A1c or Ambulatory Glucose Profile?
The 2020 ADA Standard Six, reviews Glycemic Targets. Two things caught my eye in this section:
- The updated estimated Average Glucose (eAG) chart not only shows the relationship to A1c and eAG, it also shows the range of glucose for any of the given A1c values. This extra data will certainly be helpful as we discuss the significance and meaning of A1c results with participants.
- Also, for participants utilizing CGM technology, this standard recommends that providers of diabetes care review the Ambulatory Glucose Profile (AGP) report each visit.
Ambulatory Glucose Profile (AGP) Report benefits: Since the A1C does not provide a measure of glycemic variability or hypoglycemia, the AGP is especially helpful for those prone to bigger glycemic swings.
Glycemic management is best evaluated by the combination of results from SMBG or CGM and A1C. A review of the AGP Report is recommended at each visit for those using CGM technology.
The overall goal is to reach Time in Target Range (70-180) at least 70% percent of the time with minimal hypo and hyperglycemia. In this snapshot ADP Report example below, we see that the A1c is 7.6%, but when we look at the right hand Time in Range side, we quickly note that this individual is struggling with frequent lows and very low glucose levels coupled with hyperglycemia. The time is range is only 47%.
This data is invaluable to help start the process of problem solving to decrease hypo and hyperglycemic events and increase time in target.
An A1c by itself, even if accompanied with frequent blood sugar checks, may not capture this complete picture of 24 hour glucose variability.
See our blog on Time in Range for more info about targets for different groups.
Those are just some of the highlights of the 2020 Standards of Care. Please join Coach Beverly on January 21st at 11:30 for her annual State of the Standards Live Webinar.
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Fiasp (faster aspart) approved for Pediatrics
After treat-to-target trial findings showed that mealtime and postprandial treatment with Fiasp resulted in effective glycemic control and safety results similar to slightly slower insulin aspart (Novolog), the FDA has approved Fiasp for use in pediatrics with diabetes.
Fiasp, a rapid-acting human insulin analog, was compared with NovoLog in a randomized trial involving 777 pediatrics (aged 2 to 17 years). There were blind meal injections and open-label postprandial injections. Week 26 of the trial showed both were effective at getting glucose to target.
In children and adolescents with type 1 diabetes, mealtime and postmeal faster aspart with insulin degludec provided effective glycemic control and superior HbA1c with no additional safety risks versus aspart (Novolog).
Read more at PubMed.
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2019 ADA Meds Management Update
Standards of Care Section 9 – Pharmacologic Approaches to Glycemic Treatment
Insulin Therapy for Type 1
This updated version of Meds Management includes more detailed information on insulin therapy for Type 1s. They note that the Diabetes Control and Complications Trial (DCCT) demonstrated that intensive therapy with multiple daily injections or insulin pump therapy reduced A1C and was associated with improved long-term outcomes. The study used short-acting and intermediate-acting human insulins. Since DCCT, rapid-acting and long-acting insulin analogs have been developed. These analogs are associated with less hypoglycemia, less weight gain, and lower A1C than human insulins in people with type 1 diabetes.
Type 2 Management Strategies – Pharmacologic Therapy of Type 2 Diabetes – 2019
Pharmacologic Approaches to Glycemic Treatment 2019. This hyperglycemia road map details strategies to achieve glucose control for both Type 1 and Type 2 Diabetes. Section 9 of Standards of Care, January 2019.
Step 1 –
According to the ADA 2019 Standards, section 9, Metformin therapy should be started along with lifestyle management at diagnosis of type 2 Diabetes (unless contraindicated). Metformin is effective, safe, inexpensive and may reduce risk of CV events and death. If contraindicated, see figure 9.1 for alternatives.
Step 2
If A1c target is not achieved after 3 months, consider metformin and any one of the six preferred treatment options based on drug specific effects and patient factors. These factors include cardiovascular disease (ASCVD), congestive heart failure (CHF) or Chronic Kidney Disease (CKD). Plus, preventing hypoglycemia, weight gain and making sure medications are affordable.
If the patient has ASCVD, CHF or CKD, consider adding a second agent with evidence of cardiovascular risk reduction (based on drug specific effects and patient factors).
Medications indicated to improve CVD, CHF and CKD outcomes include:
- SGLT-2 Inhibitors – empagliflozin (Jardiance), canagliflozin (Invokana), dapagliflozin (Farxiga)
- GLP-1 Receptor Agonist – liraglutide (Victoza), semaglutide (Ozempic)
Step 3
If A1c target is still not achieved after 3 months, combine metformin plus two other agents for a three-drug combination. Drug choice should be based on avoidance of side effects such as hypoglycemia, weight gain, cost, and individual preference.
Step 4
If A1c target is still not achieved after 3 months, add combination injectable therapy to the three-drug combination.
For all steps, consider including medications with evidence of CV risk reduction, based on drug specific effects and patient factors.
Medication Therapy Based on A1c
- Upon initial diagnosis of type 2, most can consider monotherapy
- If A1c is greater than or equal to 1.5% above target, consider dual therapy
- If A1c is greater or equal to 10%, or if BG 300 or more, or pt is markedly symptomatic (polyuria/polydipsia), consider insulin and injectable therapy.
Want to learn more about this topic?
- Meds Management Update Ready for On Demand Viewing!
- Join our Standards of Care Webinar – Jan 21, 2020
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Metformin May Prevent Breast & Other Cancers
Multiple studies have examined metformin for its potential tumor and cancer fighting ability. The National Center for Biotechnology Information (NCBI) published such a study in 2016. Researchers found substantial pre-clinical evidence suggesting anti-cancer properties of metformin based on in-vitro and in-vivo analysis. Their analysis suggested metformin could be used as a radiation sensitizer or immunotherapy drug, besides its direct anti-proliferative properties .
In mice with lung cancer, metformin was used and researchers saw a 72% reduction in tumor burden. Tumors are known to exhibit the Warburg effect, but metformin blunts this and consequently downregulates the growth of cancer stem cells.
Several observational studies showed a correlation between metformin use and lessened cancer incidence. The results demonstrated that metformin users have statistically significant reductions in liver, pancreatic, colorectal and breast cancers.
You can read more details on the study and enjoy their infographics and tables of data here.
Coach Beverly reports no conflict of interest for medication postings.
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October Newsletter | New Oral GLP-1: an Easier Pill to Swallow?
October Newsletter Now Available!
Our October Newsletter is brimming with medication updates! From Oral GLP-1 to Semaglutide and pre-filled Glucagon, we’re keeping you up to date AND updating our PocketCards. Did you know you can hire Coach Beverly to come speak in your hometown? Read this month’s Newsletter to find out how to request her time.
October News Topics Include:
- Oral GLP-1: Easier to Stomach than Injectables?
- Canagliflozin Slows Kidney Disease and Protects the Heart
- Diabetes & Breast Cancer
- 25% Off Live Webinars
- Updated DiaBingo
- 7 Strategies to Survive Halloween
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Metformin Decreases All Cause Mortality
A post-analysis of the SAVOR-TIMI 53 trial and a review of 17 different observational studies showed metformin use is associated with decreased all-cause mortality in people with type 2 diabetes and a high risk of cardiovascular events.
In a previous systematic review of 17 observational studies published in the Annals of Internal Medicine in 2017, researchers concluded that metformin use is associated with decreased all-cause mortality in patients with CKD, congestive heart failure, or chronic liver disease with hepatic impairment.
Find out more details about the Harvard Medical School study here.
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Pre-Filled Glucagon Pen Approved by FDA
Xeris Pharmaceuticals new pre-filled glucagon pen, Gvoke, just received FDA’s stamp of approval to treat severely low blood sugar levels in people with diabetes.
The Gvoke glucagon pen is filled with a liquid stable form of glucagon and is approved for use in people with diabetes, age 2 and above. Xeris will have the pre-filled syringe version available in 4-6 weeks and the auto-injector version available in 2020.
The Xeris glucagon pen was created to simplify glucagon injections. This new Gvoke pen does not require any mixing, since it is filled with liquid stable glucagon.
Availability of a glucagon delivery device is critical to treat severe hypoglycemia and prevent serious consequences of untreated severe hypoglycemia such as cardiovascular events, seizure, coma, or even death.
Read more about the Gvoke Glucagon Pen and auto-injector here .
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Eversense CGM approved for Treatment Decisions
Continuous glucose monitoring (CGM) uses interstitial fluid to provide real time glucose readings. Some CGMs have a nonadjunctive dosing indication, which means that users can base treatment decisions on the CGM reading.
Most recently, Eversense CGM received the nonadjunctive indication from the FDA. This means that Eversense users will not have to check fingersticks to make treatment decisions in the near future.
However, users will still need to calibrate the Eversense CGM twice daily and will need to download a new app before they can base treatment on the CGM readings.
The Eversense is the first long-term implantable CGM device that can be used for up to 90 days before replacing. The sensor is inserted via an in-office procedure in the upper arm by a trained physician. A fluorescent chemical coating on the outside of the sensor generates a small amount of light in response to the amount of sugar that is present in fluid under the skin (interstitial glucose). This light signal is converted into a glucose reading and transmitted wirelessly every five minutes to a compatible mobile device.
Read more in Endrocrine Today – FDA approves nonadjunctive indication for Eversense CGM.
For more information visit the Eversense Website
Want more practice for the exam? Try our new Technology Toolkit, meant to assist with studying based on the updated CDCES content outline!
Earn 3 CEs and join coach Beverly for her second airing of the Toolkit Live on September 11 and 13, 2019. Purchase includes On-Demand viewing now and the ability to join live later.
Two Online Courses are included in this Technology Toolkit:
- Tech 101 – Pumps and Sensors Update and Overview and
- Tech 102 – Insulin Pump Calculations: From Basal to Square Bolus
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