Empowering Pharmacists asDiabetes Medication Experts

and Educators

In Collaboration with

Objectives

• Quantify the burden of suboptimal management of patients with type 2 diabetes mellitus (T2DM), including rehospitalization, hyperglycemia, and hypoglycemia

• Outline the safety, efficacy, and evidence-based role of newer agents, including incretin-based therapy and sodium glucose cotransporter-2 (SGLT-2) inhibitors in the management of T2DM

• Apply current guidelines and evidence to the review and adjustment of medication regimens in poorly controlled T2DM patients on admission and discharge

• Outline the role of health-system pharmacists as diabetes educators and discuss approaches to optimizing patient counseling

It Is Estimated That…

• 1 in 3 babies born in 2012 will live to 100 years of age

• 1 in 3 babies born in 2000 will develop diabetes

– 2 out of 3 in high-risk ethnic groups

• Therefore, the need for diabetes prevention and education is imperative

– ALL healthcare professionals are needed

Christensen K, et al. Lancet. 2009;374(9696):1196-1208. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/diabetes/news/docs/lifetime.htm. Updated March 12, 2010. Accessed February 23, 2014.

Need for Improved Glycemic Control in the United States

• Glycemic targets must be individualized

• The ADA recommends an A1C of <7% as a reasonable goal for many nonpregnant adults

• Many US adults with diagnosed diabetes do not have an A1C of <7%

ADA = American Diabetes Association.Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379. American Diabetes Association. Diabetes Care. 2013;36(Suppl 11):S11-S66. Cheung BMY, et al. Am J Med. 2009;122:443-453.

Percentage of US Adultswith Diagnosed Diabetes

and AIC <7%70

50

40

30

20

0

10

Pe

rce

nt

(%)

57.1

61.9

44.240.6

Overall

53.960

WhiteNon-

Hispanic

BlackNon-

Hispanic

MexicanAmerican

Other

Suboptimal Glycemic Control Resultsin Hospitalizations

• Individuals with suboptimal glycemic control are at risk for short-term complications that often require hospitalization

• The overall rate of admission for US adults with short-term complications is increasing

*2006 data not available.Agency for Healthcare Research and Quality. National Healthcare Quality Report, 2011. 2012.

70

60

55

50

45

30

35

Ra

te p

er

10

0,0

00

Pe

op

le

Hospital Admissions forShort-Term Complications*

2004

65

2005 2007 2008

Achievable Benchmark

All Patients

40

Poor Glycemic Control Persists in Hospitals in the United States

49,191,313 POC-BG measurements (12,176,299 ICU and 37,015,014 non-ICU values) were obtained from 3,484,795 inpatients (653,359 in the ICU and 2,831,436 in non-ICU areas)

POC = point of care; BG = blood glucose; ICU = intensive care unit.Swanson CM, et al. Endocr Pract. 2011;17(6):853-861.

25

15

35

5

0

Pa

tie

nt

Da

ys (

%)

ICU Non-ICU

32.2

6.3

32

5.7

30

20

10

HyperglycemiaPrevalence(<70 mg/dL)

HyperglycemiaPrevalence(>180 mg/dL)

2014 Standards of Medical Care in Diabetes: Revisions (Hospital Specific)

• IX: Diabetes care in the hospital

– Discharge planning should start at admission

• Clear diabetes management instructions provided

– Elimination of the sole use of sliding scale in the inpatient hospital setting

– All diabetes patients have “diabetes” clearly identified in the EMR

– Order for blood glucose monitoring and goals

– Obtain A1C in patients with risk factors for undiagnosed diabetes with hyperglycemia in hospital

American Diabetes Association. Diabetes Care. 2014;37:(Suppl 1):S14-S80.

OAD = oral antidiabetic; IV = intravenous; SC = subcutaneous; ACE = American College of Endocrinology; ADA = American Diabetes Association. ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care. 2006 & 2009. Diabetes Care. 2009;31Suppl 1):S1-S110. Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97(1):16-38.

IV InsulinCritically ill patients, ICU

Adjusted to maintain BG 140-180 mg/dL and

pre-meal BG <140 mg/dL

SC Insulin(basal, prandial, correction)

Noncritically ill patientsAdjusted to maintain

pre-meal BG <140 mg/dL andrandom BG <180 mg/dL

2014 Standards of Medical CareIX: Diabetes Care in the Hospital

OADs Not generallyrecommended

Insulin Recommended

Antihyperglycemic Therapy

Medication Reconciliation

Obtain a complete an

accurate medication list

Review medication list

dailyfor changes

from previous

Reconcileeach

discrepancy

Reconcile any discrepancy

between medications on admission and

discharge*

Hospital Stay DischargeAdmission

Repeat at each point of transition

2014 Standards of Medical CareIX: Diabetes Care in the Hospital

*To ensure continuity of care across care settings, effective transfer of information should include timely, accurate, and complete documentation of discharge medications.Cua YM, et al. Ann Acad Med Singapore. 2008;37(2):136-141.

Medication Reconciliation

Medication-Related Patient Care Concerns

• Medication errors cause at least one death every day and injure approximately 1.3 million people annually (United States)

• Delays in treatment and medication nonadherence are the major reasons behind avoidable costs in the healthcare system

– Avoidable costs >$200 billion are incurred each year in the US healthcare system, representing 8% of the country’s total annual healthcare expenditures

• Significant cost to patients

• Unnecessary utilization of healthcare resources

• $400 million hospital visits (annually)

Medication error reports. Food and Drug Administration Web site. http://www.fda.gov/Drugs/ DrugSafety/MedicationErrors/ucm080629.htm. Updated March 5, 2009. Accessed February 28, 2014. Identify those who need adherence help. Modern Medicine Web site. http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/ identify-those-who-need-adherence-help. Published July 15, 2013. Accessed February 28, 2014.

Clinical Inertia

• Delays in evidence-based treatment to patients

– > $40 billion per year in avoidable costs

• Diabetes is the largest avoidable impact to the US healthcare system

– Delays increased outpatient visits and hospitalizations

• Keys to adherence:

– Identifying patients with chronic conditions

– Creating a program that focuses on patients engagement

Identify those who need adherence help. Modern Medicine Web site. http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/ identify-those-who-need-adherence-help. Published July 15, 2013. Accessed February 28, 2014.

Time Since Diabetes DiagnosisIs Key in Adherence

• Less adherent:

– Newly diagnosed T2DM patients

• Possibly due to lack of routine

– Fewer medications

• More adherent:

– Patients with long-standing T2DM

– More medications

– Older

MedPage Today. Time Since Diabetes Dx Key in Adherence. http://www.medpagetoday.com/ MeetingCoverage/ADA/40092. Accessed February 27, 2014.

Adherence Declinesover First Year of Therapy

Adapted from Medication Adherence: Working Together to Achieve Better Treatment Outcomes. Merck 2010.

80

70

100

90

60

50

40

30

20

0

10

Feb

Ad

he

ren

ce

(%

)

Asthma

Dyslipidemia

Diabetes

Hypertension

Jan AprMar JunMay AugJul OctSep DecNov

The Need for a Pharmacist

• The US healthcare system currently functions (is paid) in an Acute Care model of care

– Wait until there is a problem then fix it

• The need is to move to a Chronic Care model (CCM)

– Prevent the problem from occurring

• In the CCM, pharmacists have a crucial role

– Medication therapy management

– Medication reconciliation

– Medication education

– Medication adherence assessment and improvement

Optimizing the Pharmacist’s Role

• Many pharmacists to practice (work) in silos

– Familiar with their position and their job

– May have insight to a few other practice environments

– Most rarely step out of their silo to learn or explore the expansion of the field

• This unawareness is carried over to the public, other healthcare professionals, and legislators

• Pharmacists are keenly aware of their capabilities. However, people outside the profession are not as in-tune

– The public, patients, and other healthcare disciplines are often uninformed or misinformed regarding the role of a pharmacist and the education and training necessary to become a licensed practitioner

Cornell S. Illinois Pharmacist. Spring 2011.

Patients at Risk for Readmission

• Inpatient diabetes education seems to reduce readmissions

– Complex diabetes patients vulnerable to multiple complications

• Retrospective study – 30-day analysis

– 2265 patients with type 1 and type 2

– A1C >9%

– 43% received inpatient diabetes education

• Result

– 34% reduction in readmission at 30 days

ADA 2013 Scientific Sessions.

Transition to Outpatient Status

• Begin discharge planning early

• Stabilize BG prior to discharge

• Obtain A1C for discharge planning if the result is not available from the previous 2 to 3 months

– A1C can now be used as a means to make the diagnosis of diabetes

Moghissi ES, et al. Endocr Pract. 2009;15(4):353-369.

Discharge Planning: New Hyperglycemia

A1C General Guidelines

<5.2% Patient does not have diabetes nor prediabetes

5.2% to 6%Patient has prediabetes (at risk); repeat screening and follow-up advisable; consider diabetes prevention strategies

6.1% to 7%Patient will likely be diagnosed with diabetes in near future; can be treated with lifestyle modifications; discharge on a diabetic diet

7.1% to 9%Patient will likely be diagnosed with diabetes in the future; treat with diet, exercise, and/or a low dose oral agent

>9%Most patients would likely benefit from basal-bolus insulin regimen at discharge

Society of Hospital Medicine Glycemic Control Task Force. Workbook for Improvement.http://www.hospitalmedicine.org/ResourceRoomRedesign/pdf/GC_Workbook.pdf. Accessed February 27, 2014.

Discharge Planning: Diagnosed Diabetes

A1C General Guidelines

<7% Continue preadmission diabetes management therapy plan

7% to 8%Increase dose of preadmission diabetes medications and/oradd a second/third oral agent or basal insulin at bedtime

>8% If on 2 diabetes medications, add basal insulin at bedtime

9% to 10% Most patients should be on basal-bolus insulin at discharge

Society of Hospital Medicine Glycemic Control Task Force. Workbook for Improvement.http://www.hospitalmedicine.org/ResourceRoomRedesign/pdf/GC_Workbook.pdf. Accessed February 18, 2014.

Focus on Selection of Pharmacotherapy for T2DM

• Desired drug effects

– Efficacious

– Protect remaining β-cell function

– Minimize hypoglycemic risks

– Minimize weight gain

– Minimize adverse effects and drug interactions

– Cardiovascular benefit

Patients Are Willing to Pay More to Avoid Weight Gain or to Lose Weight

• Patients Value

– Weight loss/avoiding weight gain

– Avoiding hypoglycemia

– Avoiding injection

– Efficacy

– Avoiding nausea

Jendle J, et al. Curr Med Res Opin. 2010;26:917-923.

Willingness-to-Pay($ USD / month)

A1C (1%)

Avoid Injection

Avoid Nausea

Avoid 1 kg wt

AvoidHypoglycemia

Weight (1 kg)

20 400 10 30

35

11

13

17

24

26

Meta-Analysis: Weight Changes with Antihyperglycemic Agents Added to Metformin

AGI = ɑ-glucosidase inhibitor; DPP-4i = DPP-4 inhibitor; GLP-1 RA = glucagon-like peptide-1 receptor agonist; SU = sulfonylurea; TZD = thiazolidinedione; SGLT-2i = sodium glucose cotransporter 2 inhibitor.Liu S, et al. Diabetes Obes Metab. 2012;14:810-820.

1

5

-3

-5

∆ W

eig

ht

(kg

)

3

-1

BiphasicInsulin

3.41

TZD Glinide DPP-4i GLP-1RA

SU BasalInsulin

AGI

2.462.17

1.40 1.38

0.23

-1.01-1.66

GLP-1 RA, DPP-4 Inhibitors, SGLT-2 Inhibitors

Highlighted forAvoiding

Weight Gain

0

4

-4

2

-2

-3.5

SGLT-2i

Hypoglycemic Risk ofAntihyperglycemic Agents Added to Metformin

Liu S, et al. Diabetes Obes Metab. 2012;14:810-820.

15

25

5

0

Od

ds

Ra

tio

vs

Pla

ce

bo 20

10

BiphasicInsulin

17.8

Glinide BasalInsulin

GLP-1RA

AGISU DPP-4i TZD

10.58.9

4.8

1.1 0.9 0.5 0.4

Increased Risk vs Placebo

No Increased Risk vs Placebo

SGLT-2i

0.6

GLP-1 Agonists and DPP-4 Inhibitors

DPP-4 Inhibitors

Drug Expected Decreasein A1C (%)

Sitagliptin(Januvia ®)

0.6

Saxagliptin(Onglyza ®)

0.73

Linagliptin(Tradjenta ®)

0.51

Alogliptin(Nesina ®)

0.6

GLP-1 Agonists

DrugExpected

Decrease in A1C (%)

Exenatide 10 mcg BID(Byetta ®)

0.8-1

Liraglutide 1.8 mg QD(Victoza ®)

1-1.6

Exenatide 2 mg QW(Bydureon ®)

1.8-2.1

Albiglutide 30-50mg QWTanzeum ®)

0.8-1

Dulaglutide 0.75 – 1.5 mg QW(Trulicity ®)

0.8-1.1

Drucker DJ, et al. Lancet. 2008;372(9645):1240-1250.

Blonde L, et al. Diabetes Obes Metab. 2009;11(Suppl 3):26-34.

Ahren B. Best Pract Res Clin Endocrinol Metab. 2007;21(4): 517-533.

Buse JB, et al. Diabetes Care. 2010;33(6):1255-1261.

Gomis R, et al. Diabetes Obes Metab. 2011;13(7):653-661.

BID = twice daily;

QD = once daily;

QW = once weekly.

Comparing Actions of DPP-4 inhibitors and GLP-1 RAs

• DPP-4 inhibitors

– Oral administration

– Block DPP-4 degradation of GLP-1

– Increase endogenous GLP-1 levels ≈ 2-fold

• GLP-1 RAs

– Subcutaneous administration

– Add exogenous GLP-1 activity

– Increase GLP-1 activity ≈ 9-fold

– Greater A1C and weight effects than DPP-4 inhibitors

EXN BID = exenatide twice daily; SITA = sitagliptin.DeFronzo RA, et al. Curr Med Res Opin. 2008;24:2943-2952. Inzucchi S, et al. Diabetes Care. 2012;35:1364-1379.

80

70

50

30

20

0

10

2-H

ou

r P

os

tpra

nd

ial

Pla

sm

a L

ev

el (

pM

)

15

Percentage of US Adultswith Diagnosed Diabetes

and AIC <7%

Baseline SITA EXN BID

64

7

EndogenousGLP-1 Level

GLP-1RA Level

60

40

Approved and Standard Investigational Doses of DPP-4 Inhibitors

AgentStandard

Dose

ModerateRenal

Impairment

Severe Renal Impairment

or ESRDMetabolism Elimination

Linagliptin 5 mg 5 mg 5 mg

~90% eliminated unchanged;

exposure decreasedby CYP3A4 orP-gp inducers

Primarilyenterohepatic (80%);

renal, 5%

Saxagliptin2.5 or 5 mg

2.5 mg 2.5 mg

Hepaticallymetabolized to

active metabolite via CYP3A4/5

Primarily renal(24% as parent compound,

36% as metabolite);also hepatic

Sitagliptin 100 mg 50 mg 25 mgNot appreciably

metabolized

Primarily renal(~79% excreted

unchanged by kidney)

Alogliptin 25 12 6.25Not appreciably

metabolized

Primarily renal(up to 71% excreted

unchanged by kidney)

CYP = sytochrome P450; P-gp = P-glycoprotein.Tradjenta [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc; 2012. Onglyza[package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2011. Januvia [package insert]. Whitehouse Station, NJ: Merck & Co, Inc; 2010. Andukuri A, et al. Diabetes Metab Syndr Obes. 2009;2:117-126. Deacon CF. Diabetes Obes Metab. 2011;13(1):7-18.

Pharmacologic and Pharmacokinetic Differences among GLP-1 Agonists

AgentDose Frequency and

Timingtmax

t1/2

Initial Dose (Duration)

Regular Dose

Elimination

Exenatide BIDBID; within 60 minutes

before morning and evening meals

2.1 hours2.4 hours

5 µg (1 month)

5 µg or 10 µg

Mainly renal; not recommended for patients with ESRD or severe renal

impairment

Liraglutide QD; any time of day8-12 hours13 hours

.6 mg (1 week)

1.2 mg or 1.8 mg

Mainly metabolized by proteolytic degradation; use caution in patients

with renal impairment

Exenatide QW QW; timing not specified2-7 weeks

N/A2 mg 2 mg Renal

Albiglutide QW; timing not specified3-5 days6-7 days

30 mg30 mg or 50

mg

Mainly metabolized by proteolyticdegradation; use caution in patients

with renal impairment

DulaglutideQW; timing not specified

2-4 weeksN/A 0.75mg 0.75 -15 mg

Mainly metabolized by degradation into its component amino acids by general protein catabolismpathways.

tmax = maximum life; t1/2 = half-life; ESRD = end-stage renal disease.

Byetta [package insert]. San Diego, CA: Amylin Pharmaceuticals, Inc; 2011. Victoza [package insert]. Bagsvaerd, Denmark: Novo Nordisk A/S; 2013. Bydureon [package insert]. San Diego, CA: Amylin Pharmaceuticals, Inc; 2012. Gilbert MP, et al. Am J Med. 2009;122(suppl 6):S11-S24. Bischoff LA, et al. Expert Opin Pharmacother. 2011;12(8):1297-1303. St Onge EL, et al. Expert Opin Biol Ther. 2010;10(5):801-6. Umpierrez GE, et al. Diabetes Obes Metab. 2011;13(5):418-425. Christensen M, et al. Expert Opin Investig Drugs. 2011;20(4):549-557.

Sodium Glucose Cotransporter-2 (SGLT-2) Inhibitors

Name Lead Company Phase

Canagliflozin(Invokana ®)

Janssen Approved March 29, 2013

Dapagliflozin(Farxiga ®)

Bristol-Myers Squibb Approved January 28, 2014

Empagliflozin(Jardiance ®)

Boehringer Ingelheim Approved August 1, 2014

Ipragliflozin Astellas Pharma III(approved in Japan)

Tofogliflozin Chugai Pharmaceutical III

LX4211* Lexicon Pharmaceuticals IIb

*LX4211 is a dual sodium-dependent glucose co-transporter 1 (SGLT-1) and SGLT-2 inhibitor.

Jones D. Nature Reviews Drug Discovery. 2011;10(9):645-646.

(180L/day)(1000mg/L)=180g/day

10%

Glucose

No Glucose

S1

S3

Glucose Regulation by the Kidney

SGLT‐2

90%

SGLT=

Sodium‐glucose

co‐transport

SGLT‐1

SGLT‐2 is located at S1 proximal  tubular cell membrane (lumen) : 

• Low affinity, high capacity for glucose  (Na/K electro‐chemical gradient)

• Nearly exclusively expressed in the kidney

• Responsible for ~90% of  total  renal glucose reabsorption

S1ProximalTubule

Na+

K+

ATPase

Glucose

GLUT2

Glucose

SGLT‐2 Interstitial Fluid  ‐ Blood

Filtrate ‐Urine Lumen

Na+

SGLT‐2MediatesGlucoseReabsorption intheKidney

GLUT2  is located at the baso‐lateral membrane  facing  (interstitial space): 

• Facilitated glucose transport  ‐ glucose concentration gradient 

• Restores glucose to circulation (Reabsorbed + Gluconeogenesis)

• Proximal tubules cannot oxidize glucose (FFA‐energy dependent)

Comparison of SGLT-2 Drugs: Dapagliflozin vs Canagliflozin

Dapagliflozin Canagliflozin

Population size (n) 282 584

Duration of study (weeks) 24 26

Power met Yes; 90% Yes; 90%

HbA1c reduction (%) -0.68 to -0.82 -0.77 to -1.03

FPG reduction (mmol/L) -0.61 to -1.58 -1.5 to -1.9

Proportion of patients with HbA1c <7%

38.9% to 55.6%(NS in D2.5 and D5 groups)

44.5% to 62.4%

Weight reduction (kg) -2.64 to -2.69 -2.8 to -3.9

NS = not significant.

Bailey CJ, et al. Diabetes Obes Metab. 2012;14(10):951-959.Stenlof K, et al. Diabetes Obes Metab. 2012. [Epub ahead of print].

Inzucchi SE, et al. Diabetes Care. 2012;35(6):1364-1379.

Healthy Eating, Weight Control, Increased Physical Activity

HighModerate riskGainHypoglycemiaLow

HighLow riskGainEdema, HF, fx’sHigh

IntermediateLow riskNeutralRareHigh

HighLow riskLossGIHigh

HighestHigh riskGainHypoglycemiaVariable

HighLow riskNeutral / lossGI / lactic acidosisLow

Metformin

If needed to reach individualized HbA1c target after~3 months, proceed to two-drug combination(order not meant to denote any specific preference)

Efficacy (HbA1c)HypoglycemiaWeightMajor side effect(s)Costs

Efficacy (HbA1c)HypoglycemiaWeightMajor side effect(s)Costs

More ComplexInsulin Strategies

Three-DrugCombinations

Two-DrugCombinations

Initial DrugMonotherapy

Insulin (multiple daily doses)

*Order of medications listed are a suggested heirarchy of usage; †Based upon phase 3 clinical trials data.Copyright © 2013 AACE.

Glycemic Control Algorithm*,†

Lifestyle Modification (Including Medically Assisted Weight Loss)

Progression of Disease

ENTRY A1c <7.5% ENTRY A1c ≥7.5%

Few Adverse Eventsor Possible Benefits

Use with Caution

ENTRY A1c >9.0%

DUALTHERAPY

SYMPTOMS

TRIPLETHERAPY

NO SYMPTOMS

OR

INSULIN±

OTHERAGENTS

ADD or INTENSIFY INSULIN

Agent Favor Avoid

DPP4s • Close to A1c target • High PPG• Advanced CKD (dose adjust)• ‘Side‐effect prone’

• h/o pancreatitis• h/o urticaria, angioedema • Self‐pay

GLP‐1s • Obese• ‘Weight‐obsessed’ • High PPG (shorter acting)• High FPG (longer acting)

• ‘Needle‐phobes’• h/o pancreatitis• CKD (eGFR<30) – exenatide• Baseline GI disease/ sxs• Gastroparesis• Medullary ca / MEN‐2• Self‐pay

SGLT‐2s • Obese• High FPG• Need additional BP reduction • ? Heart failure

• h/o yeast infections• h/o UTIs (?)• CKD (eGFR<45)• Baseline orthostatic sxs• h/o stroke (?)• Self‐pay

Considerations with Newer Agents

Weight Effect

Hypoglycemiaβ-Cell

ProtectionCVD

BenefitsCost Other Considerations

AGIs Neutral Low risk Possible Possible $ to $$GI adverse effects (gas),

dose frequency

Amylinomimetic Loss Low risk Possible Yes $$GI adverse effects (nausea), injectable, dose frequency

Bile Acid Sequestrant

Neutral or loss

Low risk Possible Yes $$GI adverse effects

(constipation), dose frequency

Biguanides Loss Low risk Possible Yes $GI adverse effects (diarrhea), renal and hepatic impairment

DPP-4 Inhibitors (gliptins)

Neutral Low risk Possible Yes $$$ Minimal adverse effects

Dopamine Agonist

Neutral or loss

Low risk Unknown Yes/no $$$GI adverse effects (nausea),

hypotension, dizziness

GLP-1 Agonists Loss Low risk Possible Yes $$$GI adverse effects (nausea),

injectable

InsulinGain or

loss Risk–bolus

Low risk–basalPossible Possible $ to $$

Injectable, dose frequency (bolus), increased SMBG

SecretagoguesSulfonylureas and Glinides

Gain Risk No $ to $$Immediate short-term

response, increased SMBG, dose frequency (glinides)

TZDs (glitazones) Gain Low risk Possible Yes/no $$

4-8 weeks for response, redistribution of SC/visceral fat,

edema, bone loss, fracture, bladder cancer

FPG = fasting plasma glucose; PPG = postprandial glucose; GI = gastrointestinal; SMBG = self-monitoring of blood glucose. Unger J, et al. Postgrad Med. 2010;122(3):145-157. Cornell S, et al. Postgrad Med. 2012;124(4):84-94.

Patient Cases

Patient JC

• JC is a 79-year-old patient with T2DM x 12 years

• A1c is 8.1% (x 4 years); BMI – 25 kg/m2; SCr – 1.1 mg/dL

• Metformin 1000 mg BID

• Glimepiride 4 mg daily

• JC is discharged from the hospital following a hypoglycemic event; He resides in an assisted living apartment & has limited mobility

absent

absent

severe

severe

few / mild

few / mild

Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.

More Stringent Less StringentPatient attitude andexpected treatment efforts

highly motivated, adherent,excellent self-care capacities

less motivated, non-adherent,poor self-care capacities

Risks potentially associated with hypoglycemia, other adverse events

low high

Disease durationnewly diagnosed long-standing

Life expectancylong short

Important comorbidities

Resources, support systemreadily available limited

Established vascular complications

Approach to Management of Hyperglycemia

Case Considerations

• JC has had T2DM for 12 years

– Aggressive therapy and tight BG control may not be warranted

• May do more harm than good

– A1c goal would be acceptable near 7.5%

– A1c needs ~0.5% lowering

• Need to target postprandial, as well as fasting blood glucose

– A1c of 8.1% is ~ 50% fasting & 50% postprandial

• Adverse effects must be considered

– Weight loss may not be necessary

– Risk of hypoglycemia must be minimized

– GI side effects should be considered

Possible Pharmacotherapy for JC

A1c Lowering Potential &BG target

Weight Effect

Hypoglycemiaβ-Cell

ProtectionOther Considerations

Increase Metformin1.5%FPG

Loss Low risk PossibleNo benefit at doses

> 2000mg/day

IncreaseSulfonylurea

1.5-2.0%FPG & PPG

Gain + risk No Increase risk of hypoglycemia

Add a TZD (glitazone)

1.0-1.5%FPG & PPG

Gain Low risk Possible

4-8 weeks for response, redistribution of

subcutaneous/visceral fat, ADRs: edema, bone loss

Add Basal insulin(long-acting)

Open to targetFPG

Gain or neutral

Low risk PossibleBest A1c lowering, injectable (may be complicated to use)

Add a GLP-1 Agonist

0.8-1.9%Short – PPG

Long – FPG & PPG

Loss Low risk Possible

GI adverse effects(nausea), cost,

injectable(may be complicated to use)

Add a DPP-4 Inhibitor

0.5-0.7%PPG

Neutral Low risk Possible Minimal adverse effects, cost

Add aSGLT-2 Inhibitor

0.6-1.0%FPG

Loss Low risk Possible UTI and urogenital infections

Planning the Future of Pharmacy

• What can you do in your practice to enhance the role of the pharmacist?

• Focus on Transition from Hospital to the Community

– Identify patients at risk for readmission

– Establish a hospital-run or community-based liaison programs

– Improve hospital to community communications

Conclusion

• The role of the pharmacists continues to evolve

– Especially in primary care and transitional care models

• As the United States moves from an Acute Care model of care to a Chronic Care model, pharmacists have a crucial role

– Medication therapy management

– Medication reconciliation

– Medication education

– Adherence assessment and improvement

• Pharmacists need to perform at the level of their training

– Step out of your silo and show others what we can do