Diabetes Treatment Guidelines 2019

Long time coming…

but I’m back. Will try using this site as place to collect clinical pearls and educational resources from around the internets. Up first- Diabetes.

There are many new treatments for DM, and I can’t keep the initials straight, so first up, my round-up of DM treatments.

Metformin- first line therapy along with lifestyle modification.

GLP-1 RA: end in “glutide”. These are all injectable, some now once weekly. Some have proven CVD reduction benefits. In order of CVD benefit: Liraglutide (Victoza/Saxenda), Semaglutide (Ozempic), Exanatide (Byetta/Byderon).

SGLT2i: end in “gliflozin” These also have been shown to reduce CVD events, along with heart failure and progression of CKD. Empagliflozin (Jardiance) and Canagliflozin (Invokana) are examples.

DPP-4i: “Gliptins” Work by increasing Incretin, which helps the body make insulin when needed, and decreases glucose creation in the liver. Sitagliptin (Januvia) and Saxagliptin (Onglyza) are examples.

These are the most updated Standards of Care in DM, published Jan 2019. Here are the AACE executive summary and slide decks. 

I am teaching about treatment of DM, so here are some of the most relevant figures. Smart people have also told me that there is a great app with these algorithms. Search AACE Type 2 Diabetes.

First and Second line Treatments

Adding Injectable Medicines

And because conflict is interesting, here are the ACP guidelines for DM published last year, which set off a bit of a firestorm between Internists and Endocrinologists. The main differences have to do with treatment targets. ACP recommends aiming for HbA1c between 7-8% for most patients, and even higher for patients with less than 10 years life expectancy, nursing home patients, or with other chronic diseases. They feel we should focus on limiting harms and avoiding hypoglycemia in this population.   The ADA suggests keeping HbA1c less than 7% for most patients, with tighter targets for healthier patients who are doing well with current treatment, or those with cardiovascular disease. They are OK with higher HbA1c targets (<8%) in those who have demonstrated hypoglycemia, limited life expectancy, or comorbidities.

Enjoy!!

A case for exercise, continued

So…. the whole commenting thing didn’t work out so well.  I choose to believe that many tried and failed, rather than that I’m talking to myself over here.   So, here’s my take on our case.  Disagree? Something to add?  Speak up on Twitter (follow @ihaterashes)

 Our case..

You have a 58 year old white male patient who you’ve seen 4-5 times in your continuity clinic.  He has diabetes (uncontrolled, with HbA1c 9.5%), HTN (typically reads low 150s/90s in clinic), and hyperlipidemia (guess what?  He refuses medicines).  Oh, and his BMI is 36.

You’ve been harping on the miraculous benefits of diet and exercise all this time, and he’s finally decided to give it a try. He tells you that he’s joined Crossfit and is ready to start exercising, once you give the OK.

Does he need some testing before you give the “OK”?  The commercials say, “Talk to your doctor before starting an exercise program.”  So what are we supposed to say or do?

For low/average risk patients there is no benefit to screening for asymptomatic coronary disease. The ACC has added stress testing in asymptomatic individuals to their list of tests to avoid in the ABIM’s Choosing Wisely Initiative. 

But our patient has diabetes, so he’s not low risk.  Not only that, but he has uncontrolled hypertension and hyperlipidemia, so he most certainly has as much risk for a cardiac event as someone who has had an MI.   In fact, if you follow the Choosing Wisely link above, you note there is a caveat for patients with diabetes over age 40.  So, should we screen him?

Some guideline writers, including the American College of Cardiology, recommend stress testing in asymptomatic diabetics over 40.   The ADA says that EKG exercise testing may be indicated for those diabetics starting an exercise program if: they are over 40, over 30 with signs of advanced diabetes (nephropathy, retinopathy), smokers, or have renal failure due to their diabetes.  

So the guideline writers would screen our patient.  Here’s my concern though, what are we going to do with the information?  He already needs aggressive medical therapy (which he’s not really getting). Perhaps we would do best to just focus on that. Should we revascularize if significant ischemia is found?  

There was one trial, DIAD, which randomized 1123 asymptomatic diabetic patients to screening with adenosine MIBI vs no screening. These patients were largely well controlled with aggressive medical management, and the overall cardiac event rate was only 3% for the whole group. There was no difference in the screened and unscreened groups, however, our patient is so uncontrolled on all risk factors, I’m not sure he fits in.  Our pre-test probability of coronary disease is likely higher than 3%, even without symptoms. 

What about the exercise itself?  I’ve not done CrossFit myself, but it looks fairly intense, with a lot of callisthenic type exercises done fast enough to get an aerobic benefit.  I would be afraid that if he jumped right into an intense “boot camp” like experience like CrossFit, that he might injure himself and then quit exercise all together. It is a tricky thing to encourage exercise, but in such a way that it is more likely to stick as a lifestyle change, rather than a month or so of intermittent involvement that quickly fades away.   

So, I would probably applaud him for his initiative, but ask him to take it a little easy and work on a simple paced exercise program to start.  I would ask a lot of questions to convince myself that he really is asymptomatic, and have a very low threshold for getting stress testing (ideally with exercise MIBI).  You could refer him to cardiopulmonary rehab, so that he could get close monitoring of his HR and BP during exercise (assuming he could pay for it- insurance likely will not).  At the same time, he needs to get his risk factors under control– start a statin, titrate his HTN and diabetic medicines. Certainly give him clear warnings of angina or even anginal equivalents that he might experience, with direction to stop if he does.

Thanks to all for the patience with my blog issues.  New site is coming soon, hopefully with fewer technical difficulties!

A case for exercise

Did you miss me?  Various things have kept me away from the blog for a while, but I thought I’d come back with a case.

You have a 58 year old white male patient who you’ve seen 4-5 times in your continuity clinic.  He has diabetes (uncontrolled, with HbA1c 9.5%), HTN (typically reads low 150s/90s in clinic), and hyperlipidemia (guess what?  He refuses medicines).  Oh, and his BMI is 36.

You’ve been harping on the miraculous benefits of diet and exercise all this time, and he’s finally decided to give it a try. He tells you that he’s joined Crossfit and is ready to start exercising, once you give the OK.

He wants to know:

  1. Don’t I need to have a stress test or something?  My dad got one every year before his last heart attack.
  2. How much exercise should I doing?  WHAT should I be doing? Can I just jump right in on the Workout of the Day?
What do you think? How would you answer him? If you aren’t sure what to say, vent about your patients like this (in a HIPAA compliant way, of course), or strategize how to get patients to exercise in the first place.  Or just tell me hello- let me know you are out there.  Any comments are appreciated.  And stay tuned,  some resolution and some more questions to come later this week.
Don’t be a Lurker, leave a comment!