Update Diabetes
by Timothy Gieseke, MD, CMD
CALTCM Treasurer

At this year’s annual meeting, Dr. Jane Weinreb gave an excellent update on glycemic care in our setting for persons with Type 1 or 2 Diabetes noting that many of our patients already have significant complications and reduced stress tolerance.  About 1/3 of our patients have diabetes.  Because of loss of muscle mass with aging and disability, our patients typically have pre-breakfast finger stick glucose at goal, but commonly have prolonged postprandial hyperglycemia, which requires our attention.  Healthy lifestyle with regular exercise to improve exercise and a nutritious reduced-carbohydrate diet are effective first line interventions that are safe and improve quality of life.  Individualized A1C goals were recommended using helpful criteria.  In addition, typical FS Glucose readings before meals and bedtime were specified for the different recommended A1Cs.

The usual initial medication in Type 2's for managing CVD risk and glycemia is metformin (assuming Creatinine Clearance > 30) since this medicine is affordable, weight neutral, and has evidence for reducing risk of microvascular and macrovascular complications.  Glyburide has too great a risk for serious hypoglycemia so its use is discouraged in our patient population.  Other oral sulfonylureas (glipizide, glimepiride) have the second greatest risk for hypoglycemia, after insulin. Even though they are affordable, hypoglycemia is costly and dangerous. In addition, they are associated with weight gain and may reduce myocardial ischemic tolerance.  Meglinitides (nateglinide, repaglinde) are now generic and are safer since they induce insulin release in a glucose dependent fashion.   

After metformin, the ADA in 2017 recommends considering incretin mediated drugs (DPP4 inhibitors - sitagliptin, linagliptin, saxagliptin, or alogliptin;   GLP-1 receptor agonists – exenatide, liraglutide, dulaglutide, albiglutide), SGLT2 inhibitors (canaglifolzin, empaglifolzin, dapagliflozin), TZDs (pioglitazone), and insulin.  Dr. Weinreb provided a helpful table on the pros and cons of each of these options.  The FDA has now approved empaglifozin and liraglutide for use for macrovascular risk reduction.  Though expensive, in selected cases, these medications may be quite beneficial and are worth your further study to insure they are used appropriately.

Dr. Weinreb also cautioned re “over-insulinization” of our patients.   She ended her presentation with comments on the new implanted glucose sensors and hybrid insulin pumps that monitor interstitial glucose real time and have feedback loops to hold insulin when hypoglycemia develops.  These are real advances for persons with Type 1 DM and those Type 2’s with brittle glycemia. Click here for a pdf of Weinreb's presentation.

At CALTCM, we are grateful for the opportunity to partner with you to improve the care of persons with Diabetes.