Medications Selection for Type 2 Diabetes

Considerations for medication selection for type 2 diabetes, initiation of GLP-1 receptor agonists and SGLT-2 inhibitors, and the initiation of basal insulin for type 2 diabetes.

These were the topics discussed at today’s presentation by Kathryn Kreider, DNP, who is an associate clinical professor of nursing at Duke University Medical Center and Duke University School of Nursing.

She began her presentation by discussing current evidence on the standards of medical care for diabetes, including recommendations from the AACE/ACE and the ADA.

Next, she discussed the importance of a patients current A1C and their A1C goal, and how this effects treatment strategies. Factors to consider when determining an A1C goal include disease duration, life expectancy, comorbidities, and patient preference. Lifestyle and behavioral modification, she added, is also very important to consider, with 5%-10% reductions in body weight able to improve glycemic control and reduce the need for medications.

“Don’t forget that we need to keep encouraging our patients toward these things and not just pretend that medications can fix everything,” she said. 

Patient-Centered Medication Intensification

“Please always ask your patients if they are taking their medications,” she stressed.

Identifying adherence issues and the causes for them is very important in the treatment of diabetes. Other factors to consider when intensifying medication include risk of hypoglycemia, renal function, and cardiovascular risk.

She went on to discuss fasting glucose vs post-prandial glucose targets, saying “you really want to think about what their specific situation is…and then give them a medication that is going to target that issue.”

Next, she reviewed an algorithm from the ADA Standards of Medical Care 2020, which discussed treatment pathways for patients with ASCVD, CKD, or HF risk and medication intensification when A1C is above target; whether there is a need to minimize hypoglycemia risk, weigh gain, or medication cost; and intensification of injectable therapies, as well as a second algorithm from the AACE for the intensification of insulin therapy.

Lastly, she reviewed a case study to help to make the information from her presentation more applicable to everyday practice.

Takeaways

She concluded by discussing the importance of individualized care for patients with type 2 diabetes, saying, “I cannot overemphasize the need to individualize therapy for patients, to have honest conversations, talk about what their goals are, and think about all the things that could be impairing their desire and ability to get to glucose targets.”

—Michael Potts

Reference:

Kreider K. Initiating Insulin and Other Medications for Type 2 Diabetes. Talk presented at: Practical Updates in Primary Care 2020 Virtual Series; November 6-7, 2020; virtual.