Improving Diabetes Outcomes

Full update January 2017

—Below are practical tips and resources to help improve outcomes in your diabetes patients—

Abbreviations: ACC = American College of Cardiology; ADA = American Diabetes Association; AHA = American Heart Association; ASH = American Society of Hypertension; CCS = Canadian Cardiovascular Society; CDA = Canadian Diabetes Association; CV = cardiovascular; JNC8 = Eighth Joint National Committee; SGLT2 = sodium-glucose cotransporter 2 (flozins).

Goal

Suggested Strategies or Resources

Set an appropriate A1C target.

Recommend an A1C <7% (ADA) or ≤7% (CDA) in many patients with diabetes to reduce complications.1,2

Select less stringent targets, such as <8% (ADA) or ≤8.5% (CDA), in certain diabetes patients such as those at risk for severe hypoglycemia, with limited life expectancy, or with advanced microvascular or macrovascular complications.1,2

Select more stringent targets, such as <6.5% (ADA) or ≤6.5% (CDA), to further reduce the risk of microvascular complications when the benefit outweighs the risk of hypoglycemia.1,2

The CDA has an online tool providers can use to individualize your patient’s A1C target at http://guidelines.diabetes.ca/bloodglucoselowering/a1ctarget.

Link to treatment guidelines from the ADA at http://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf, and from the CDA at http://guidelines.diabetes.ca/App_Themes/CDACPG/resources/cpg_2013_full_en.pdf and http://guidelines.diabetes.ca/cdacpg_resources/JCJD_6921.pdf.

Listen to PL VOICES, Managing Type 2 Diabetes in Elderly Patients (U.S. subscribers), or read about A Personalized Approach for A1C Goals.

Choose the most appropriate agent(s) to achieve the A1C target.

Start with metformin in most patients with type 2 diabetes.1,3 Metformin has negligible risk of hypoglycemia, does not cause weight gain, and may reduce cardiovascular risk.1,2

Keep in mind that thinking regarding metformin use in renal impairment is changing; many experts feel that its use is acceptable in patients with mild to moderate renal impairment.4 This change was recently incorporated into the U.S. prescribing recommendations for metformin-containing products. See our commentary, Clinical Use of Metformin in Special Populations, for details on metformin use in renal impairment, heart failure, and liver impairment.

Add meds to metformin for patients with type 2 diabetes based on A1C lowering, side effects, and cost.1,3 In patients with clinical cardiovascular disease, consider empagliflozin or liraglutide they reduce CV and overall mortality when added to standard care in patients with CV disease or at high CV risk (liraglutide).1,3 See our chart, Diabetes Medications and Cardiovascular Impact, for more information.

When goals aren’t met, scrutinize the patient’s med list for Drugs That Significantly Increase Blood Glucose.

For more information on drug therapy for type 2 diabetes, see our resources:

Ensure safe use of diabetes meds.

New insulin concentrations and products can create confusion. For strategies and resources to help prevent errors with insulin, see our chart, Tips to Improve Insulin Safety.

Metformin use may require special considerations in some patients. See our commentary Clinical Use of Metformin in Special Populations, for details on metformin use in renal impairment, heart failure, and liver impairment.

Keep in mind that that metformin is associated with B12 deficiency. Check levels every two to three years for patients at risk or with anemia or neuropathy (Canada: check every one to two years).1,13,14 For most patients, recommend 1000 to 2000 mcg/day of oral or sublingual cyanocobalamin for treatment of B12 deficiency and maintenance.15 For details on monitoring, diagnosis, and treatment, see our commentary, Management of Vitamin B12 Deficiency.

Some diabetes meds (glitazones, gliptins) have been associated with heart failure. For more information on gliptins and heart failure, see our commentary, DPP-4 inhibitors (Gliptins) and Risk of Heart Failure.

SGLT2 inhibitors (flozins) have been associated with ketoacidosis and serious urinary tract infections. Download a pdf of the FDA Safety Communication here.

Pioglitazone should not be used in patients with active bladder cancer, and risks and benefits should be considered before using pioglitazone in patients with a history of bladder cancer (U.S.).16 (Canada: contraindicated in patients with bladder cancer or a history of bladder cancer.17) Tell patients to report bloody or red urine, new or worsening urinary urgency, or pain with urination.16,17 Read the FDA Safety Alert here.

Give patients our patient education handout, How to Handle Low Blood Sugar (U.S. subscribers, Canadian subscribers).

Use a statin when appropriate.

Use a statin for primary prevention for most diabetes patients 40 years of age and older.5,6

  • AHA/ACC: diabetes and age 40 to 75 years with LDL 70 to 189 mg/dL (1.8 to 4.9 mmol/L) and an estimated 10-year risk of atherosclerotic cardiovascular disease of 7.5% or higher.5
  • CCS: diabetes and age ≥40 years, or diabetes >15 years’ duration and age ≥30 years, or diabetes with microvascular disease.6

Also consider a moderate or high-intensity statin in diabetes patients under age 40 or over 75 with risk factors, such as hypertension or smoking.1

Use a high-intensity statin (e.g., rosuvastatin 20 to 40 mg once daily or atorvastatin 80 mg once daily) for diabetes patients of any age with CV disease.1

For a complete list of statin indications, see our charts, 2013 ACC/AHA Cholesterol Guidelines (U.S. subscribers) or Canadian Cardiovascular Society Dyslipidemia Recommendations (Canadian subscribers).

For more information on choosing and using a statin, see our charts:

To help promote safe statin use, give patients our patient education handout, What You Should Know About Statins.

Meet an appropriate blood pressure goal.

Aim for a BP <140/90 mmHg in most diabetes patients (JNC 8, ASH, ADA).1,7, The ADA adds the caveat that a

target of <130/80 mmHg may be suitable for some patients (e.g., high CV risk), but only if it can be easily achieved.1 Note that Canadian guidelines recommend a goal of <130/80 mmHg for patients with diabetes.2,8

Start with an ACEI or ARB for hypertension in most diabetes patients.1,2,7,8

  • Those without specific indications for an ACEI or ARB (e.g., kidney disease) can start with a calcium channel blocker (ADA and Canadian guidelines specify dihydropyridine) or thiazide diuretic, especially African Americans (ASH, JNC8).1,2,7,8,9

For more information about blood pressure goals and choosing appropriate antihypertensives, see our resources:

Help pharmacy technicians brush up on treatment of high blood pressure with our technician tutorial, Hypertension 101.

Give patients our patient education handout, Blood Pressure Medications and You.

Start low-dose aspirin when appropriate.

Use low-dose aspirin (e.g., 81 mg/day) in diabetes patients with a history of atherosclerotic cardiovascular disease (e.g., heart attack, stroke).1,2

Aspirin’s benefit for primary prevention in patients with diabetes appears similar to that of the general population.10 Consider low-dose aspirin for primary prevention in diabetes patients at increased cardiovascular risk (e.g., age 50 and over with at least one other major risk factor such as hypertension, smoking, etc).1

Get more information about who will benefit most from low-dose aspirin from our chart, Aspirin for Primary Prevention.

Give patients our handout, Aspirin and Your Heart.

Make sure patients are up-to-date on vaccines.

Encourage adherence to the latest immunization schedule recommendations, which include administration of pneumococcal vaccine, influenza vaccine, and hepatitis B (ADA recommendation only) vaccine to patients with diabetes.1,2

  • ADA: Annual vaccination against influenza is recommended for all persons with diabetes six months of age and older. Vaccination against pneumonia with pneumococcal polysaccharide vaccine (PPSV23) is recommended for people with diabetes two through 64 years of age. At age 65 years, administer the pneumococcal conjugate vaccine (PCV13) at least one year after vaccination with PPSV23, followed by another dose of PPSV23 at least one year after PCV13 and at least 5 years after the last dose of PPSV23. Give the hepatitis vaccine series to unvaccinated adults with diabetes who are age 19 to 59 years. Also consider the hepatitis B vaccine series for unvaccinated adults with diabetes who are age 60 years or older.1
  • Immunization schedules can be found at http://www.cdc.gov/vaccines/schedules/hcp/adult.html (U.S.) and http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-chroni-eng.php#a7 (Canada; immunizations for persons with chronic diseases).

Ensure patients stay on appropriate medications through transitions of care.

Use the toolbox from AHRQ to optimize medication reconciliation (http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/match/match.pdf).

For more information on transitions of care, see our resources:

Pharmacy technicians can learn to assist patients with med lists using our technician tutorial, Mastering Medication Lists and Histories.

Help improve medication adherence.

Tailor medication regimens and educate patients with diabetes to help them adhere.

See our resources on improving adherence:

When patients are part of the decision-making process, they are more likely to be adherent. Most conditions have several reasonable treatment options, each carrying a different balance of risks and benefits. In these situations, “shared decision making,” which involves providing balanced information on the benefits and risk of each option, can be used.11

Use our resources to help educate diabetes patients about the need to tailor their medication regimens in specific situations:

Prevent and manage diabetes complications.

See our resources:

Use self-monitoring of blood glucose appropriately.

Recommend self-monitoring of blood glucose for patients who can benefit, such as those with type 1 diabetes, those with type 2 diabetes treated with insulin, or those with poorly controlled type 2 diabetes.1,2

In type 2 patients not taking hypoglycemic agents, multiple daily self-monitoring is not necessary except when therapy adjustments may be needed (e.g., acute illness, poor control, new meds, etc).12

For more information about self-monitoring of blood glucose, see our resources:

Give patients our handout: Understanding Your Blood Sugar Numbers (U.S. subscribers, Canadian subscribers).

Educate patients about diet, exercise, and other lifestyle changes.

Encourage beneficial lifestyle changes such as maintaining a healthy weight, smoking cessation, and regular physical activity for diabetes patients.1

Consider referral of diabetes patients to diabetes educators as appropriate. To find a certified diabetes educator, go to https://www.diabeteseducator.org/patient-resources/find-a-diabetes-educator.

Consider referral of diabetes patients to registered dietitians as appropriate. To find a registered dietitian, go to http://www.eatright.org/programs/rdfinder/.

For more information on beneficial lifestyle changes for patients with diabetes, see our resources:

Give patients our patient education handouts to take home:

Help schedule screenings as appropriate.

Encourage type 2 diabetes patients to schedule eye exams at least every two years (or at least every year if there is evidence of retinopathy), get screened for nephropathy annually (ADA: at least annually), get screened for neuropathy annually, and get foot exams at least annually.1,2

Learn about quality measures.

Learn more about quality measures for patients with diabetes from our toolboxes:

Use medication therapy management (MTM) to optimize treatment for patients with diabetes (U.S. pharmacists).

Medicare Part D patients with diabetes are eligible for MTM.

U.S. pharmacists can use our conversation starter, Improving Diabetes Care, as a guide when talking with diabetes patients during medication reviews or other patient interactions.

For more information on MTM, see our resources:

Use our technician tutorials to engage pharmacy technicians in the process of MTM:

Project Leader in preparation of this clinical resource (330202): Melanie Cupp, Pharm.D., BCPS

References

  1. Standards of medical care in diabetes – 2017. Diabetes Care 2017;40(Suppl 1):S1-135.
  2. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2013;37:S1-S12.
  3. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Pharmacologic management of type 2 diabetes: 2016 interim update. Can J Diabetes 2016;40:484-6.
  4. Clinical Resource, Clinical Use of Metformin in Special Populations. Pharmacist’s Letter/Prescriber’s Letter. March 2015.
  5. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129(25 Suppl 2):S1-45.
  6. Anderson TJ, Gregoire J, Pearson GJ, et al. 2016 Canadian Cardiovascular Society guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol 2016;32:1263-82.
  7. Clinical Resource, Hypertension Treatment in Patients with Diabetes. Pharmacist’s Letter/Prescriber’s Letter. April 2016.
  8. Hypertension Canada. Prevention and treatment. XII. Treatment of hypertension in association with diabetes mellitus. http://guidelines.hypertension.ca/prevention-treatment/hypertension-with-diabetes/. (Accessed January 1, 2017).
  9. Clinical Resource, Treatment of Hypertension: JNC 8 and More. Pharmacist’s Letter/Prescriber’s Letter. February 2014.
  10. Clinical Resource, Aspirin for Primary Prevention. Pharmacist’s Letter/Prescriber’s Letter. November 2015.
  11. Clinical Resource, Medication Adherence Strategies. Pharmacist’s Letter/Prescriber’s Letter. September 2016.
  12. Choosing Wisely. Endocrine Society. October 16, 2013. http://www.choosingwisely.org/societies/endocrine-society/. (Accessed January 3, 2017).
  13. Product information for Glucophage and Glucophage XR. Bristol-Myers Squibb Company. Princeton, NJ 08543. June 2015.
  14. Product monograph for Glucophage. Sanofi-Aventis Canada Inc. Laval, QC H7L 4A8. September 2015.
  15. Clinical Resource, Management of Vitamin B12 Deficiency. Pharmacist’s Letter/Prescriber’s Letter. May 2016.
  16. Product information for Actos. Takeda Pharmaceuticals America, Inc. Deerfield, IL 60015. December 2016.
  17. Product monograph for Actos. Takeda Canada Inc. Mississauga, ON L5N 2V8. May 2012.

Cite this document as follows: Clinical Resource, Improving Diabetes Outcomes. Pharmacist’s Letter/Prescriber’s Letter. February 2017.

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