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dchampigny

Managing Diabetes in primary care

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I'm a new grad who has started his first job in primary care in a rural area in the eastern US. Our demographic has a lot of the standard stuff, DM2, HTN, etc.

 

I've been seeing a great mix of type 2 diabetics in the population. I've been encountering some challenges related to diabetes management, particularly insulin administration.

 

I have not really inherited any patients with whom I have personally made the diagnosis of diabetes, but rather patients who primarily see my SP for diabetes but are non-compliant/difficult to control.

 

I know the basics of medication management........working on diet and exercise for a while, checking A1C every 3-4 months, starting metformin and have had some patients who we have put on glypizide or glyburide as an adjunct when metformin doesn't get the A1C down. I have less experience with some of the newer agents (invokana, etc) as most of our patients are not covered for these or can not afford. 

 

My questions related to medication are related to WHEN to add another medication: I usually start the conversation when the A1C is greater than 7.5 because our population is resistant to adding medications, it takes 2-3 visits to convince them when another drug is needed. What are your go tos as an adjunct to metformin?

 

 

Adding Insulin has been another issue that has come up for me. I've mostly inherited patients who have been started on insulin and I am then adjusting the dose. Patients will call in with their sugar values for the week. I typically start with Lantus and titrate up to about 60-65 units at night and then split to two doses (morning and evening) once around that value. What does everyone else typically do? Split earlier? Give a larger dose and split later?

 

I also do not have much experience with starting Humalog. Would love if someone could explain their regimens. I've been reading dynamed and uptodate, but haven't gotten much out of it. 

 

 

I guess my main problem is that most of my patients have VERY inconsistent sugar readings when they call in. When they get triaged to me, I struggle with whether or not to increase their insulin. Example: someone goes from having a 92 fasting sugar one day and then the very next day going up to 220 fasting. It's hard to gauge. We do have an endocrinology practice in our building, but almost all of my patients refuse.

 

Any thoughts would be greatly appreciated!

 

DC

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I never start sulfonyureas--too many downsides, too many other better things available.  Metformin first, obviously, but then a DPP-4, and then either an SGLT-2 or GLP-1 or basal insulin, depending.  Diet and exercise are a key part of diabetic control, and need to be constantly communicated at every visit.  I tell my patients that by daily walking they stay healthier while keeping big pharma from getting their money. :-)  Most of them don't want needles, so we maximize oral therapy.

 

We see no medicaid patients in my practice, so it's really just a question of "what does their insurance cover?" for the newer agents.  Reps give us samples and visit us constantly, so I can get people on effective meds quickly.

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From cheat sheet that I copied when I had to do this several years back:

 

Increase basal, glargine (Lantus) or detemir (Levemir) by 1 un/day (10%) until a.m. fasting <110 mg/dL.  Start at 10 un either h.s. or morning.

 

When adding short-acting divide total insulin dosing to 50% in a.m., 25% before supper, and 25% h.s..  Give three days before assessing results and changing again.

Pre-prandial goal is 80-150 mg/dL, and random <180 mg/dL.  May lessen short-acting before three days if hypoglycemic.

 

Check 2-4 a.m. FSBS q wk during initial weeks then prn

 

Rapid (lispro, glulisine, Aspart)-onset 5-10", peak 45-75", duration 2-4'

 

Regular (100 un/ml)-onset 30", peak 2.5-5', duration 4-12'

 

NPH (neutral protamine Hagledorn)-onset 1-2', peak 4-12', duration 14-24'

 

glargine (Lantus) >24'

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All diabetics require individualization, but one approach is when insulin is needed, try to first gain control of fasting sugars. I'll have them start basal insulin at night and check sugar q AM and log it for me to review. I will titrate the basal insulin up until AM sugars are maintaining around 90 - 130. Once fasting sugar controlled, reconsider the A1c. If a1c is not at goal after controlling fasting sugar, then you need to work on postprandial spikes which is where your rapid acting insulin like novolog/humalog come in to play. 

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lifestyle changes - pound that point (unlikely to work)

 

metformin

 

glipizide

 

insulin......

 

 

I don't buy into all the new novel agents.....  they lower maybe 1% on A1C and so many people are so far over goal it is a joke to try to come up with the magic mix to get an A1C from 11 to 6 - other then insulin - only time I vary off this is CDL drivers - avoiding insulin if possible - if possible

 

That and if you start to add up the actual cost of having 3,4,5 agents on board - it is crazy expensive....

 

I did not make them diabetic, I am left to pick up the pieces of a life time of bad decisions, so I tell them honestly and straight up that I almost all DMII end up on insulin and it is likely the second best treatment out there - with the first best being ADL - ie exercise, healthy eating, weight loss to BMI <25

 

 

Most start insulin.....

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Metformin if single digit. Follow up 3 months. 

Not controlled, look at access to medicines. Let them sell themselves. GLP-1's have the side effect of weight loss. Wonderful. 

Close follow up if not-controlled, still learning to be compliant, loose follow up if well controlled. 

If severe diabetes, refer to endo. If you can't do that, weekly follow up with regular glucose testing for insulin adjustments. Start low, go slow. 

Even if medicaid, they still have access to some of the newer medicines, know how to look at the Medicaid preferred drug list. 

Diet and exercise always. Recognize if orthopedic/psychiatric comorbidities may sabotage that. 

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