Another great (as always) podcast and show notes, #168 Diabetes Update with Jeff Colburn MD, By from The Curbsiders:
SGLT2 INHIBITORS, GLP1 AGONISTS, INSULIN THERAPY, A1C PITFALLS, GLYCEMIC TARGETS, AND MORE!
Step up your diabetes game! We answer your questions from #MedTwitter. Returning guest, Jeff Colburn MD, FACP, FACE (USU) gives us a much needed diabetes update. Topics include: the pitfalls of A1C testing, the A1C target controversy, lifestyle interventions, continuous glucose monitoring, pathophysiology of type 2 diabetes (T2DM), use of SGLT2 inhibitors, GLP1 agonists, and how to initiate and titrate insulin therapy.
And here are some excerpts:
Diabetes Update Pearls from Kashlak
Dr. Colburn mentions the following rough calculation: A1C of 6% = average glucose of 126 mg/dL. Add 30 mg/dL for every 1% increase in A1C (e.g. 7% = average glucose 156 mg/dL and so forth).
When adding an SGLT2 inhibitor* to insulin therapy, Dr. Colburn recommends lowering a patient’s total daily insulin dose by 20-30% to prevent hypoglycemia –expert opinion.
*SGLT2 (sodium-glucose co-transporter 2) inhibitors are prescription oral medications used to treat type 2 diabetes.
Brand and generic names of SGLT2 inhibitors and combination products that contain SGLT2 inhibitors include:
- canagliflozin (Invokana)
- canagliflozin/metformin (Invokamet)
- canagliflozin/metformin extended release (Invokamet XR)
- dapagliflozin (Farxiga)
- dapagliflozin/metformin extended release (Xigduo XR)
Check a basic metabolic panel one week after initiation of an SGLT2i –expert opinion.
Dr. Colburn points out that lower limb amputations, euglycemic DKA and Fournier’s gangrene are infrequent adverse outcomes with the use of SGLT2 inhibitors and should not prevent most patients from deriving a therapeutic benefit –expert opinion.
Once weekly GLP1 agonists* take about 5 half lives (5 weeks) to reach steady state. Dr. Colburn recommends lowering a patient’s total daily insulin dose by 20-30% to make room for these agents –expert opinion.
*Incretin mimetics (GLP1 agonists) are a relatively new group of injectable drugs for treatment of type 2 diabetes.
The drugs, also commonly known as glucagon-like peptide 1 (GLP-1) receptor agonists or GLP-1 analogues, are normally prescribed for patients who have not been able to control their condition with tablet medication.
Additional Resources:
(1) Standards of Medical Care in Diabetes—2019 Abridged for Primary Care Providers [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Clin Diabetes. 2019 Jan;37(1):11-34. doi: 10.2337/cd18-0105.
(1) How to Use Ketogenic Diets in Patients With Type 2 Diabetes
Jay H. Shubrook, DO; Rucha J. Mehta, MD. August 27, 2019 from medscape.com.
The above is an outstanding introduction to the practical use of ketogenic diet. Dr. Mehta provides detailed practical instruction on initiating and monitoring a ketogenic diet.
(2) Focus on Lifestyle Changes: The Indian Diabetes Guidelines
Jay H. Shubrook, DO; Rucha J. Mehta, MD. September 21, 2018 from medscape.com.
(1) Choosing a First Injectable in Type 2 Diabetes: Try a GLP-1
Jay H. Shubrook, DO; Neil S. Skolnik, MD. February 11, 2019 from medscape.com.
(1) Mayo Clinic Shared Decision Making National Resource Center
(1) Diabetes Medication Choice from the Mayo Clinic Shared Decision Making National Resource Center
