Optimizing Insulin Therapy and Cardiovascular Care in Patients With Type 2 Diabetes

In this educational session, Eric Ip, PharmD, BCPS, CSCS, CDE, from Kaiser Permanente presented on the treatment standards, interpretation, and assessment of insulin therapy regimens in patients with type 2 diabetes (T2DM). Ip practices within a collaborative care agreement, allowing him autonomy and prescribing authority in his practice.

Based on current American Diabetes Association (ADA) guidelines, the goal for glycated hemoglobin (A1C) is less than 7% for most patients. Other goals are also important to treatment, such as a preprandial plasma glucose level between 70 and 130 mg/dL, as well as the maintenance of a postprandial glucose level under 180 mg/dL. A notable change to the ADA guideline, Ip emphasized, was the recent introduction of a blood pressure goal of under 140/80 mm Hg. Other goals remain unchanged, including the goals for dyslipidemia, use of aspirin, statins, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs), as well as the administration of recommended vaccinations.

Pharmacists play an advisory role in ensuring the appropriate use of ACE inhibitors, ARBs, statin, and aspirin among patients with T2DM. However, in many US states, pharmacists can ensure that patients with diabetes also receive a recommended yearly influenza vaccine, a pneumococcal vaccine, and a hepatitis B vaccine series.

Relatively few patients are able to reach the goals set forth by the ADA guidelines. Fewer than 36% of patients achieve the A1C target of 7% or lower, and an even larger percentage of patients (60%) fail to achieve glycemic control before and after meals. Patients who meet multiple goals set forth by guidelines, such as appropriate A1C control, dyslipidemia control, and blood pressure control, comprise just 12.2% of patients with T2DM.

Ip noted that the consequences of poor adherence to guidelines include a higher incidence of myocardial infarction, stroke, and peripheral vascular disease. Additional microvascular complications of poor adherence include neuropathy and retinopathy. Eventually, the complications of T2DM may lead to the amputation of limbs, kidney failure, and blindness. Establishing an effective therapeutic regimen that may include insulin could help patients to achieve better outcomes and avoid or delay some of these complications of T2DM.

Continuing, Ip reviewed prior approaches to T2DM management, starting with the traditional stepwise approach, then moving on to a flow chart—based approach, and finally introducing the 2012 update to the ADA/European Association for the Study of Diabetes guidelines. This update recommends the use of lifestyle changes, followed by the addition of metformin. The 2012 update differs from prior guidelines in that 2-drug combinations with metformin include a choice from among several possible add-on therapies, including sulfonylureas, options such as sitagliptin and saxagliptin, and pioglitazone and rosiglitazone. Injectable treatments such as basal insulins and glucagon-like peptide-1 inhibitors are also acceptable add-on therapies to metformin. In a departure from previous guidelines, the updated 2012 guidelines recommend the use of insulin in multiple daily doses if a 3-drug combination fails to control blood sugar levels adequately.

Next, Ip presented an exhaustive review of the latest guidelines and standards of care in T2DM treatment in the context of clinical cases. Through these cases, Ip demonstrated the value of initiating therapy with a basal insulin, noting that approximately 60% of patients can achieve an A1C level under 7% with a basal insulin regimen. The value of these treatments was emphasized, noting that basal insulins are well tolerated, effective, and simple to implement with a daily bedtime injection.

Additional treatment goals, including blood pressure and cholesterol, were reviewed, as all are components of reducing cardiovascular risk. One point made was that common drug interactions and dosing escalation errors may lead to poor outcomes for patients taking statins, notably simvastatin. Ip noted that simvastatin should not be initiated at the 80-mg dose, but only at the 40-mg dose when other medications are being used. He reminded the audience that the use of several strong liver enzyme inhibitors is contraindicated with simvastatin, and that it is important to enforce dosage limitations with other enzyme inhibitors such as verapamil, diltiazem, amlodipine, ranolazine, and amiodarone.

Providing additional insight regarding the role of insulins, Ip also presented methods for initiating and adjusting appropriate insulin therapy in accordance with the promotion of increased use of these products per the new guidelines. Ip’s presentation may help healthcare professionals to more effectively assess blood glucose readings, tailor therapy to a patient’s specific needs, avoid common drug interactions, and achieve better outcomes for patients with T2DM.

In closing, Ip discussed recent publications that quantified the impact in terms of reduction in cardiovascular risk that pharmacist interventions had on patient outcomes. One of the most recent publications included findings from his organization and can be found at http://www.ajhp.org/content/70/10/877.