Diabetes Case 17

A 45 year old male with type 2 diabetes comes to see his endocrinologist. His Hba1c had been 6.7 last visit 6 months back. HIs A1c has now has gone up to 8.2 on recent labs. He is currently on metformin 1000mg bid. The patient had been following carb counting but has been non-compliant with his diet lately. He reports fasting glucose in 150-230 range most days. He checks before dinner occasionally and reports glucose usually over 200. He denies any hypoglycemia.

The patient has gained 15 lbs. weight in past 6 months and has a BMI of 39. He does not have any long term CV complications at this time. Family history is remarkable for both parents with type 2 diabetes and dad with coronary artery disease and unilateral above knee amputation. The patient is tolerating metformin well.  His BP is well controlled on lisinopril 10mg daily.

Question 1

In addition to diet modification, which of the following would be the next best treatment option for optimizing this patient’s diabetes management?

A. Continue metformin, start Januvia 25 mg daily. Monitor glucose twice a day and have patient follow up in 3 months. Advice patient to monitor glucose before each meal and send glucose profile back for review and adjustment in medication in 2 weeks.
B. Discontinue metformin and start patient on basal bolus regime with Lantus and Humalog. Advice patient to monitor glucose before each meal and send glucose profile back for review and adjustment in medication in 2 weeks.
C. Continue metformin, start Trulicity 0.75mg once a week. Advice patient to monitor glucose before each meal and send glucose profile back for review and adjustment in medication in 2 weeks.
D. Continue metformin, start Jardiance 10mg daily. with plan to add Dpp-4 inhibitor next visit. Advice patient to monitor glucose before each meal and send glucose profile back for review and adjustment in medication in 2 weeks.
Incorrect!
Correct!
Correct Answer
C. Continue metformin, start Trulicity 0.75mg once a week. Advice patient to monitor glucose before each meal and send glucose profile back for review and adjustment in medication in 2 weeks.

This patient has a Hba1c of 8.0. He is obese and currently does not have any CV complications. The best treatment option for him would be to choose a medication that will address not only his high glucose but also his obesity and risk of complications.

The first choice for a second-line therapy by the new American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) guidelines is GLP1 RAs or SGLT-2 inhibitors for patients with atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease. For patients without these conditions, the ADA/EASD lists five options of noninsulin second-line therapy. On the other hand, the 2019 consensus statement from the American Association of Clinical Endocrinologists/American College of Endocrinology lists nine options, with GLP1 RAs as the first recommended therapy, followed by SGLT2 inhibitors and dipeptidyl peptidase 4 (DPP4) inhibitors, and sulfonylurea as the last option.

Currently Trulicity is the only GLP-1 agent that in addition to improving glucose and having the weight loss benefit will also provide primary prevention for CV disease.

Adding basal / bolus regime is currently not needed as many other options are available. Moreover, adding insulin will not provide the weight loss benefit and primary prevention CV benefit.

-Adding SGLT-2 inhibitor may be a good option however based on the above guidelines and primary prevention benefit associated with Trulicity once weekly GLP-1 seems like the best option.  And it will also help him lose weight.

 

References:

1-Trulicity [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC.

2-Gerstein HC, Colhoun HM, Dagenais GR, et al. Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double‐blind, randomised placebo‐controlled trial. Lancet. 2019;394(10193):121‐130.

3-Gerstein HC, Colhoun HM, Dagenais GR, et al. Design and baseline characteristics of participants in the Researching cardiovascular Events with a Weekly Incretin in Diabetes (REWIND) trial on the cardiovascular effects of dulaglutide. Diabetes Obese Metab. 2018;20(1):42‐49.

This patient has a Hba1c of 8.0. He is obese and currently does not have any CV complications. The best treatment option for him would be to choose a medication that will address not only his high glucose but also his obesity and risk of complications.

The first choice for a second-line therapy by the new American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) guidelines is GLP1 RAs or SGLT-2 inhibitors for patients with atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease. For patients without these conditions, the ADA/EASD lists five options of noninsulin second-line therapy. On the other hand, the 2019 consensus statement from the American Association of Clinical Endocrinologists/American College of Endocrinology lists nine options, with GLP1 RAs as the first recommended therapy, followed by SGLT2 inhibitors and dipeptidyl peptidase 4 (DPP4) inhibitors, and sulfonylurea as the last option.

Currently Trulicity is the only GLP-1 agent that in addition to improving glucose and having the weight loss benefit will also provide primary prevention for CV disease.

Adding basal / bolus regime is currently not needed as many other options are available. Moreover, adding insulin will not provide the weight loss benefit and primary prevention CV benefit.

-Adding SGLT-2 inhibitor may be a good option however based on the above guidelines and primary prevention benefit associated with Trulicity once weekly GLP-1 seems like the best option.  And it will also help him lose weight.

 

References:

1-Trulicity [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC.

2-Gerstein HC, Colhoun HM, Dagenais GR, et al. Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double‐blind, randomised placebo‐controlled trial. Lancet. 2019;394(10193):121‐130.

3-Gerstein HC, Colhoun HM, Dagenais GR, et al. Design and baseline characteristics of participants in the Researching cardiovascular Events with a Weekly Incretin in Diabetes (REWIND) trial on the cardiovascular effects of dulaglutide. Diabetes Obese Metab. 2018;20(1):42‐49.