Diabetic medication

[NightOwl]

Hi

I am new to the profession and would like some help on managing dm pt. my question is how much does the dm medication drop HBA1C:

Metformin, glipizide, actos, januvia, tradjenta, victoza

 

Also if i decide to put a dm 2 pt on insulin, how much hba1c would be drop and how soon can i expect to see result.

 

Thank you for all tour help in advance

[SocialMedicine]

does work provide you with resources? you need to have the ability to learn this very basic information outside of a non official chat forum. if you create hypoglycemia in a patient and he brings you to court it is not going to be ok if you respond "socialmedicine on the PA forum told me this agent lowers sugar minimally". If work does not provide you with anything I would personally purchase uptodate. Keep it for half a year or so .. print out articles of all the common conditions you treat. It is a bit pricey but you need to develop a foundation. The amount of blood sugar reduction depends on the medication and its dose. With insulin regiments you can work to control any hgb a1c. It does not sound like you get the fundamentals of insulin pharmacology. read, read, read.

[bradtPA]

Everyone is different, depends on how much beta cell function they have left, and the medication dose.

 

1 gram of metformin BID can drop an A1C 1%. Don't use if serum cr is greater than 1.4 in females, 1.5 in males.

DPP4s can drop it about 0.5%, GLP1s 0.5-1%. Sulfonylurias can drop it 0.5-1.0%. Welchol can drop it 0.5%, avoid in hypertriglyceridemia. Mixing them you wil often see a synergistic effect. Insulin depends on the type and how much insulin resistance there is, start low and slow and titrate up until controlled. Work with your SP until you are comfortable dosing these meds on your own, that's what they are for...

[d2305]

Metformin and Victoza don't cause hypoglycemia. Insulin and glipizide can. Metformin is a good first line agent to start with. GI upset is the main side effect. The drop in HgbA1C will vary.

[NightOwl]

Everyone is different, depends on how much beta cell function they have left, and the medication dose.

 

1 gram of metformin BID can drop an A1C 1%. Don't use if serum cr is greater than 1.4 in females, 1.5 in males.

DPP4s can drop it about 0.5%, GLP1s 0.5-1%. Sulfonylurias can drop it 0.5-1.0%. Welchol can drop it 0.5%, avoid in hypertriglyceridemia. Mixing them you wil often see a synergistic effect. Insulin depends on the type and how much insulin resistance there is, start low and slow and titrate up until controlled. Work with your SP until you are comfortable dosing these meds on your own, that's what they are for...

 

Thank you my friend. My school provide basic foundation but for new grads it is much more to learn. Thank you for your tips

[ventana]

rule of thumb... (very rough)

most oral agents will drop from 0.75 to 1.5 - I usually figure about 1 on the A1C

 

HgA1C> 10 just needs insulin

 

Actos - don't use it

 

Metformin - use it in anyone that can tolerate it - but careful of kidney function

 

I am quicker to use insulin these days in non-commercial drivers

[CByersPAC]

Let me second the recommendation for UpToDate. It is worth the cost of a subscription.

[cbrsmurf]

the american diabetes association guidelines/flowchart should provide you with some answers

also, uptodate

 

unless there is a contraindication, i would always put a pt on metformin first, even in the patient with polyuria and polydypsia (dm2)

 

there is also a novel oral DM medication out called invokana, looks promising, but I probably won't use it until at least a couple years down the road.

[zepoPA]

Please DO NOT start anyone on Insulin until you understand it's mechanism of action. Until you can comfortably adjust Sliding Scales, know without a shadow of a doubt the difference between fast acting, slow acting, and mixed types of insulin, along with the proper schedules based on EACH patient's food schedules, etc.

Read and comprehend that proper glycemic control is much more than simply dropping A1C's on someone chart.

if your SP is not available to clarify different scenarios, it is best you refrain from seing uncontrolled diabetics. Just my $0.02 As far as oral hypoglycemics, memorize their side effects and contraindications. Such as which one you should not use in patients over 60y.o., which one is best not to give to a patient with Hx of ETOH abuse who could potentially have disorders of the pancreas, etc.

Side effects and complications must be comprehended to a point where you can easily explain them to the patient. And it is ok to ask your SP to guide you if necessary. Most reasonable SPs prefer to answer YOUR questions and not the attorney's questions.

[ventana]

Let me second the recommendation for UpToDate. It is worth the cost of a subscription.

 

 

just an aside,up to date is not considered a true reference source, if you ever get sued, he really cannot quote that you referred to up to date as it is not a printed textbook. an attending in the NICU actually got sued, and got torn apart on the stand due using up-to-date. This is certainly just one case. But having good textbooks is helpful as well.

 

I am not sure I completely believe this is. It certainly is respected resource, it is however true that it is forever changing and therefore I can see how the attorneys would pull it apart.

 

 

I also 2nd the idea of not starting a medicine i.e. insulin without understanding. However, this is something that you should be able to wrap your head around with a little bit of additional reading at home. Certainly starting 10 units of Lantus on someone with an A1 C of 13 is not going to be harmful, and they can follow with the primary care doc or more experienced PA or NP on the next follow-up, which should be within a week. Ideally diabetes education, becoming mandatory with affordable care act, has to be offered and started immediately.

[Guest Paula]

just an aside,up to date is not considered a true reference source, if you ever get sued, he really cannot quote that you referred to up to date as it is not a printed textbook. an attending in the NICU actually got sued, and got torn apart on the stand due using up-to-date. This is certainly just one case. But having good textbooks is helpful as well.

 

I am not sure I completely believe this is. It certainly is respected resource, it is however true that it is forever changing and therefore I can see how the attorneys would pull it apart.

 

 

I also 2nd the idea of not starting a medicine i.e. insulin without understanding. However, this is something that you should be able to wrap your head around with a little bit of additional reading at home. Certainly starting 10 units of Lantus on someone with an A1 C of 13 is not going to be harmful, and they can follow with the primary care doc or more experienced PA or NP on the next follow-up, which should be within a week. Ideally diabetes education, becoming mandatory with affordable care act, has to be offered and started immediately.

 

I agree with starting patients on Lantus with an extremely high A1C. In my practice I start Lantus initially with high A1C's, get lab studies and will start metformin once labs are back and renal function is ok. I've had several patients who have gained good control and we eventually d/c'd lantus. Sometimes the patients could not afford lantus and have no insurance. So, I take that into consideration. Close follow up is important and it is important to not drop the blood sugar too quickly. My patients come back to see me weekly when they have a new diagnosis of DM, type 2.

[Ridiculopathy]

check out aace.com and their algorithms

[joanna.nola]

Please DO NOT start anyone on Insulin until you understand it's mechanism of action. Until you can comfortably adjust Sliding Scales, know without a shadow of a doubt the difference between fast acting, slow acting, and mixed types of insulin, along with the proper schedules based on EACH patient's food schedules, etc.

Read and comprehend that proper glycemic control is much more than simply dropping A1C's on someone chart.

if your SP is not available to clarify different scenarios, it is best you refrain from seing uncontrolled diabetics. Just my $0.02 As far as oral hypoglycemics, memorize their side effects and contraindications. Such as which one you should not use in patients over 60y.o., which one is best not to give to a patient with Hx of ETOH abuse who could potentially have disorders of the pancreas, etc.

Side effects and complications must be comprehended to a point where you can easily explain them to the patient. And it is ok to ask your SP to guide you if necessary. Most reasonable SPs prefer to answer YOUR questions and not the attorney's questions.

I'm resurrecting this discussion because I need help with diabetes management.  I work in a FQHC with a young SP who doesn't give me the time I want re: insulin management.  He'll often answer--"yeah that sounds ok." or he just seems to suggest something random without explaining it.  I've sought out other sources (docs/NPs/PAs), booted some patients to SP when necessary, but I'm still not full comfortable with insulin management.  I do need to get much better at this and worry I don't know everything you've highlighted above.

In terms of treatment, we don't use a wide variety of orals because of the high price.  We tend to only use metformin OR metformin + sulfonylurea OR metformin + insulin OR insulin alone (IF creatinine too high for metformin).  We can get Lantus/Levemir cheap at our pharmacy.  We see lots of uncontrolled patients--and many that are complicated by some of the issues you describe above--ETOH use, elderly.  Our population is particularly difficult because many or not exactly compliant, have eating schedules that are complicated by working overnight or not having access to food all the time, do not measure their blood glucose because they can't always afford strips, or are working multiple jobs where they can't use a meter.  I realize it is dangerous to use insulin when a patient is not compliant, does not measure blood sugar etc, but I also can't stand by while their A1C is so high.  In that case they usually are just getting a basal dose of Lantus/Levemir that is fairly low with little adjustment because they never have their logs for adjustment and don't f/u as directed.  I spend A LOT of extra time with these patients, usually working through my lunch, having them meet with the nurse etc.   I'd like to become REALLY good at DM management of our population (taking into account the variety of mostly social complications of being poor), because it is so needed and my SP and the other docs dislike managing DM and provide little education to patients, usually handing over the meds and sending them on their way (without really finding out if pts understand etc--I know this because I see their pt sometimes).  We do have a nurse educator, and now have group visit classes, but that is not enough.  What are the best resources other than aace.com?  I think I need to become particularly adept at sussing out how to adjust around my patient's eating habits.

[EMEDPA]

until you get really good at DM management the easiest method in type 2's requiring medication is start metformin if no contraindication, encourage lifestyle changes, next add lantus once daily at bedtime while continuing metformin at max dose(if tolerated, diarrhea , etc), titrate up lantus, next add sliding scale regular insulin up to 3x daily after meals.

I find NPH 70/30 and other mixes difficult to understand for folks new to dm management. patients MUST have and use a glucometer and know how to interpret results. I never understand dm pts on multipple meds who don't even own a glucometer.

[joanna.nola]

yeah, sometimes I "inherit" a person on 70/30 who is not controlled.  i usually try to switch them to lantus (which we can get cheap) because I feel like I can adjust that more easily.  but this can sometimes be a difficult transition.   Wal-mart has a very cheap meter/strips (the "Prime/Reli-on") which I usually direct people to get.  walgreens has strips that are like $1/piece and that is insane.  but some people seem to not understand how important it is to keep track of their BG, and I really struggle to convince them.

[joanna.nola]

BTW...has anyone used the AAPA module on DM?  It seems like something I'd benefit from--actual cases are a good way to learn.  It's free to members and I'm currently not an AAPA member.  

[cinntsp]

BTW...has anyone used the AAPA module on DM?  It seems like something I'd benefit from--actual cases are a good way to learn.  It's free to members and I'm currently not an AAPA member.  

 

What module?  They have a discount on SimCare available, but that's still nearly $300.

[Guest Paula]

The module has been advertised on the daily AAPA news blast.

[rev ronin]

I love the simplicity of Group Health's approach to DM II: Metformin, Sulfonylureas, and insulin, and that's it: Keep it simple, cheap, and well-tested.

[rev ronin]

just an aside,up to date is not considered a true reference source, if you ever get sued, he really cannot quote that you referred to up to date as it is not a printed textbook. an attending in the NICU actually got sued, and got torn apart on the stand due using up-to-date. This is certainly just one case. But having good textbooks is helpful as well.

I'm not sure I believe that.  If the use of UpToDate was questioned on the stand, then competent defense counsel would have brought in UpToDate editorial and publishing staff to rebut that attack.  If the note documented UpToDate was used as a reference, then UpToDate can show what that page looked like on that particular date, and the references can be checked, and expert witnesses can fight over the appropriateness of that specific instantiation of the page.

 

Sad fact is, a lot of medical professionals use WIkipedia, which is far less accountable.  Fact is, textbooks are out of date before they are published, and any bias towards textbooks and against UpToDate or similar online, asynchronously-updated references is misplaced.

[GetMeOuttaThisMess]

I love the simplicity of Group Health's approach to DM II: Metformin, Sulfonylureas, and insulin, and that's it: Keep it simple, cheap, and well-tested.

 

The problem is not the blood sugar reading proper but instead the co-morbid disease risks that are associated with diabetes.  If you look at the endo guidelines closely they don't say anything about monitoring blood sugars (as I recall) for NIDDM patients.  Why?  You get all the information you need from the HbA1c value.  An exception to this would be the newly diagnosed patient who may wish to see how one type of meal/food item impacts their postprandial sugar as compared to a comparable meal/food item.  What they do say to inquire about are S/S associated with HYPOglycemia.  Also be aware that there is nothing magical about the 6.5-7.0% value of the HbA1c.  The value is arbitrary.  It's all about complications and trying to avoid or delay onset of same.  Also remember that you're talking about two animals here.  IDDM, where studies imply that tight control is of benefit, and NIDDM where tight control actually has a higher incidence of all-cause mortality compared to the hit/miss group (kind of like the ezetimibe study where the better cholesterol patients were dying off more frequently than those not so well managed).

 

Also, as a general rule of thumb, oral agents can drop HbA1c values arguably up to 2%.  That's why folks at 10% or more need to just suck it up and get onto insulin.  Lose a person if applicable (weight), get off the sofa, exert yourself by walking farther than the fridge and you may be able to get back off the insulin, and possibly the oral meds as well.  Don't forget to keep an eye out for HHNS.

[LIPPER]

I believe standard of care is to initiate insulin for A1c > 9. Of course you can try orals initially after A1c begins to respond. Sulfon's are now frowned upon in primary care and I've not seen an endo use, let alone initiate one. Insurances are also recognizing the risks and are starting to DENY even generic glipizide.

 

The SGLT-2's certainly look promising. We have a number of patients that are responding well. Furthermore Janssen and AstraZeneca are in a bidding war of sorts; Farxiga is free for self-pay/commercial insurance for the time being. Invokana4 months free to start the $5/month.... There are a truckload of SGLT's coming down the pike (much like over abundance of ARB's) so things will start getting tall annoying soon.

 

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[GetMeOuttaThisMess]

^^^ It is, based on the math (high end acceptable HbA1c of 7%+max benefit of 2% from meds), however the local "standard of care", i.e.-med school, arbitrarily throws out 10% since it's easy to remember and it's a nice, round figure.