Helping Patients Achieve Their A1C Goals: Case Studies in Type 2 Diabetes
Clinicians apply glycemic goals and pharmacologic recommendations in the context of patient concerns and practical limitations. The best treatment option in theory may be one that is incompatible with patient goals, lifestyle, finances, or other issues. The following cases illustrate challenges in the application of American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) guidelines to patient care.
Case 1. A Young Woman Newly Diagnosed With Type 2 Diabetes
Sonja, a 38-year-old female, presented for routine follow-up of prediabetes diagnosed 2 years ago. No medication was initiated at that time. Her past medical history includes gestational diabetes mellitus (GDM) 4 years ago. Her father and two sisters, as well as several aunts and uncles, have type 2 diabetes mellitus (T2DM). Comorbid conditions include irritable bowel syndrome (diarrhea-dominant), for which she receives no treatment. Sonja is Hispanic. She is a nonsmoker who works full time as a dentist.
Sonja was diagnosed with T2DM at this visit based on the following changes in her laboratory values compared with those of 2 years ago: fasting glucose increased from 113 to 133 mg/dL; glycated hemoglobin (A1C), from 5.8% to 7.1%; weight, from 179 to 185 lb; and body mass index (BMI), from 29 to 30 kg/m2. Over the last 2 years, she lost 9 lb (about 5% body weight), then regained 15 lb. She walks or jogs four to five times per week unless it is “too cold outside.”
GDM, Prediabetes, and Preventing Progression to T2DM
As a Hispanic woman with a history of GDM and a family history of T2DM, Sonja has multiple strong risk factors for developing T2DM.1-3 Therapeutic lifestyle changes can prevent
or delay T2DM to a greater degree than metformin. A lifestyle intervention program with goals of 7% weight loss and at least 150 minutes per week of physical activity reduced the incidence of diabetes by 58% compared with placebo over 2.8 years of follow- up; metformin reduced diabetes incidence by 31%.4
The AACE consensus statement recommends consideration of metformin or acarbose therapy to reduce the risk of progression to T2DM. Given Sonja’s risk for T2DM, it would have been reasonable to start medication along with therapeutic lifestyle changes 2 years ago. Cardiovascular (CV) risk factors such as dyslipidemia and hypertension also should be addressed at this stage.5
This supplement is intended for physicians, nurses, nurse practitioners, physician assistants, CDEs, and other clinicians involved in the diagnosis and management of metabolic and endocrine disorders.
DONNA L. JORNSAY, MS, CPNP, CDE, CDTC
CHRISTINE KESSLER, CNS, ANP, BC-ADM, CDTC, FAANP
DAVIDA F. KRUGER, MSN, APRN-BC, BC-ADM
ELLEN D. MANDEL, DMH, MPA, PA-C, RDN, CDE
LUCIA M. NOVAK, MSN, ANP-BC, BC-ADM, CDTC
JOYCE ROSS, MSN, ANP, CRNP, FPCNA, FNLA
SCOTT URQUHART, PA-C, DFAAPA
KIM ZUBER, PA-C
Method of Participation
Participants should read the activity information, review the activity in its entirety, and complete the online post-test and evaluation. Upon completing this activity as designed and achieving a passing score on the post-test, you will be directed to a webpage that will allow you to receive your certificate of credit via email or you may print it out at that time.
The online post-test and evaluation can be accessed at https://tinyurl.com/meds16suppl
Inquiries may be directed to Global Academy for Medical Education email@example.com or (973) 290-8225.
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Cincinnati and Global Academy for Medical Education, LLC The University of Cincinnati is accredited by the ACCME to provide continuing medical education for physicians.
The University of Cincinnati designates this Live Activity for a maximum of 2.0 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Postgraduate Institute for Medicine (PIM) is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This educational activity for 1.3 contact hours is provided by Postgraduate Institute for Medicine. Pharmacotherapy contact hours are .4 for Advance Practice Registered Nurses and will be designated on your certificate.
Primary care providers are often the first point of care for diabetes and kidney disease. The Metabolic & Endocrine Disease Summit 2016, a CME/CE conference, explored the latest advances in the management of these conditions. Obesity raises the risk of many other conditions. Providers would benefit from a discussion of how to address this frequently encountered problem in clinical practice. Lipoprotein (Lp) (a) is an inherited, independent risk factor for atherosclerotic cardiovascular disease. New therapies show some promise for addressing this form of dyslipidemia. Diabetes raises the risk of major depressive disorder, and depression increases the risk of diabetic complications. Psychosocial intervention can improve glycemic control and symptoms of diabetes-related distress. Nephropathy is a common complication of diabetes but glycemic control, careful choice of medications, and regular monitoring can promote renoprotection.
Diabetes presents issues throughout a patient’s life; three touchpoints are the transition of a young adult from pediatrics to adult care, the detection and management of diabetes during pregnancy, and diabetes in the older adult. Anticipation of the relevant issues and implementation of a transition program can contribute to retaining young adults in care. Preconception counseling and early detection of diabetes can reduce the risk of adverse outcomes. Clinicians must be knowledgeable about how to balance the many complex issues to consider when establishing glycemic targets and selecting a treatment plan for an older adult with diabetes. At this writing, four new insulin-only preparations have been approved by the US Food and Drug Administration (FDA) since February 2015. The ability to differentiate these options is important for clinicians.
After reading and studying this journal supplement, participants should be better able to:
- Differentiate the many insulin options available to treat people with diabetes, and their applications in clinical practice
- Display an understanding of the contributors to and consequences of obesity, and interventions to address unhealthy weight
- Evaluate the contribution of elevated Lp (a) to vascular risk and its influence on treatment
- Apply the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) glycemic goals and pharmacologic recommendations in the context of individual patient concerns and practical limitations.
- Incorporate consideration of renal function in monitoring, medication choice, and general management of diabetes
- Understand common errors in medication choice and dosing that are associated with kidney injury, and plan how to avoid them
- Demonstrate an understanding of the effect of depression—and its treatment—on diabetes
- List tools to assess and manage depression in patients with diabetes
- Identify risks of transition of young adults with diabetes from pediatric to adult services, and list elements of successful transition
- Demonstrate familiarity with assessment and treatment recommendations for older adults with diabetes
- Detect and manage pregestational and gestational diabetes mellitus to reduce risk of complications for the mother and child during and after pregnancy
In accordance with the ACCME Standards for Commercial Support of CME, the speakers for this course have been asked to disclose to participants the existence of any financial interest and/or relationship(s) (e.g., paid speaker, employee, paid consultant on a board and/or committee for a commercial company) that would potentially affect the objectivity of his/her presentation or whose products or services may be mentioned during their presentation. The following disclosures were made:
Planning Committee Members
Susan P. Tyler No Relevant Relationships
Rick Ricer, MD No Relevant Relationships
Eileen McCaffrey No Relevant Relationships
Sylvia Reitman No Relevant Relationships
Shirley Jones No Relevant Relationships
The following PIM planners and managers, Judi Smelker-Mitchek, RN, BSN, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, and Jan Schultz, RN, MSN, CHCP, hereby state that they or their spouse/ life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
Donna L. Jornsay, MS, CPNP, CDE, CDTC, has indicated that she is a Consultant for Becton, Dickinson and Company and Eli Lilly; a Shareholder of Medtronic Diabetes; and is on the Speaker’s Bureau for Insulet.
Christine Kessler, CNS, ANP, BC-ADM, CDTC, FAANP, is a Consultant for AstraZeneca, Medtronic, and Novo Nordisk; and is on the Speaker’s Bureau for Novo Nordisk.
Davida F. Kruger, MSN, APRN-BC, BC-ADM, has indicated that she is on the Advisory Board of Abbott, Dexcom, Eli Lilly, Janssen Pharmaceuticals, Novo Nordisk; and Intarcia; on the Speaker’s Bureau for Abbott, Astra Zeneca, Boehringer Ingelheim, Dexcom, Eli Lilly, Janssen Pharmaceuticals, Novo Nordisk, Valeritas; has stock in Dexcom; and received grants/research support from Astra Zeneca, Dexcom, Eli Lilly, Helmsley Foundation, Lexicon, and Novo Nordisk, and receives research support of 40% salary from NIH.
Ellen D. Mandel, DMH, MPA, PA-C, RDN, CDE, has nothing to disclose.
Lucia M. Novak, MSN, ANP-BC, BC-ADM, CDTC, has indicated that she is on the Speaker’s Bureau for AstraZeneca, Janssen Pharmaceuticals, and Novo Nordisk.
Joyce Ross, MSN, ANP, CLS, CRNP, FPCNA, FNLA, has indicated that she is a on the Advisory Board for Akcea Therapeutics, Kaneka America, Kastle Pharma; and on the Speaker’s Bureau for AbbVie, Amarin, Amgen, Kaneka America, KOWA, and Sanofi/Regeneron.
Scott Urquhart, PA-C, DFAAPA, has indicated that he is on the Advisory Board for AstraZeneca and Shire; a Consultant for Abbott and Acella Pharma; and on the Speaker’s Bureau for Abbott and AstraZeneca.
Kim Zuber, PA-C, has indicated that she is on the Speaker’s Bureau for Amgen and Janssen Pharmaceuticals.
All information provided by program participants is confidential and will not be shared with any other parties for any reason without permission.
Contact Information for Technical Questions
Please technical questions or concerns to Global Academy for Medical Education at 973-290-8225 or email firstname.lastname@example.org.
The faculty acknowledge the editorial assistance of Global Academy for Medical Education, LLC, and Eileen McCaffrey, medical writer, in the development of this supplement. It has been reviewed and approved by the faculty as well as the editors of Clinical Endocrinology News.
Neither the editors of Clinical Endocrinology News nor the Editorial Advisory Board nor the reporting staff contributed to its content. The opinions expressed are those of the faculty and do not necessarily reflect the views of the supporter or of the Publisher.
Copyright © 2017 by Global Academy for Medical Education, LLC, Frontline Medical Communications Inc., and its Licensors. All rights reserved. No part of this publication may be reproduced or transmitted in any form, by any means, without prior written permission of the Publisher. Global Academy for Medical Education, LLC, will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned This continuing medical education (CME) supplement was developed from faculty presentations at the Metabolic & Endocrine Disease Summit October 5 - 8, 2016.
1. Scott RA, Langenberg C, Sharp SJ, et al. The link between family history and risk of type 2 diabetes is not explained by anthropometric, lifestyle or genetic risk factors: The EPIC-InterAct Study. Diabetologia. 2013;56(1):60-69.
2. Xiang AH, Li BH, Black MH, et al. Racial and ethnic disparities in diabetes risk after gestational diabetes mellitus. Diabetologia. 2011;54(12):3016-3021.
3. DeSisto CL, Kim SY, Sharma AJ. Prevalence estimates of gestational diabetes mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007-2010. Preventing Chronic Disease. 2014;11:E104.
4. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.
5. Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm--2016 executive summary. Endocr Pract. 2016;22(1):84-113.
6. Monnier L, Lapinski H, Colette C. Contributions of fasting and postprandial plasma glucose increments to the overall diurnal hyperglycemia of type 2 diabetic patients: Variations with increasing levels of HbA(1c). Diabetes Care. 2003;26(3):881-885.
7. Glucophage [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2017.
8. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: A patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2015;38(1):140-149.
9. Jardiance [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc; 2016.
10. Invokana [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; 2017.
11. Ongylza [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2017.
12. Farxiga [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2017.
13. Tradjenta [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc; 2017.
14. Januvia [package insert]. Whitehouse Station, NJ: Merck & Co. Inc.; 2017.
15. Nesina [package insert]. Deerfield, IL: Takeda Pharmaceuticals America Inc; 2016.
16. Actos [package insert]. Deerfield, IL: Takeda Pharmaceuticals America, Inc.: 2016. 17. Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of
intensive glucose lowering in Type 2 Diabetes. N Engl J Med. 2008;358(24):2545-2559. 18. Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, cardiovascular outcomes,
and mortality in type 2 diabetes. N Engl J Med. 2015;373(22):2117-2128.
19. Best JH, Hoogwerf BJ, Herman WH, et al. Risk of cardiovascular disease events in patients with type 2 diabetes prescribed the glucagon-like peptide 1 (GLP-1) receptor agonist exenatide twice daily or other glucose-lowering therapies: a retrospective analysis of the LifeLink database. Diabetes Care. 2011;34(1):90-95.