November 2020: Treatment of Diabetes – 2020 Updates

Overview and Statistics

  • Diabetes is a chronic disease that affects the way people produce or respond to insulin. It can lead to high blood sugar levels which, over time, damage the body.
  • Diabetes can cause serious health conditions, such as heart disease, vision loss, and kidney disease. Early treatment and management of patients with diabetes is key in minimizing complications.
  • 34.2 million people have diabetes in the United States. This accounts for 10.5% of the US population.1
  • 88 million adults have prediabetes, which accounts for 34.5% of the US population.1
  • It is estimated that more healthcare costs are spent on diabetes than any other condition.2 

Full Guidelines – Standards of Medical Care in Diabetes 2020:

Type 1 & Type 2 Diabetes

Type 1 diabetes is characterized by the loss of pancreatic beta cells, which leads to absolute insulin deficiency. It accounts for 5-10% of diabetes cases in the United states.1 Treatment of type 1 diabetes usually involves coordination of meals and carbohydrate intake along with insulin replacement. Type 2 diabetes is characterized by hyperglycemia and insulin resistance, with some impairment to insulin secretion. Treatment options include oral therapy, injectable therapy, as well as insulin products.

Pharmacologic Therapy3

  • Metformin is the gold standard initial therapy for type 2 diabetes and should be started at the time of diagnosis unless there are contraindications.
  • The choice of treatment beyond initial therapy should be decided based on patient-specific factors, such as cardiovascular disease, chronic kidney disease, obesity, cost concerns, etc.
Figure SEQ Figure\* ARABIC 2: Compelling Indications for Type 2 Diabetes Medication Selection

Key

GLP-1 RA: Glucagon-like peptide-1 receptor agonist
SGLT2: Sodium/glucose linked transporter inhibitor
TZD: Thiazolidinedione
DPP4: Dipeptidyl peptidase-4 inhibitor
ASCVD: Atherosclerotic cardiovascular disease
CKD: Chronic kidney disease
HF: Heart failure

  • Patients with ASCVD, CKD, or HF
    • Patients should be started on GLP-1 RA or SGLT2 inhibitors with proven ASCVD benefit.
      • GLP-1 RA with significant ASCVD benefit: liraglutide and semaglutide
      • SGLT2 inhibitors with significant ASCVD benefit: empagliflozin and dapagliflozin
    • In a patient already on one of these treatments, who’s A1C is above target, consider using a GLP-1 RA together with a SGLT2 inhibitor.
  • Patients with compelling need for weight loss
    • These patients should be started on either a GLP-1 RA with proven efficacy for weight loss or a SGLT2 inhibitor.
      • Semaglutide has been shown to provide the most weight loss benefit of all the GLP-1 RAs.
  • Patients where cost is a major issue
    • Sulfonylureas or TZDs should be considered for their low acquisition cost.
    • If a patient’s A1C is still not at goal, consider using both classes together.
    • Alternative options include basal insulin therapy or lowest cost DPP4 inhibitors.

Diabetes Medication Management Workgroup

In order to further improve the care for those within our network, Affinia Health Network is participating in a statewide collaboration to specifically improve diabetes care. Our goal is to provide primary care clinicians with evidence-based guidance on type 2 diabetes management to improve quality of care, reduce inappropriate (or inefficient) use of pharmaceuticals and lower the cost of care. This collaboration will analyze data, identify opportunities, and develop workflows and interventions to further improve care. For more information, please contact the Affinia Health Network Pharmacy Department at AffiniaPharmacy@mercyhealth.com.

References

  1. National Diabetes Statistics Report, 2020. Center for Disease Control and Prevention. https://www.cdc.gov/diabetes/data/statistics-report/index.html. Reviewed August 28, 2020
  2. Dieleman JL, Baral R, Birger M, Bui AL, Bulchis A, Chapin A, Hamavid H, Horst C, Johnson EK, Joseph J, Lavado R, Lomsadze L, Reynolds A, Squires E, Campbell M, DeCenso B, Dicker D, Flaxman AD, Gabert R, Highfill T, Naghavi M, Nightingale N, Templin T, Tobias MI, Vos T, Murray CJ. US Spending on Personal Health Care and Public Health, 1996-2013. JAMA. 2016 Dec 27;316(24):2627-2646. doi: 10.1001/jama.2016.16885.
  3. Standards of Medical Care in Diabetes, 2020. American Diabetes Association. https://care.diabetesjournals.org/content/43/Supplement_1. Published January 1, 2020.
About the author

PharmD Candidate

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