435 - Diabetes Standards of Care (Part 2) – Medications, Let’s “Yz”-up

From the Guidelines and the American Diabetes Association (ADA)

1) Diabetes Standards of Care 2022 (Part 2) – Medications

The Standards are developed by the ADA’s multidisciplinary Professional Practice Committee, which comprises physicians, diabetes educators, and other expert diabetes healthcare professionals. The Standards include the most current evidence-based recommendations for diagnosing and treating adults and children with all forms of diabetes.  The ADA’s grading system uses A, B, C, or E to show the evidence level that supports each recommendation.  This is the 2^nd part of a two-part summary.

Pharmacotherapy Recommendations – Prediabetes:

·         Metformin for prevention of T2D should be considered in those with prediabetes, especially for those with BMI ≥35, those aged <60 years, women with prior gestational DM, and/or those with rising A1C despite lifestyle intervention. A

·         Periodic measurement of vitamin B12 levels should be considered in metformin- treated patients, especially in those with anemia or peripheral neuropathy. B

Pharmacotherapy Recommendations- Type 2 Diabetes (T2D):

·         First-line therapy must be customized and generally includes metformin and comprehensive lifestyle modification. A

·         Other medications (glucagon-like peptide 1 [GLP-1] receptor agonists, sodium–glucose cotransporter 2 [SGLT2] inhibitors), with or without metformin based on glycemic needs, are appropriate initial therapy for individuals at high risk for ASCVD, heart failure (HF), and/or chronic kidney disease (CKD). A

·         Metformin should be continued upon initiation of insulin therapy (unless contraindicated or not tolerated) for ongoing glycemic and metabolic benefits. A

·         Early combination therapy reasonable in some patients at treatment initiation. A

·         Early introduction of insulin should be considered if evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10%) or blood glucose levels (≥300) are very high. E

·         For those with established ASCVD or indicators of high CV risk, established CKD, or HF, an SGLT2 and/or GLP-1 with demonstrated CVD benefit recommended independent of A1C and in consideration of patient-specific factors. A

·         A GLP-1 is preferred to insulin when possible. A

·         If insulin is used, combination therapy with a GLP-1 is recommended for greater efficacy and durability of treatment effect. A

·         Be aware of the potential for overbasalization with insulin therapy. Clinical signals that may prompt evaluation of overbasalization include basal dose more than 0.5 IU/kg/day, high bedtime-morning or post-preprandial glucose differential, hypoglycemia (aware or unaware), and high glycemic variability. Indication of overbasalization should prompt reevaluation to further individualize therapy. E

Hypertension/Blood Pressure Control in T2D – Recommendations:

·         All hypertensive patients with DM should monitor their blood pressure at home. A

·         Confirmed office-based BP ≥140/90 should, in addition to lifestyle therapy, have prompt initiation and timely titration of medication to achieve BP goals. A

·         Confirmed office-based blood pressure ≥160/100 should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce CV events. A

·         Treatment for HTN should include drug classes demonstrated to reduce CV events. A  ACE inhibitors or ARBs recommended first-line therapy for HTN with CAD. A

·         Those not meeting BP targets on three classes of BP medications (including a diuretic) should be considered for a mineralocorticoid receptor antagonist (MRA). B

Statin Treatment in T2D – Recommendations:

Primary Prevention:

·         Aged 40–75 without ASCVD, use a moderate-intensity statin therapy. A

·         Aged 20–39 years with additional ASCVD risk factors, it may be reasonable to initiate statin therapy in addition to lifestyle therapy. C

·         With higher risk, especially with multiple ASCVD risk fctors or aged 50–70 years, it is reasonable to use high-intensity statin therapy. B

·         With 10-year ASCVD risk of > 20%, reasonable to add ezetimibe to maximally tolerated statin therapy to reduce LDL cholesterol levels by 50% or more. C

Secondary Prevention

·         For all ages with T2D and ASCVD, high-intensity statin therapy should be added to lifestyle therapy. A

·         For ASCVD considered very high risk using specific criteria, if LDL cholesterol is ≥70 mg/dL on maximally tolerated statin dose, consider adding additional LDL-lowering therapy (such as ezetimibe or PCSK9 inhibitor). A

·         If intolerant of intended intensity dose, use maximally tolerated statin dose. E

·         For >75 already on statin therapy, reasonable to continue statin treatment. B

·         For >75 years, reasonable to initiate statin after discussion of risks/benefits. C

·         Statin therapy is contraindicated in pregnancy. B

Other lipoprotein targets:

·         With fasting triglyceride levels ≥500, evaluate for secondary causes and consider medical therapy to reduce the risk of pancreatitis. C

·         With ASCVD or other CV risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135–499 mg/dL), consider addition of icosapent ethyl.  A

Other Combination Therapy:

·         Statin plus fibrate combination therapy has not been shown to improve ASCVD outcomes and is generally not recommended. A

·         Statin plus niacin therapy has not been shown to provide additional CV benefit above statin therapy alone and may increase stroke risk, so is not recommended. A

 Antiplatelet Agents and T2D – Recommendations:

·         Use aspirin therapy (75–162 mg/day) for secondary prevention with a history of ASCVD. A  For aspirin allergy – clopidogrel (75 mg/day). B

·         Long-term treatment with dual antiplatelet therapy should be considered for prior coronary intervention, high ischemic risk, and low bleeding risk to prevent major adverse CV events. A

·         Aspirin therapy (75–162 mg/day) may be considered as primary prevention in those with increased CV risk, after a comprehensive discussion of benefits/risks. A

Patients with T2D and established ASCVD:

·         With established ASCVD, multiple ASCVD risk factors, or CKD, a SGLT2 and/or GLP-1 with demonstrated CVD  benefit is recommended.  A

·         With established heart failure with reduced ejection fraction (HFrEF), a SGLT2 with proven benefit recommended to reduce risk of worsening HF and CV death. A

·         With stable heart failure, metformin may be continued for glucose lowering if e-GFR remains >30 but should be avoided in unstable or hospitalized patients with HF. B

Patients with T2D and CKD/DKD (diabetic kidney disease) –  Recommendations:

·         Use a SGLT2 inhibitor with an e-GFR ≥25 and urinary albumin ≥300 to reduce CKD progression and CV events. A

·         Consider use of SGLT2 inhibitors additionally for CV risk reduction when e-GFR and urinary albumin creatinine are ≥25 or ≥300, respectively. A

·         With ≥300 mg/g urinary albumin, a reduction of 30% or greater in mg/g urinary albumin is recommended to slow CKD progression. B

·         Do not discontinue renin-angiotensin system blockade for minor increases in serum creatinine (≤30%) in the absence of volume depletion. A

·         An ACE inhibitor or an angiotensin receptor blocker is not recommended for the primary prevention of CKD if normal BP, normal urinary albumin-to-creatinine ratio (<30 mg/g creatinine), and normal e-GFR rate. A

Pharmacotherapy for Obesity/Weight Loss in T2D – Recommendations:

·         Nearly all FDA-approved medications have been shown to improve glycemic control and delay progression to diabetes for those at risk.

·         If response is effective (typically defined as >5% weight loss after 3 months’ use), further weight loss is likely with continued use. When early response is insufficient (typically <5% weight loss after 3 months’ use) or if significant safety/tolerability issues, consider discontinuation of the medication.  A

Mark’s Comments:

I’ve also attached 3 very helpful algorithms/summaries (2 attachments) for prescribing/intensifying non-insulin medications, prescribing/intensifying insulin, and comparing all the medications with their indications, strengths, and limitations.  These would be worth saving and/or printing for future reference.   

References:

·         ADA Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers.  Clin Diabetes January 2022;40(1):10–38.  Link

·         DM Standards of care 2022.  Diabetes Care January 2022;45(Supplement 1).  Link

From PeerRxMed ( www.PeerRxMed.org )

2)  Let’s “Yz”-up!  No One Should Care Alone … Ever

“Why is it important to swim with a buddy?”  Our local YMCA swim instructor

One of the inspirations for the PeerRxMed process was the YMCA youth swimming program and in particular, their “buddy system” for swimmers.  I learned to swim at the “Y”, and prior to the pandemic, was a regular fixture at our local branch.   Before a children’s swimming class gets in the pool, the instructor always asks, “Why is it important to swim with a buddy.”  The most common answer is an enthusiastic “So somebody is watching out for you!”, often followed closely by “So you don’t drown!” and “Because it’s more fun!”  There is great wisdom in all 3 of these answers.

On January 21^st, Medscape released the results of their annual “Physician Burnout and Depression Report.”   They chose to subtitle this one “Stress, Anxiety, and Anger,” which certainly caught my attention.   However, what really caught my attention were some of the survey results.  Beyond the ongoing and tragic epidemic of professional burnout (47% overall – up from 42% a year ago), there were some other numbers that were quite notable and very relevant to the PeerRxMed movement.  For instance, the question, “How do you cope with burnout?” had more colleagues answering, “Isolate myself from others” (45%) than “Talk with family members/close friends” (41%), and almost 25% said they use alcohol to cope.  

It gets worse ….  To the question “Has burnout had a negative effect on your relationships?”, 68% of our colleagues answered “Yes.”  In addition, 21% said they felt depressed and 5% indicated they believed they were clinically depressed.   For those experiencing burnout or depression, half indicated “I can deal with this without help from a professional.”  And this survey was completed in September of 2021, before the worst of the delta and omicron surges! 

So once again we must ask, “What’s up with this!?”  Medscape doesn’t explore that question, but my own experience and the evidence would suggest it is because our professional bias toward independence, isolation, and aversion to help-seeking is built into the culture of medicine – it’s what we’re selected to do, trained to do, socialized to do, programmed to do, expected to do.  In many ways, it’s our “badge of honor.”  Somehow, we’ve come to believe that as long as we “armor-up” we are magically invulnerable to the tragedy and suffering we’re surrounded by each day.     

PeerRxMed was created to help break down the many barriers the culture of medicine has created which interfere with our fundamental human need to connect with and support each other.   The past 2 years have only brough into finer focus the need that existed before the pandemic and will be here after.  So let’s be sure to regularly check in with our colleagues to ensure that none of them are trying to “swim” without a buddy.   Doing so in the face of the statistics above is just reckless … and lonely.   Let’s “Yz”-up.  No one should care alone … ever.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org