1. Tailoring type 2 diabetes management to each patient: case studies
15th MGSD Congress
27-29 April, 2017
Tailoring type 2 diabetes management to each patient: case studies
S. Al Sifri (Kingdom of Saudi Arabia)
Organized by

2. Case Studies Saud Alsifri, MD, FACE Alhada & Taif Armed Forces Hospitals

3. Voting Cards to be used

4. Noora
Middle-aged female Story of 2 years, First seen in January 2015, Last clinic visit February 2017

5. Patient Profile 56 years old Weight: 88Kg BMI: 30.5 kg/m2
Primary school teacher
Married with two children
Diagnosed with Type 2 diabetes for 10 years.
Known with Hypertension, Dyslipidemia.

6. Past Clinical history At diagnosis: Few years after diagnosis:
Started on lifestyle changes for few years, which brought her HbA1c from 8.9% to 7.5% and helped her to lose some weight.
Few years after diagnosis:
Metformin 500mg tid was added to lifestyle changes, in order to bring her HbA1c from 8.6% to 7.8%.
However, Metformin caused gastrointestinal side effects, so slow-release metformin (Metformin XR) was prescribed in order to address these side effects.
After a period of control, Noora’s HbA1c began to rise and the dose of metformin XR was uptitrated to 3 tablets od
10 years after diagnosis
Although the patient initially achieved control, her HbA1c has increased again to 8.7%.
Reluctant to Use Injections.

7. Physical Examination Height: 170 cm Weight: 88 kg BMI: 30.5 kg/m2 BP :
138/85 mmHg
Pulse: 72
Fundoscopy: Grade I
Neck: Thyroid not palpable
Heart: Normal
Lungs: Normal
Abdomen: no murmurs
Arteries: Normal
Neuro: decreased vibration & monofilament in feet

8. Labratory results 8.6 mmol/L 4.0-8.0 mmol/L 300 mmol/L 80-350 mmol/L
Test
Results
Normal values
Glucose
8.6 mmol/L
mmol/L
Uric acid
300 mmol/L
mmol/L
Creatinine
90 µmol/L
eGFR 80 ml/min
µmol/L K
3.8 mmol/L
mmol/L Na
136 mmol
mmol/l
HbA1c
8.7%
4.0 – 6.0 %
Urinalysis
Neg. proteinuria
Neg
Alb/creat
1.0 mg/mmol
mg/mmol CK
125
u/l
TSH
4.2
mUI/l
LDL
2.6 mmol/L
<3.0 mmol/L
Total chol
6.8 mmol/L
<5.20 mmol/L TG
1.8 mmol/L
<1.70 mmol/L
HDL
0.8 mmol/L
>0.99 mmol/L
Labratory results

9. Glycemic targets What would be your HbA1c Goal for her ?
Between %!
< 7 %!
> 8 %!
I’m happy with this HbA1c!

10. T2D management considerations for individualised
treatment: ADA/EASD Position Statement 2015
HbA1c Less than 6.5%
HbA1c 7%
HbA1c more than 8%
More stringent
Less stringent
Hyperglycaemia management approach
Hypoglycaemia and
AE risks
Low
High
Disease duration
Newly diagnosed
Long-standing
Life expectancy
Long
Short
Important comorbidities
Absent Few/mild Severe
Established vascular complications
Absent Few/mild Severe
Patient attitude
and expectations
Highly motivated Less motivated
Resources and support system
Readily available Limited
T2D, type 2 diabetes; AE, adverse event; CV, cardiovascular; ADA, American Diabetes Association; EASD, European Association for the Study of Diabetes. Adapted from Inzucchi SE et al. Diabetes Care 2015;38:140−149

12. Clinical course before January 20159
Time (Years) 8 7 6
HbA1c (%)
8.9
7.5
Diet & lifestyle changes
Diagnosis 2007
8.6
7.8 3 12
Metformin XR 3tabs od
Metformin 500mg tid
8.7
CLINIC VISIT
Jan 2015 Visit

13. Current clinical challenge
Metformin XR alone, at the current dosage, is not providing Noora with the glycaemic control she requires .
Despite good initial weight loss, she has been unable to maintain her weight despite making lifestyle changes

14. Concerns for choosing treatment
What is your main concern at this time for Noora?
Glycemic efficacy.
The Hypoglycaemia Risk, and weight gain.
CV Safety and Outcome.
All of the above.

15. Treatment options
What would be your preferred choice for Noora’s glycemic control?
Continue Metformin, and Add DPP-4 I !
Continue Metformin, and Add Liraglutide!
Continue Metformin and add Pioglitazone !
Continue Metformin, and Add SU!

16. EASD/ADA Guidelines. Diabetes Care 2015

17. Considerations Will the treatment choice...
Provide the glycaemic control that Noora’s requires.
Minimise the risk of hypoglycaemia and other S/E
Helps Noora maintain her body weight

18. Clinical Course (cont.)
Noora continued on Metformin XR 3 tablets od and started on Gliclazide MR 60 mg od.
After 4 months her A1c dropped to 7.3 %, and Weight 89 Kg, BP 132/85 mmgh, Reports no Hypoglycemia.

19. Treatment options What would you do at this time ? Continue the same !
Change Gliclazide MR into another SU !
Increase the dose of Gliclazide MR !
Continue Gliclazide MR and add a new agent !

20. Clinical Course (cont.)
Gliclazide MR increased to 90 mg od and continued Metformin.
4 months later, HbA1c 6.8 %, Weight 87 Kg, No hypos.
Continued on Same treatment.
6 months later, seen in OPD, HbA1c 6.9 %, Weight 86 Kg, No hypos.

21. Outcome till February 2017
Gliclazide MR 90mg was added to metformin XR 3 tab.
Noora has regained glycaemic control
HbA1c decreased to 6.9%
Weight maintained at 86 Kg
BP 130/80 mmHg
Noora has also benefited from the additional features of Gliclazide MR
She has maintained her weight
She has not experienced hypoglycaemia.

22. Clinical course: HbA1c HbA1c (%) Time (months) Diagnosis Jan 20158 7 6
HbA1c (%)
8.9
7.5
Diet & lifestyle changes
Diagnosis
8.5
7.8
3yrs
10 yrs
6yrs
9yrs
metforminXR 3tabs od
Add Gliclazide MR 60mg od
Metformin 500mg tid 9
Inc. Gliclazide MR 90mg od
Continue Same
8.7
Continue same
Continue Same
7.3
6.8
6.9
Jan 2015
Feb 2017 30 36 40

24. Ali
Young middle-aged male Newly diagnosed, First seen in August 2016, Last clinic visit January 2017

25. Patient Profile 48 years old Weight: 80Kg BMI: 27.3 kg/m2
Government officer
Married with three children
Diagnosed with Type 2 diabetes for 2 months.
Not following diet, and minimal daily activity.
No known chronic illness.

26. Physical Examination Height: 178 cm Weight: 80 kg BMI: 27.3 kg/m2 BP :
125/75 mmHg
Pulse: 78
Funduscopic: Normal
Neck: Thyroid not palpable
Heart: Normal
Lungs: Normal
Abdomen: no murmurs
Arteries: Normal
Neuro: Normal

27. Laboratory results 10.6 mmol/L 4.0-8.0 mmol/L 60 µmol/L eGFR 90 ml/min
Test
Results
Normal values
Glucose
10.6 mmol/L
mmol/L
Creatinine
60 µmol/L
eGFR 90 ml/min
µmol/L K
4.1 mmol/L
mmol/L Na
140 mmol
mmol/l
HbA1c
9.0%
4.0 – 6.0 %
Urinalysis
+ve proteinuria
Neg
Alb/creat
4.0 mg/mmol
mg/mmol

28. Glycemic targets What would be your HbA1c Goal for him ? < 6.5 % !
Between % !
> 7.5 %!
I’m happy with this HbA1c!

29. Treatment options
What would be your preferred choice for Ali’s glycemic control?
Lifestyle modification only!
LSM and DPP-4I!
LSM and start Metformin!
LSM, Metformin and SUs !

30. Clinical Course (cont.)
Given Instructions on diet and exercise by D. educator, and started on Metformin IR 500 mg od, to be increased gradually over the coming 4 weeks to reach Metformin mg bd.
Came back after 1 month reporting nausea, vomiting, bloating, and diarrhoea with metformin.

31. Clinical Course (cont.)
Metformin IR was replaced with Metformin XR 750 mg od, to be gradually increased by 1 tab. Every week.
Return back to his regular clinic visit after 3 months.
Reporting nausea, stomach pain, and bloating with metformin XR, even with one tablet.

32. Clinical Course (cont.)
At this time, HbA1c 8.8 %, weight: 80 Kg.
Trying his best to maintain Lifestyle modification, but very hard for him.
Taking no medications.

33. Treatment options
What would be your preferred choice for Ali’s glycemic control at this time?
Continue Lifestyle modification only!
Start Gliclazide MR 60 mg od!
Start DPP-4I !
Start SU and Basal Insulin!

34. Clinical Course (cont.)
He was started on Gliclazide MR 60 mg od and stressed over diet, exercise and SMBG twice daily.
Came after 4 months, HbA1c 7.1 %, weight 78 kgs, No hypos, maintaining diet and exercise.
Renal function: e-GFR; 90 ml/min, UACR; 3.6 mg/mmol.

35. Treatment options What would you suggest for his glycemic control?
Keep the same!
Add DPP-4I !
Increase Gliclazide MR 90 mg od!
Add Basal Insulin!

36. Clinical Course (cont.)
His Gliclazide MR dose increased to 90 mg od along with maintaining LS changes.
After 3 months, HbA1c 6.6 %, weight 78 kgs, No hypos, following diet and exercise.
Renal function: e-GFR; 90 ml/min, UACR; 1.6 mg/mmol, Negative Proteinuria.

37. Summary

38. Pros and cons of 2nd line diabetes therapies1
Sulfonylurea
Gliclazide MR
Pioglitazone
SGLT-2 I
Insulin
GLP-1 RA
DPP-4 I
Efficacy ++ **
+++
Cardiovascular outcome studies
Yes
Yes2 No
(in progress)
Hypoglycaemia as consequence of individual drug
Higher*
Low
Weight gain NO
Wt Loss
Wt loss
Disadvantages
Hypoglycaemia
Being in SU class
Fluid retention
Increased risk of osteoporosis and fractures3 Bladder cancer4
UTIs, Genital Infections, Dehydration
Gastrointestinal side effects
Long-term safety not established
DPP-4=dipeptidyl peptidase-4; GLP-1=glucagon-like peptide-1.
1Adapted from Nathan DM, et al. Diabetologia. 2009; 52: 17–30; 2Ruige JB, et al. Circulation. 1998; 97: 996–1001; 3Lecka-Czernik B. Curr Osteoporos Rep. 2010; 8: 178–184 4EMA/CHMP/568262/2011 press release accessed July 23rd
*Compared to non-insulin secretagogues

39. Summary of Canadian Guidelines: Checklist
2016
CHOOSE initial therapy based on glycemia
START with Metformin +/- others
INDIVIDUALIZE your therapy choice based on characteristics of the patient and the agent
REACH TARGET within 3-6 months of diagnosis 39

40. Thank
You
HOPE= SAUD
Amie Vanderford