Therapy of Type 2 Diabetes Mellitus: UPDATE Glycemic Goals in the Care of Patients with Type 2 Diabetes- 2013 ADA and AACE Guidelines: Room For Improvement (Be HAPPY/ Avoid Burnout, While Caring for Patients with DM) Stan Schwartz MD, FACP, FACE Affiliate, Main Line Health System Clinical Associate Professor of Medicine, Emeritus, U of Pa. Part 8 1

Non-Insulin Therapy for Type II Diabetes 2

Concurrent Therapy 3

The ABCs of Diabetes Care: Recommended Goals A1C ADA recommends < 7.0% in general, < 6.0% in selected individuals AACE/IDF recommend ≤ 6.5% Blood pressure < 130/80 mm Hg Cholesterol LDL-C: < 100 mg/dL (< 70 mg/dL in very high-risk patients) HDL-C: > 40 mg/dL in men and > 50 mg/dL in women Non–HDL-C: < 130 mg/dL (< 100 mg/dL in high-risk patients) Triglycerides: < 150 mg/dL American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12-S54. AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. Endocr Pract. 2007;13(suppl 1):3-68. IDF Clinical Guidelines Task Force. Diabet Med. 2006;23:579-593. AACE = American Association of Clinical Endocrinologists IDF = International Diabetes Federation

Treating the ABCs Reduces Diabetic Complications Strategy Complication Reduction of Complication Blood glucose control Heart attack  37%1 Blood pressure control Cardiovascular disease Heart failure Stroke Diabetes-related deaths  51%2  56%3  44%3  32%3 Lipid control Coronary heart disease mortality Major coronary heart disease event Any atherosclerotic event Cerebrovascular disease event 35%4 55%5 37%5 53%4 1 UKPDS Study Group (UKPDS 33). Lancet. 1998;352:837-853. 2 Hansson L, et al. Lancet. 1998;351:1755-1762. 3 UKPDS Study Group (UKPDS 38). BMJ. 1998;317:703-713. 4 Grover SA, et al. Circulation. 2000;102:722-727. 5 Pyŏrälä K, et al. Diabetes Care. 1997;20:614-620.

Steno-2- Synergy in Care- Treating Glucose, BP, Lipids

USE GLP-1 RECEPTOR AGONISTS AND SGLT-2 Inhibitors for Wt. Reduction

- HYPERGLYCEMIA - - SGLT2 3.Muscle- Hepatic glucose production: Non-Insulin Therapy for Hyperglycemia in Type 2 Diabetes, Treating Defronzo’s Octet: WITHOUT HYPOGLCEMIA Match Patient Characteristics to Drug Characteristics 1.Pancreatic insulin Secretion: Incretin, ranolazine 5.Gut CHO Absorption: Incretin, Pramlintide, Glucosidase inh. - 7.Brain- TZD,INCRETIN, bromocryptine 2.Pancreatic glucagon Secretion- Incretin 8.Kidney- SGLT2 HYPERGLYCEMIA Peripheral glucose uptake De - - 3.Muscle- TZD, Incretin Hepatic glucose production: Metformin, incretin 4.Liver 6.Fat- TZD, metformin 10

Revised Treatment Algorithm The New ADA Guidelines for Type 2 Diabetes: AKA- David Nathan’s Regimen- DNR- COST BASED Revised Treatment Algorithm Intensive insulin At diagnosis: Lifestyle + metformin STEP 1 STEP 2 Tier 1* Tier 2† STEP 3 Add basal insulin Add sulfonylurea Add GLP-1 agonist Add pioglitazone ± SU HbA1C >7.0% NOT Glyburide, chlorpropamide NOT Rosiglitazone

New ADA Guidelines- 4/20/12 SU most prominent Added back glyburide For EUROPEAN SENSIBILITIES NO MEDICAL LOGIC Also, SLOW COMBO TX Inzucchi, Diabetologia 4/20/12