?
Diabetes Self-Management Education and Support (DSMES)
Medical Nutrient Therapy – Low fat, low carb, high fiber, low calorie -diets, DASH, Mediterranean diets, saturated fat < 7% of total daily calories, carb-counting, 150 minutes per week of physical moderate intensity exercise with no more than 2 consecutive days without exercise, 2 or more times/week of weight training (large muscles)
What pharmacologic interventions could be considered for this patient’s drug therapy problems?
DM
Continue with metformin 1000 mg BID and add one of the following:
10 units/day basal insulin (Long acting insulin or NPH)
Adding sulfonylurea or
Adding GLP-1 agonist or
Adding DPP-4 inhibitor or
Adding meglitinide or
Adding TZD or
Adding SGLT-2 inhibitor
HTN:
Increasing lisinopril dose to 40 mg PO daily or
Adding long acting DPH CCB such as amlodipine to lisinopril 20 mg or
Adding HCTZ diuretic to lisinopril 20 mg or
Increasing to lisinopril 40 mg and adding HCTZ
Increasing to lisinopril and amlodipine
What pharmacotherapeutic regimen would you recommend for each of the patient’s drug therapy problems?
DM – patient A1C≥ 10% and stays symptomatic (nocturia, polyuria, polydipsia)
Metformin 1000 mg BID + Basaglar 10 units QHS
Increase Basaglar dose by 2 units every 3 days until FBG < 130 mg/dL
HTN:
Lisinopril 20 mg + Amlodipine 5 mg or
Zestoretic (Lisinopril 20 mg + HCTZ 25 mg)
What parameters should be monitored to evaluate the efficacy and possible adverse effects associated with the optimal regimens you selected?
HbA1c
Blood glucose level (especially fasting blood glucose level)
Symptoms of hypoglycemia
In hypokalemic patients, monitor potassium levels
Weight
Renal and hepatic functions (may need lower doses)
What alternative therapies might be appropriate if the initial plan for diabetes treatment fails?
If with 0.5 units /kg/day Basaglar insulin goal is not met, then:
Add GLP-1 agonist such as Victoza OR
Add one injection of rapid acting insulin to the largest meal. Increase dose 2 units every 3 days until goal SMBG is met. OR
Switch to premix BID. Give same total daily dose as basaglar but give 2/3 in the morning and 2/3 with dinner. Increase dose 2 units every 3 days until goal SMBG is met. OR
Switch to premix BID. Give same total daily dose as basaglar but give 50% with breakfast and 50% with dinner. Increase dose 2 units every 3 days until goal SMBG is met.
Discuss the phenomenon known as the metabolic syndrome and the role that insulin resistance is postulated to play in its sequelae (complications).
Metabolic Syndrome (aka insulin resistance syndrome) is a group of metabolic risk factors (insulin resistance, elevated blood pressure, central obesity, atherogenic dyslipidemia) that often co-occur and increase the likelihood of type 2 DM and cardiovascular diseases. Presence of 3 or more of the following is sufficient for diagnosis
TG>175 mg/dL
FBG≥ 100 mg/dL
Elevated BP (SBP≥130 or DBP≥85 mmHg)
increased waist circumference
low HDL levels (men: <40 mg/dL, women<50 mg/dL)
Central obesity leads to insulin resistance and increased blood free fatty acid levels. Increased free fatty acid in blood leads to decreased insulin signaling and makes the body more resistant to insulin. Insulin resistance leads to decreased uptake of potassium, amino acids, glucose and fatty acids by liver, skeletal muscles, and adipose tissue.
ADIPOSE TISSUE – insulin resistance causes decreased lipogenesis, and decreased lipolysis.
LIVER – Insulin resistance causes decreased glycogenesis, protein synthesis, and lipogenesis and increased glycogenolysis, ketogenesis, gluconeogenesis and ureagenesis.
MUSCLES – insulin resistance leads to increased glycogenolysis and proteolysis, and decreased gluconeogenesis, glucose oxidation and protein synthesis.
Through these effects, insulin resistance leads to type 2 DM (Reduced insulin receptors on muscle a fat cells à decreased cell response to insulin à decreased uptake of blood glucose à B-pancreatic cells must produce more insulin for normal BG. If not à BG remains elevated throughout the day à T2DM), Dyslipidemia (increased TG, small dense LDL, and decreased HDL) (Low insulin receptor on fat cellsà decrease lipid uptakeà increased stored TG breakdown à increased FFA release into bloodà increased VLDL secretion from liverà increased blood TG), hypertension which are all associated with metabolic syndrome.
Explore and discuss the importance of monitoring postprandial blood glucose levels and its impact on overall glucose control, A1C levels, and progression of diabetes complications.
Postprandial blood glucose level provides for assessment of short term fluctuations of BG levels and potential hyperglycemic complications after food intake. Monitoring postprandial blood glucose levels allows us to assess pancreases ability to secrete sufficient insulin in response to elevated blood glucose levels after a meal. Insulin prevents glycogenolysis when blood glucose level is elevated after eating a meal and signals liver to store glucose as glycogen, muscles to uptake glucose,
FBG is a better predictor of HbA1c, overall glucose control, and progression of complications than postprandial blood glucose level.
PBG should be monitored if FBG is at goal but A1C remains above goal.
Research the various blood glucose monitors available, and compare, among available monitors, the features that meet the needs of individual patients and improve adherence to testing regimens.
To improve adherence to testing regimens, selection of blood glucose monitors should be determined based on patients’ needs and preferences for each of the features:
Memory capability
If the results can be downloaded to a management software
Preferred testing site (pain, etc.)
Amount of blood required for testing
Research new therapies for diabetes and discuss their potential role in the management of patients with type 2 DM
Insulin pumps
New medications with different mechanisms of actions
Medicatiosn that can be administered with much lower frequency
Keep a food diary, including carbohydrate counting for each meal, and exercise log for 1 week. Evaluate and discuss your experience from the viewpoint of a patient with type 2 DM.
Ongoing – so far, the experience has been challenging as I would have to be more careful about what I eat and my sedentary habits. Upon request, a more complete response to this question can be provided (after results of one-week food diary becomes available).
Investigate continuous blood glucose monitoring systems (CGMS) technology, and discuss the role of CGMS in a patient with type 2 DM.
Multiple studies have been done. The conclusions are as follows:
It improves glycemic control in T2DM patients requiring multiple daily injections of insulin
It may improve glycemic control in patient with T2DM
Intermittent real time continuous blood glucose monitoring systems may improve glycemic control in patient with T2DM who do not receive mealtime insulins
Research and compare current insulin pumps in the market. Discuss the role of insulin pump therapy in a patient with type 2 DM and what patient characteristics make or eliminate the patient as an insulin pump candidate.
It improves the quality of life in patients requiring multiple daily injections of insulin
It decreases incidence of hypoglycemia in patients requiring multiple daily injections of insulin
Ability to manage insulin pump
Ability to cope to the pump
willingness to use an insulin pump
significant insulin resistance with failure to achieve glycemic control in spite of sufficient titration of insulin dose and adherence to healthy diet, exercise and lifestyle.
Patient may not have major cognitive impairment or operative disability
Acceptable level of adherence to SMBG
Intensive insulin therapy
Patients with frequent blood glucose levels that are lowv
Those with gastroparesis
Pregnant women