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Case studies in the managment of type 2 diabetes
This document presents case studies in the management of type 2 diabetes, illustrating treatment strategies for patients with uncontrolled diabetes on multiple oral agents. It discusses the initiation of insulin therapy, the adjustment of doses for basal and bolus insulins, and emphasizes the importance of monitoring blood glucose levels and HbA1c. Various treatment recommendations and insulin types are highlighted, along with the consideration of patient-specific factors such as comorbidities and lifestyle habits.
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Case studies in the managment of type 2 diabetes
- 1. Case Studies InThe Management of Type 2 Diabetes Nasser Al-Juhani, MD,FRCP (U.K),ArBIM.SBIM,PHMD Consultant of Endocrinology & Metabolic diseases
- 2. Rreceived honoraria/consultation feesfrom AstraZeneca, Sanofi, Eli Lilly, Novo Nordisk, Boehringer Ingelheim, Merck, AstraZeneca and Pfizer. DISCLOSURE
- 3. Case 1 Poorly controlledtype 2 diabetes on triple oral therapies
- 4. • A 55-year-oldman with type 2 diabetes for 10 years. • Background retinopathy • C/O poluria,polydepsia and 4 Kg weight loss over past 3 months • Wt=70,Ht=166 cm, BMI is 25.4. • Metformin 1 g BID po • Empagliflozin 10 mg OD po • Sitagliptin 100 mg od • Normal renal & liver function • eGFR 58 • Urine:albuminuria + ,no ketones • ECG: normal • HbA1c is 9.0 %. 1.1 What is your next treatment (s) recommendation? A. Add Gliclazide MR B. Add repaglinide C. Add pioglitazone D. Add basal insulin E. Add GLP-1 RA Case 1
- 5. When to considerinsulin in T2DM? • Uncontrolled on 3 agents start INSULIN • When 2 OAD being used-maximally & AIC is not at goal ≥ 7% If AIC < 8.5 Add 3rd OHA or insulin or GLP-1RA If AIC >8.5 Add insulin (or GLP-1RA) 3rd OHA : AIC drop 1% Greater cost
- 6. • A 55-year-oldman with type 2 diabetes for 10 years. • Background retinopathy • C/O poluria,polydepsia and 4 Kg weight loss over past 3 months • Wt=70,Ht=166 cm, BMI is 25.4. • Metformin 1 g BID po • Empagliflozin 10 mg OD po • Sitagliptin 100 mg od • Normal renal & liver function • eGFR 58 • Urine:albuminuria + ,no ketones • ECG: normal • HbA1c is 9.0 %. 1.2 What will you select as the basal insulin for this patient? A. NPH B. Glargine U100 C. Glargine U 300 D. Detemir E. Premixed insulin 70/30 Case 1
- 7. The Next Generationof Basal Insulin with a Smoother PK/PD Profile than Lantus® TOUJEO •Smoother PK/PD profile than Lantus® •Full 24h coverage •Less hypos than Lantus •Improved patient experience LANTUS • Once daily • Less hypos than NPH • Treat to target NPH PK/PD Profile: Pharmacokinetic/Pharmacodynamic Profile
- 8. Starting Basal Insulin+OHA(S) • Glargine 300 (Toujeo®) : 14 u at bedtime ,10 pm (0.2 U X 70 kg) • Continue oral agent (s) at same dosage • Daily FBG • REQUEST PATIENT to increase basal dose 2 units every 3 days to keep FBG target 80-130 mg/dl During 6 & 12 months of follow-up • Glaring -U300 dose was titrated to 45-U daily • FBG averages 106 -115 mg/dL • A1C = 6.6 – 6.9 % 5-18
- 9. At 2-year follow-up •His weight increased 2 kg, BMI is 26. • Background retinopathy/nephropathy • Normal renal & liver function • Has irregular eating habits; occasionally misses meals during the day • HbAic 8.1% Case ……Con”d 57 yr man,DM2,Failure of 3 OADs Plus Basal insulin Fasting 2H Post breakfast Pre Lunch 2H Post Lunch Pre dinner 2H Post dinner HbA1c 110 175 120 220 140 170 8.1% • Metformin 1 g BID • Empagliflozin 10 mg OD • Sitagliptin 100 mg OD • Glargine-U300) 45-U od pm Target1 <110 <180 <130 <180 <130 <180 <7 Suspect PPH, IF FBG<130 mg/dl & AIC> goal >7%
- 10. A. Increase thedose of basal insulin B. Add bolus insulin with lunch meal C. Add bolus insulin with 3 main meals D. Switch to twice daily premixed insulin E. Add GLP-1 Receptor agonist Choose the most suitable option?
- 11. How much rapid-actinganalog at meal will you initiate? Glulisine (Apidra®) 4 Units OR 0.1-U/kg
- 12. Start Glulisine(Apidra®) 4 -U at lunch INSTRUCT PATIENT to adjust rapid-acting analog dose at meal by 2 units every 3 days until BG in the target. Keep 2HPBG target 140-180 mg/dl FBG target 80-130 mg/dl Target HbAIC <7% How do you adjust a rapid-acting analog at meals??
- 13. CASE 1 ……Con”d 6-MonthFollow-Up • Glargine 300 (Toujeo®) 46-U 10 pm • Glulisine (Apidra®) 16-U at lunch and, patient is doing well • Continue metformin 1 gm bid po/ Empagliflozin 10 mg od • may D/C or continue Sitagliptin (more cost) • A1C = 6.8% • Patient feels well, has infrequent “ minor hypoglycemia,” • Over time, if postprandial glucose becomes elevated at meals other than lunch, add pre-meal insulin at that meal
- 14. Holman RR etal. Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes. N Engl J Med 2007; 357(17): 1716–1730 >6 out of 10 basal insulin patients will need another insulin to reach target After 1 year of treatment with basal oral therapy, How many patients out of 10 will need another insulin?
- 15. When to targetpost-prandial blood glucose? ADJUST BASAL insulin Controls pre-meal glucose 1st Fix the Fasting & Pre-dinner (PRE-MEALS) 80-130 mg/dl (4.4-7 mmol/l) ADJUST BOLUS insulin : if HbAic<8.0 %, the contribution of post-meal glucose becomes more Pre-meal may be at target, but postmeal glucose values are high Monitor 2-HPP 2hr PPG< 140-180 mg/dl (<10 mmol/l) ** AVOID HYPOGLYCEMIA <4 mmol/l( < 70mg/dl) Controls post-meal glucose
- 16. Patient Not atTarget with Basal Insulin Move on to Multiple Daily Injections Or twice daily PreMix Or GLP-1 RA
- 17. Case 2 Morning hypoglycemia onpremixed Insulin
- 18. 55-year-old man T2DM x 10 years Painful sensory neuropathy & nephropathy eGFR 55, Creatinine 0.9 mg/dl Erratic work schedule sweating at some nights Metformin XR 1500 mg od Dapagliflozin 10 mg od Premixed insulin analogue: - 70/30 50 U am and 40 U pm Hbaic 7.5% FBG 200-280 mg/dl • Morning hyperglycemia : – Check blood sugar at bedtime and between 2-3 a.m. – Or Continuous glucose monitoring Case 2
- 19. 19 BF PRE LUNCH PRE DINNER HS 0300 MON260 112 155 140 56 TUE 225 110 168 126 47 WED 280 88 153 120 60 THU 190 106 136 130 59 Case 2
- 20. Classification of severity: Non-severeversus severe symptomatic: • Non-severe: Patient has symptoms but can self-treat and cognitive function is mildly impaired • Severe: Patient has impaired cognitive function sufficient to require external help to recover (Level 3) Reclassification of hypoglycaemia1–3 1. Seaquist ER et al. Diabetes Care 2013;36:1384‒1395. 2. International Hypoglycaemia Study Group. Diabetes Care 2017;40:155‒157. 3. Frier BM. Nat Rev Endocrinol 2014;10:711‒722. Alert value for hypoglycemia Plasma glucose 3.9 mmol/L (< 70 mg/dl) and no symptoms Serious clinically important biochemical hypoglycemia Plasma glucose 3.1 mmol/l (55 mg/dl) Level 1 Level 2
- 21. Cause Bedtime 2-3a.m. Fasting Insufficient dinner rapid acting dose/carbohydrate consumption at night High High High Somogyi effect Normal Low High Dawn phenomenon Normal Normal High Morning hyperglycemia
- 22. Case 2 Shifting frompremixed to Basal-Bolus insulin For recurrent nocturnal HYPOGLYCEMIA TDD= 90 U/day 80% of 90 U is 72 U 50% as basal: Glargine 300 (Toujeo®) – 36 units od 10:00 pm 36 U divided for three meals, (largest dose may given at largest meal) : 12 U before breakfast 12 U before lunch 12 U before dinner
- 23. Case 3 Newly diagnosedD.M Type1D.M or type 2 D.M ?
- 24. 20-year-old malewith newly diagnosed DM 6 kg weight loss & polyuria for 1 month Brother had T2DM BMI 34.4 , acanthosis nigricans Lab results: BG 340 mg/Dl (18.8 mmol/l); A1C, 13% Creatinine, 0.8 mg/dL Ketones -ve Anion gap, normal In addition to Lifestyle modification What is your next treatment recommendation? A. Metformin B. Metformin plus Gliclizide C. Metformin plus empagliflozin D. Metformin plus liraglutide E. insulin Case 3
- 25. When should insulinbe started in T2DM? Newly diagnosed T2DM: • ADA/EASD 2020 Consider initial injectable combination GLP-1 RA+Basal insulin or prandial/basal insulin IF HbAIC 10% or 2% above target
- 26. Case 3 20 Yrold male Newly diagnosed D.M,BMI 34.4, AIC=13% (cont.) Type 1 D.M or type 2 D.M ?
- 27. Physical exam • Obese/ acanthosis nigricans suggest DM2 • Thin suggest DM1 Family history • More with DM 2 but occurs also with DM 1 Complication • Suggests undiagnosed DM 2 Age at onset • <30 year • >30 year Differentiating Type 1 Vs. Type 2 DM
- 28. • Fasting serumC-peptide levels • Normal or High C-peptide : • DM1 (with honey moon) or DM2 Follow up :SMBG • If insulin dose is reduced and no ketones, may consider a trial of stopping insulin • If glucose high or ketones+ , resume insulin Low C-peptide : DM1 or late DM2- Insulin Testing for antibodies - GAD-65 - Islet-cell - IA2 - Insulin -ZS • High…DM1 • Normal…Idiopathic DM1 or DM2 Differentiating Type 1 Vs. Type 2 DM
- 29. Conclusions Insulin Treatment inType 2 Diabetes • Basal treatment NPH or (glargine100 or 300) , detemir, degludec Start 10 U and titrate • Bolus treatment premeal (Lispro/glulisine/aspart) Start at 4 U premeal and titrate; • Premixed therapy • Start at 10 U BID and titrate • Basal bolus therapy • Start at 0.5 U/kg, 40-50% basal, 20% bolus each meal