ADA Clinical Guideline Overview for Diabetes



Davida Kruger, MSN, APN-BC, BC-ADM: Welcome to this HCPLive® Peers & Perspectives® presentation titled, “Optimal Management of Diabetes: Expert Nurse Practitioner Perspectives.”

I am Davida Kruger, and I am a nurse practitioner at the Henry Ford Health System in Detroit, Michigan. I'm joined today by my friend and colleague, Lucia Novak, who is also a nurse practitioner, at Capital Diabetes & Endocrine Associates in Silver Spring, Maryland. Our discussion today focuses on improving outcomes of patients with type 2 diabetes. We shall also discuss the safety and efficacy of available treatment options with a focus placed on GLP-1 [glucagon-like peptide-1] receptor agonists.

Welcome Lucia. How are you? Let’s begin today.

Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: Hi, Davida. Thank you so much. I’m so looking forward to this conversation with you.

Davida Kruger, MSN, APN-BC, BC-ADM: Thank you. It will be fun and educational.

Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: For me too.

Davida Kruger, MSN, APN-BC, BC-ADM: Why don’t we start by talking about the 2020 American Diabetes Association [ADA] Standards of Medical Care guidelines. As you know, I’ve been treating diabetes for the last 38 years, which always surprises me.

Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: That’s because you look 40.

Davida Kruger, MSN, APN-BC, BC-ADM: Thank you. I think of all the changes that have occurred, and when I started in 1982, we had very long-acting sulfonylureas for type 2 diabetes. We then jumped immediately to mixed-before insulin. We didn’t have a lot of choices with that. We did not have blood glucose monitoring. We did not have hemoglobin A1C [glycated hemoglobin]. We certainly didn’t have continuous glucose monitoring. I now think of the ADA guidelines, and we’ll talk about this in detail as we go through, but one of the huge changes is recognizing, and I always think of you when you say, “It’s not just about the sugar—sugar.” We now think more about not just glucose control, but the fact that diabetes is a cardiovascular disease. How do we prevent that? For me, that’s the biggest change when I think of the ADA guidelines. What about you?

Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: I would agree. We now have 11 different noninsulin classes from which to choose, so while it “isn’t just about the sugar—sugar,” the sugar is still important because we know that it translates to the microvascular complications.

Yes, I feel like 2018 is probably when the ADA started to acknowledge the impact of the cardiovascular effects of some of these medications, mainly because of the cardiovascular outcomes trials that were required to be in place. We got some great data, and that’s when I saw the ADA guidelines providing a roadmap for the clinician as far as what to prescribe for patients with underlying cardiovascular disease. Even in those without cardiovascular disease, they included how to choose what to go to intensified treatment with, after metformin.

Davida Kruger, MSN, APN-BC, BC-ADM: The other thing that’s a huge change is that we’re not jumping to insulin as quickly. It used to be that, after metformin, you used a basal insulin. There are a couple of oral agents you might have put in there, but you used the basal insulin. We’re now saying if the patient is not symptomatic, you can probably wait until the A1C is greater than 10%; if they’re symptomatic, it’s perhaps at 9%. What we’re saying is that insulin is still a great option, and 80% or 90% of our patients at some point probably will end up on insulin. But we’re saying that, if you’re going for an injectable, the first injectable after metformin should be your GLP-1 receptor agonist. Then of course, the other kids on the block that are still popular and should be used are the SGLT2 [sodium-glucose cotransporter-2] inhibitors because both of them not only provide us with glucose control, but they also decrease cardiovascular death, and they decrease MIs [myocardial infarctions] and stroke.

With the SGLT2 inhibitors, they also decrease heart failure. They have an improvement in kidney function. It is a huge change in the way we think about it, but it’s because we now have these medications that target the disease as a whole and the patient as a whole. That’s an exciting thing.

We’re not going to talk about the cost today because we can never lose sight of that, but what I will say is that I think the insurance companies have also recognized the importance of these medications. I can’t think of any insurance company, whether it be Medicare, Medicaid, or commercial, that doesn’t give us at least 1 option in each of these 2 categories. Is that what you think?

Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: Yes, that’s been my experience, and I completely agree. Cost is just not something that anyone can address. If you don’t have any drug coverage at all, then that’s when we’re in trouble. Even the drug companies themselves have now stepped forward as far as patient assistance programs, and there are other programs that will enable patients to have access to medications regardless of what they think they might be able to afford. I agree with you: cost is not something we can really address.

Davida Kruger, MSN, APN-BC, BC-ADM: I want to thank the audience for watching this HCPLive® Peers & Perspectives®. If you enjoyed the content, please subscribe to our e-newsletter to receive upcoming Peers & Perspectives® and other great content right in your inbox. Thank you all for joining us today.

Transcript Edited for Clarity

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