Are you Prescribing Too much Insulin for Persons with Type 2 Diabetes?

by Timothy Gieseke, MD, CMD

In the October 4, 2018 issue of Diabetes Care, the ADA and EASD (European Association for the Study of Diabetes) published their consensus report for Management of Type 2 Diabetes, 2018.  Both organizations now favor the use of Incretin Receptor Agonists or SLG2 Inhibitors for persons with established macrovascular disease (or high risk for Cardiovascular Disease), for improving glycemic control, if metformin alone isn’t adequate or not appropriate.  

This recommendation affects the large majority of our patients in the post-acute and long term setting and appears to be a game changer.  Since 2006, multiple studies have documented the risk of death in these patients when we have attempted to tightly control their hyperglycemia with other hypoglycemic agents, particularly the rapid acting insulins and long acting sulfonylureas.  We also know that both the latter agents have not reduced the risk of MACE (Major Adverse Cardiovascular Events). On the basis of high quality studies, we now have evidence that both of the newly recommended classes of medicine reduce the risk of MACE by ~ 1/3 within ~ 3 years and the SLG2’s almost immediately reduce the risk of CHF.  Though both classes of meds are expensive, they are priced similar to the insulin analogs whose price tripled between 2003 and 2013. Because of their effectiveness for reducing the risk of MACE and because the cost of these complications is so high, a TAR is seldom required for their use in the SNF setting. In terms of safety, both have a negligible risk of hypoglycemia if used alone or with Metformin.  Both improve post-prandial hyperglycemia, which is the main defect in our older patients with Type 2 Diabetes.

My main experience over the last 2 years has been with the long acting Incretin Receptor Agonists - Liraglutide (Victoza), Dulaglutide (Trulicity), and Exenatide (Bydureon).  I have found them to be well tolerated, to have some associated weight loss, and more importantly, to improve post-prandial glycemic control with much less need for rapid acting insulin analogs as well as a much lower risk of serious hypoglycemia (a so called “soft landing”).  If you haven’t tried these agents yet, I recommend trying one first in those with serious obesity and insulin resistance, where there is a clear potential benefit.

I have had a much more limited experience with the SLG2 inhibitors because of fear of dehydration with secondary euglycemic DKA (Diabetic Ketoacidosis) risk.  These agents are glycosuric and do reduce intravascular volume depletion and HBP.  This is the likely mechanism for the near immediate reduction in risk of CHF.  However, many of our patients are already at risk for dehydration, so these agents should be used with great caution until we have more experience in low risk patients.  

Please read the above consensus report and come to your own conclusions.  Please also click on the link to the January 2018 ADA Standards of Medical Care in Diabetes—2018 Abridged for Primary Care Providers.

I will be presenting a diabetes talk at the 2019 CALTCM Summit for Excellence entitled “Reducing Hypoglycemic Risk in Diabetes Care” on the morning of Saturday April 6 during the "Hot Topics" session - I hope to see you there. I look forward to your thoughts on improving our care for persons with Type 2 Diabetes in the post-acute and long-term care setting.

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