Diabetes management: Beyond hemoglobin A1c

Cleveland Clinic Journal of Medicine. 2019 September;86(9):595-600 | 10.3949/ccjm.86a.18031
September 3, 2019|Cleveland Clinic Journal of Medicine
Vinni Makin, MBBS, MD, FACE;M. Cecilia Lansang, MD, MPH
Author and Disclosure Information

Vinni Makin, MBBS, MD, FACE
Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic; Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Clinical Assistant Professor, Ohio Heritage College of Osteopathic Medicine, Cleveland, OH

M. Cecilia Lansang, MD, MPH
Director, Inpatient Diabetes Service; Chair, Cleveland Clinic Health Systems Diabetes Care Committee; Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic; Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Address: Vinni Makin, MBBS, MD, FACE, Department of Endocrinology, Diabetes, and Metabolism, F20, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; makinv@ccf.org

Release date: September 1, 2019
Expiration date: August 31, 2020
Estimated time of completion: 1 hour

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ABSTRACT

Diabetes management is a tailored affair. Patients live with the disease for decades and need increasingly complicated treatment regimens to attain glycemic goals. But other goals such as cardiovascular risk reduction, weight control, and avoidance of hypoglycemia also need consideration.

KEY POINTS

  • Some glucagon-like peptide 1 (GLP-1) receptor agonists have been shown to reduce cardiovascular risk, and liraglutide carries an indication for this use.
  • The sodium-glucose cotransporter 2 inhibitors empaglifozin and canaglifozin carry indications to prevent cardiovascular death in patients with diabetes with established cardiovascular disease.
  • Metformin, GLP-1 receptor agonists, and dipeptidyl peptidase 4 inhibitors are beneficial in terms of promoting weight loss—or at least not causing weight gain.
  • Disadvantages and adverse effects of various drugs must also be considered.

LOOSER TARGETS FOR OLDER PATIENTS

In 2010, among US residents age 65 and older, 10.9 million (about 27%) had diabetes,30 and this number is projected to increase to 26.7 million by 2050.31 This population is prone to hypoglycemia when treated with insulin and sulfonylureas. An injury sustained by a fall induced by hypoglycemia can be life-altering. In addition, no randomized clinical trials show the effect of tight glycemic control on complications in older patients with diabetes because patients older than 80 are often excluded.

A reasonable goal suggested by the European Diabetes Working Party for Older People 201132 and reiterated by the American Geriatrics Society in 201333 is a hemoglobin A1c between 7% and 7.5% for relatively healthy older patients and 7.5% to 8% or 8.5% in frail elderly patients with diabetes.

Consider prescribing medications that carry a low risk of hypoglycemia, can be dose-adjusted for kidney function, and do not rely on manual dexterity for administration (ie, do not require patients to give themselves injections). These include metformin and DPP-4 inhibitors.

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DRUG COMBINATIONS

Polypharmacy is a concern for all patients with diabetes, especially since it increases the risk of drug interactions and adverse effects, increases out-of-pocket costs, and decreases the likelihood that patients will remain adherent to their treatment regimen. The use of combination medications can reduce the number of pills or injections required, as well as copayments.

Due to concern for multiple drug-drug interactions (and also due to the progressive nature of diabetes), many people with type 2 diabetes are given insulin in lieu of pills to lower their blood glucose. In addition to premixed insulin combinations (such as combinations of neutral protamine Hagedorn and regular insulin or combinations of insulin analogues), long-acting basal insulins can now be prescribed with a GLP-1 drug in fixed-dose combinations such as insulin glargine plus lixisenatide and insulin degludec plus liraglutide.

COST CONSIDERATIONS

It is important to discuss medication cost with patients, because many newer diabetic drugs are expensive and add to the financial burden of patients already paying for multiple medications, such as antihypertensives and statins.

Metformin and sulfonylureas are less expensive alternatives for patients who cannot afford GLP-1 analogues or SGLT2 inhibitors. Even within the same drug class, the formulary-preferred drug may be cheaper than the nonformulary alternative. Thus, it is helpful to research formulary alternatives before discussing treatment regimens with patients.