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Barriers to Diabetes Control Mark E. Molitch, MD NHANES: Achieving ADA Recommendations, 2003-2006 • Individuals reaching glycemic control targets: • HbA1c <7% 57.1% • Individuals achieving other ADA goals of therapy: • BP <130/80 mm Hg 45.5% • LDL <100 mg/dL 46.5% • Only 12.2% of individuals met all 3 goals Abbreviations: BP, blood pressure; HbA1c, glycosylated hemoglobin; LDL, low-density lipoprotein; NHANES, National Health and Nutrition Examination Survey Cheung BM, et al. Am J Med. 2009;122:443-453. 2 Treatment Algorithm for Type 2 Diabetes STEP 1 At diagnosis: Lifestyle + Metformin HbA1c >7.0% STEP 2 Add basal insulin STEP 3 Add sulfonylurea Add DPP-4 inhibitor Add GLP-1 agonist Add pioglitazone Intensive insulin NOT glyburide, chlorpropamide NOT rosiglitazone Abbreviations: DPP-4, dipeptidyl peptidase-4; GLP-1, glucagon-like peptide Nathan DM, et al. Diabetes Care. 2009;32:193-203. 4 Combination Therapy in Type 2 Diabetes: Decision Considerations HbA1c efficacy Reductions from baseline Reaching target Synergy of mechanisms of action Side effects and toxicity profile Frequency and severity of hypoglycemia Effect on weight gain Avoiding polypharmacy and complex regimens Compliance and convenience Cost 5 Barriers to Diabetes Control • • • • Clinical inertia Financial Adverse effects of oral agents Insulin • • • Fear of injections Fear of hypoglycemia Complexity of management • Targets of treatment • Need to adjust to individual patient • Cultural 6 Earlier and More Aggressive Intervention May Improve Treating to Target Compared With Conventional Therapy Typical progression is to wait for HbA1c to reach 8–9% before moving to next step Monotherapy Uptitrate dose of monotherapy Add 2nd and then 3rd drug Moving more aggressively to more potent treatment can achieve goal of HbA1c of < 7% more quickly Add basal insulin then multiple insulin injections per day 6 Advantages & Disadvantages of Type 2 Diabetes Medications Class (examples) Potency Risk of hypoglycemia Weight Other (glipizide, glyburide, glimepiride) +++ +++ Greatest increase Less likely to maintain control as monotherapy Meglitinides (nateglinide, + ++ Increase Short acting Metformin +++ + Neutral Thiazolidinediones ++ + Greatest increase Fluid retention, worsen CHF, fractures. Risk of cardiac events. + + Decrease Intestinal gas, poor tolerance + + Neutral + + Decrease Injection, GI effects +++ +++ Greatest increase Injection Sulfonylureas rapaglinide) (Rosiglitazone, Pioglitazone) α-Glucosidase inhibitors (acarbose, GI intolerance, rare lactic acidosis miglitol) DPP-4 inhibitors (sitagliptin, saxagliptin, Headache, risk of infection linagliptin) GLP-1 analogs (exenatide, liraglutide) Insulin AACE/ACE Diabetes Algorithm for Glycemic Control. Endrocr Pract. 2009;15:540-559. 7 Barriers to Insulin Therapy: Common Concerns Insulin therapy might cause: • Worsening insulin resistance – But reduction of glucose toxicity improves resistance • More cardiovascular risk – But reduction in glucose improves cardiovascular risk • Weight gain – Yes, it does occur with improved metabolic efficiency • Hypoglycemia – Very rare with type 2 diabetes – Common with type 1 diabetes as approaching optimum glycemic control 9 Challenges and Opportunities in Minority Populations • • • • • • Rapidly growing populations High rates of type 2 diabetes and its complications Groups with unique culture, health beliefs, myths, and food preferences Diverse level of education and socio-economic status Insufficient culturally oriented diabetes care, education, and research programs Health care system and health professional barriers Cultural competency is key to approaching patients in a beneficial way 10 Why We Cannot Always Extrapolate to Older Adults with Diabetes • Heterogeneity • Comorbid conditions – Functional limitations – Cognitive decline • Polypharmacy • Life expectancy versus – Time to incidence or progression of microvascular or macrovascular complications – Time to expected benefit of intervention 11