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Diabetes – New Guidelines and Treatments
Anna Gibson, Pharm D.Lead Pharmacist, Deaconess Specialty Clinics
September, 2015
I have no actual or potential conflicts of interest to disclose.
Disclosures
Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient-Centered Approach
Update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes
Diabetes Care 2015;38:140–149 | DOI: 10.2337/dc14-2441
ADA position statement
Individualize goals based on:◦ Risks of hypoglycemia◦ Disease duration◦ Life Expectancy◦ Important Comorbidities◦ Vascular complications◦ Patient attitude and support system
Treatment Goals
Diabetes agents – site of action
http://diabetesmanager.pbworks.com/w/page/17680289/Oral%20Pharmacological%20Agents%20for%20Type%202%20Diabetes. Accessed 10/14/2014 1624.
Potent insulin regulating hormones◦ Released in response to glucose or fat ingestion◦ Potentiate insulin secretion◦ Additive effects
Glucose-dependent insulinotropic Polypeptide (GIP)
Glucagon-like peptide (GLP-1) Both metabolized rapidly by DPP-4 In Type 2 diabetes, GLP secretion is
decreased and GIP-induced stimulation of postprandial insulin secretion is diminished.
Incretins
GLP-1 agonists
http://diabetesmanager.pbworks.com/w/page/17680289/Oral%20Pharmacological%20Agents%20for%20Type%202%20Diabetes. Accessed 10/14/2014 1624.
Exenatide (Byetta®, Bydureon®)◦ Byetta: 5-10 mcg sq BID before meals◦ Bydureon: 2 mg sq once weekly
Liraglutide ◦ Victoza: 0.6 – 1.8 mg SQ daily◦ Saxenda (weight loss only): Start at 0.6 mg daily,
increase weekly to 3 mg daily Albiglutide (Tanzeum®)
◦ Once weekly SQ injection – 30-50 mg◦ Powder for injection – have to mix with provided diluent
and wait 15 or 30 minutes before administration. Dulaglutide (Trulicity®)
◦ Once weekly SQ injection – 0.75-1.5 mg
GLP-1agonists
a. Promote the release of endogenous incretins
b. Inhibit the breakdown of endogenous incretins
c. Act synergistically with exogenous GLP-1 agonists
d. Promote glucose excretion in the kidneys
What is the Mechanism of action of a DPP-4 inhibitor?
a. Promote the release of endogenous incretins
b. Inhibit the breakdown of endogenous incretins
c. Act synergistically with exogenous GLP-1 agonists
d. Promote glucose excretion in the kidneys
What is the Mechanism of action of a DPP-4 inhibitor?
DPP-4 inhibitors
http://diabetesmanager.pbworks.com/w/page/17680289/Oral%20Pharmacological%20Agents%20for%20Type%202%20Diabetes. Accessed 10/14/2014 1624.
Sitagliptin (Januvia®)◦ 100 mg daily
Saxagliptin (Onglyza®)◦ 2.5-5 mg daily
Alogliptin (Nesina®)◦ 25 mg daily
Linagliptin (Tradjenta®)◦ 5 mg daily
DPP-4 inhibitors
SGLT-2 inhibitors
http://diabetesmanager.pbworks.com/w/page/17680289/Oral%20Pharmacological%20Agents%20for%20Type%202%20Diabetes. Accessed 10/14/2014 1624.
Monotherapy or add-on. Efficacy comparable to sulfonylurea Weight loss Not recommended in patients with history
of bladder cancer Increase glucose excretion in urine –
increased risk for UTI/mycotic infections in genital area
Diuretic effect
SGLT-2 inhibitor
Dapagliflozin (Farxiga®)◦ 5-10 mg once daily◦ Not recommended in creatinine clearance less than 60
ml/min Canagliflozin (Invokana®)
◦ 100-300 mg once daily◦ Dose adjustment required for creatinine clearance less
than 60 ml/min, do not use in less than 45 ml/min. Empagliflozin (Jardiance®)
◦ 10-25 mg once daily◦ Do not use in creatinine clearance less than 45 ml/min
SGLT-2 inhibitor
a. 48 year old woman, newly diagnosed type 2 diabetic with a history of chronic UTI
b. 66 year old man, 10 year history of diabetes, Creatinine clearance 40 ml/min
c. 52 year old woman, 5 year history of diabetes, previously well controlled on metformin, now with Hgb A1C 8.4.
d. 67 year old man with uncontrolled diabetes who currently takes furosemide to control hypertension
Which patient is the best candidate for an SGLT-2 inhibitor?
a. 48 year old woman, newly diagnosed type 2 diabetic with a history of chronic UTI
b. 66 year old man, 10 year history of diabetes, Creatinine clearance 40 ml/min
c. 52 year old woman, 5 year history of diabetes, previously well controlled on metformin, now with Hgb A1C 8.4.
d. 67 year old man with uncontrolled diabetes who currently takes furosemide to control hypertension
Which patient is the best candidate for an SGLT-2 inhibitor?
Insulin Glargine◦ Patent on U100 (Lantus®) expired in 2/2015
Biosimilar approved in Europe Submitted to FDA as new drug in US (Basaglar®)
Tentative approval in 8/14
◦ Insulin Glargine U-300 Toujeo® Longer half-life and flatter activity curve
Less hypoglycemia
Insulin lispro ◦ 200 unit/ml◦ Humalog U-200 Kwikpen®◦ Not for IV use or for use in insulin pumps◦ Can not be mixed with any other insulins
New insulins in the pipeline
Insulin Peglispro◦ Basal insulin
Insulin Degludec (Tresiba®)◦ Ultra long acting◦ 100 unit/ml, 200 unit/ml – pens only◦ 42 hour half life may allow some patients to inject
only 2-3 times per week.
New insulins in the pipeline
Inhaled insulin◦ Afrezza®◦ 4 units per inhalation◦ Contraindicated in patients with chronic lung disease◦ Administer at the beginning of each meal◦ Round up to nearest 4 units◦ Cough, throat pain or irritation◦ Teach on proper inhalation technique
Oral insulin (Oral-Lyn®)◦ Phase 3 trials◦ Insulin spray◦ Absorbed through oral mucosa◦ Onset 5 minutes, peak 30 minutes, duration 2 hours◦ Approved in other countries, In US on Treatment IND only.
New insulins in the pipeline
Implementation of drug therapy
3 months
3 months
Add from any class with differing mechanism of action
May reach goal faster if initiate double therapy at onset◦ Consider especially if Hgb A1C > 9
DPP-4 and GLP-1 have similar mechanisms SGLT-2’s have not been tested with GLP-1’s
Implementation of drug therapy
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