For many reasons, our education committee chose to focus this year on reducing the risk of hypoglycemia in persons with diabetes. CMS has data from April 2016-March 2017 showing this is a major reason for a higher first 30 day all-cause SNF Readmissions rate. As of Jan 1, 2019, the CMS “SNF Readmission Measure” (SNF-RM) adjusts payments to facilities based on this measure. From multiple randomized controlled studies, we know that serious hypoglycemia increases mortality. For this reason, in high risk patients, AGS and ADA have recommended higher A1C targets in those with higher hypoglycemic risk.
Last October, the ADA and EASD published a consensus guideline on managing Type 2 Diabetes (see link to pdf below) that changed their prior algorithm for add on medications after failure of lifestyle and Metformin in persons with established or high risk for cardiovascular disease (most PALTC persons with diabetes). They now recommend Incretin Receptor Agonists (Liraglutide) or SGL2 inhibitors (Empaglifozin) as the next agents to be used based on their FDA approved indication for reducing MACE (Major Adverse Cardiovascular Events), close to zero risk for hypoglycemia, and their weight loss potential. The January 2020 AACE guidelines (see link to pdf below) agreed.
In my own practice, for the past 2 years, I have been using Incretin Receptor Agonists (Incretin RAs) first rather than insulin or as an addition for those already taking basal insulin and or rapid acting insulin. I have been favorably impressed with the improved glycemic control with very low risk for hypoglycemia. I often have been able to greatly reduce the dose or stop the more risky rapid acting insulins. In addition, I have been able to safely reduce the frequency of finger stick glucose measurements and have seldom had a serious hypoglycemic event (no ER visits). While GI intolerance is a potential problem, this has actually been quite rare. Incretin RAs are expensive, but are priced similar to insulin, which has become expensive (quadrupled since 2002). Because of their FDA indication for MACE reduction, all insurances will cover them for patients with established or high risk for MACE.
I don’t yet have much experience with use in patients on Sulfonylureas and Metformin who are at glycemic goals. However, sulfonylurea agents remain high risk weight gain and for serious hypoglycemia, especially if there is a failure to eat a meal or is a change of condition or diet plan. The new guidelines do support efforts to minimize their use.
If you aren’t aware of “block testing” for finger stick glucose checks, this could be a QAPI project for your facility to reduce unnecessary testing and safely save staff time and the expense of these expensive test strips. See my ppt slide on this subject.
For more information on current diabetes practice, please see the attached copy of my presentation at the 2019 CALTCM Summit for Excellence and the supplemental articles regarding the new guidelines.
Our education committee is now planning our 2020 Summit and welcomes your ideas to insure we represent your interests; please send your ideas to: [email protected]
Supplemental Materials:
Dr. Gieseke's Slides from the 2019 CALTCM Summit for Excellence: Gieseke Reducing Hypoglycemic Risk in Diabetes Care CALTCMSummit2019.pdf
AACE AND ACE Consensus Statement on the Comprehensive Type 2 Diabetes Management Algorithm.pdf