1. Diabesity Management Colette Walter, NP

2. Objectives 1. Pharmacologic management and understanding of treatment related to the overweight diabetic patient. 2. Understanding of mechanism of action of all diabetic medications and associated weight loss implications. 3. Utilizing pharmacotherapy from a nurse practitioner stand point in aggressively treating diabetes and concomitant obesity.

3. Disclosure None

4. Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI ≥30 kg/m 2 ) Diabetes 1994 2000 No Data 26.0% No Data 9.0% CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics 2013

5.  Type II Diabetes Overview Insulin Resistance Beta-cell failure over time Usually older Latent Autoimmune (Type 1.5) –Mixed features –~10% of Type II

6. Islet  -cell Impaired Insulin Secretion NeurotransmitterDysfunction Decreased Glucose Uptake Islet  -cellIncreased Glucagon Secretion IncreasedLipolysis Increased Glucose Reabsorption IncreasedHGP Decreased Incretin Effect

7. Type II Diabetes American Diabetic Association European Association for the Study of DM –2012 revamp protocols –New medications –Glucose control focus –CV risks Weight, smoking cessation, lipid, Statins & antiplatelets

8. Goals Obesity Smoking Cessation Lifestyle A1c < 7.0% FBS 70-130 Postprandial <180

9. Surgery Pharmacotherapy Lifestyle Modification Diet Physical Activity

10. Pharmacotherapy Biguanides Sulfonylureas Meglitinides TZDs Alpha-Glucosidase Inhibitors DPP-4 inhibitors Bile acid sequestrants Dopamine-2 agonists SGLT2 inhibitors GLP-1 receptor agonist Amylin mimetics Insulins

11. Focus Biguanides GLP-1 RA SGLT-2 inhibitors PRAML (amylin mimetics)

18. Biguanides MOA  hepatic glucose production Cheap Slight weight loss Moderate GI symptoms CVD benefit No bone, CHF, or Hypoglycemia *** Renal dosing

19. SGLT2 inhibitor MOA  glucose uptake proximal nephrons Expensive – discounts Weight loss No GI sx  BP, no hypoglycemia All Stages (mono or combo) Increase Cr, LDL, Polyuria, GU infx ? Bone loss

20. PRAML MOA activates amylin receptors Slows gastric emptying, glucagon sec  weight & PPG GI symptoms Hypoglycemia with insulin Injectible qac Frequent dosing Education required

21. GLP-1 RA Glucagon-like Peptide RA MOA – activates GLP-1 receptors –Insulin secretion, glucagon sec, gastric empty Weight loss GI upset  HR, pancreatitis, thyroid tumors Injectible QD, QW Renal dosing