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T2DM Non-Insulin Management

Stephanie Ureña, PGY 1

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Overview

CASE

TREATMENT WITH MEDICATION

PRACTICE CASES

RELATIONSHIP INTO FOOD INSECURITY

GUIDELINES

PRACTICE COUNSELING

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Case

50 yo M with pmhx of PAD (multiple revascularization procedure) and htn presenting as a new patient.
On Chart Review, Hgb A1C of 12 one month ago.

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��Medication Side Effects and A1C Effects

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Navigating GI Side Effects

Metformin: Slow dose titration, slow release formula, administer with food
GLP1: Smaller meals, mindful eating (i.e. stop eating when full), decreasing intake of high-fat or spicy food, consider slow-dose titration
GLP1/GIP: Same as above, of note, contraindicated for people with hx of gastroparesis

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Sample Cases

Patient with pmhx of CKD
Patient with pmhx of MI
Patient with pmhx of very elevated sugars and want to lose weight
Patient with pmhx of HFrEF
Patient with pmhx of HFpEF
Patient with elevated sugars only interested in oral medication

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In 2023, non-Hispanic Black or African American adults were 1.4 times more likely than non-Hispanic white adults to be diagnosed with diabetes

In 2022, Hispanic adults were 60% more likely than non-Hispanic white adults to be diagnosed with diabetes by a physician.

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Why?

Increased likelihood of diabetes increased with level of acculturation
The Western diet: high intake of red and processed meat, white bread, and refined sugars.
Inadequate diabetes education and lack of access to preventive health care.
Values- i.e. finishing all food even if not hungry
Discrimination and coping

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T2DM and Food Insecurity

Pressure individuals to more frequently choose energy-dense, nutritionally poor, and more highly processed food items that tend to be lower in cost than more healthy alternatives.
Volatile sugars:

These foods can lead to increased insulin resistance and higher blood glucose levels among individuals with diabetes.
Low food availability at the end of the month can also result in hypoglycemia.

Individuals anticipating a lack of food in the future or with recent experiences of food inadequacy may also compensate by binging when food is available.

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Interventions

Food Pantries
Medically Tailored Meals
Produce prescription programs
SNAP
WIC
DSME (Diabetes Self-Management Education) Referral

Food is Medicine Coalition: FIMC is the national convening coalition for nonprofit medically tailored meal (MTM) and grocery (MTG) providers. We equip nonprofits to launch new medically tailored meal (MTM) programs through the FIMC Accelerator, support a diverse community of practice for existing practitioners through Membership, and accredit MTM agencies against a standard to ensure fidelity to high quality MTM intervention.

National Produce Prescription Coalition: advance federal and state policy change that leverages Produce Prescriptions as prevention & intervention for diet-related disease and further embeds this effective model into healthcare and food retail systems.

https://fimcoalition.org/programs/

https://nppc.health/about/

https://www.cdc.gov/diabetes/education-support-programs/index.html

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Guidelines

Hgb A1C every three months if your medications have changed or your last A1C was not in your target range.

Every six months if your last A1C was in goal range.

Albumin to Creatinine ratio: Once a year, if you have type 2 diabetes or have had type 1 diabetes for at least five years. More frequently, if your previous test above the target (At least twice a year if your previous test showed signs of kidney disease.)

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Guidelines

Lipids: Adults with diabetes under age 40:

at diagnosis and at least every five years afterward.
At age 40 and/or when you start statin medications to treat high cholesterol.
Four to 12 weeks after beginning medication, you’ll get retested to make sure you’re on the right dose. If your numbers look good, you’ll repeat it annually.

Diabetic foot exam annually
Optho for Diabetic Retinopathy: People with any type of diabetes who have eye disease: at least annually

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Example of Diabetic Retinopathy

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What is the Hgb A1C goal?

Goal for most non-pregnant adults. Achieving A1C targets of <7% (53 mmol/mol) has been shown to reduce microvascular complications of type 1 and type 2 diabetes when instituted early in the course of disease.

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Let's Practice Counseling

Patient who is amenable to all medications and Hgb A1C of 10 with no comorbidities
Patient who would like to do one medication at a time and Hgb A1C of 10
Patient who last had Hgb A1C 1 month ago (10) and wants a repeat test today
Patient who declines Metformin because of GI side effects

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Summary

MAKE SURE YOU ARE LOOKING AT A PATIENT'S COMORBIDITIES WHEN FIRST SUGGESTING MEDICATIONS.

COUNSEL PATIENTS ABOUT SIDE EFFECTS BEFORE THEY HAPPEN AND BRING UP REALISTICALLY BY HOW MUCH MEDICATIONS LOWER THE A1C.

MANY MEDICATIONS CAUSE GI SIDE EFFECTS THAT CAN IMPROVE WITH MODIFICATIONS AND TIME.

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Summary

Sometimes the answer is in the resources that the patient has available!

The ideal Hgb A1c depends on patient/disease factors.

Don’t forget to check how often the need labs/referrals/foot exams!

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Sources