Improving Diabetes Outcomes

Full update March 2019

Below is our toolbox of practical tips and resources to help improve outcomes in your patients with diabetes, with a focus on nonpregnant adults.

Guidelines from the ADA and Diabetes Canada are available at:


Abbreviations: ABI = ankle-brachial index; ACC = American College of Cardiology; ACEI = angiotensin-converting enzyme inhibitor; ADA = American Diabetes Association; AHA = American Heart Association; ARB = angiotensin receptor blocker; ASCVD = atherosclerotic cardiovascular disease; CCS = Canadian Cardiovascular Society; DC = Diabetes Canada; CV = cardiovascular; eGFR = estimated glomerular filtration rate; ISH = International Society of Hypertension; JNC8 = Eighth Joint National Committee; SGLT2 = sodium-glucose cotransporter 2 (flozins).

Goal

Suggested Strategies or Resources

Set an appropriate A1C target.

Recommend an A1C <7% (ADA) or ≤7% (DC) in many patients with diabetes to reduce complications.1,2

Select less stringent targets, such as <8% (ADA) or ≤8.5% (DC), in certain diabetes patients such as those at risk for severe hypoglycemia, with limited life expectancy, or with advanced vascular complications.1,2

Select more stringent targets, such as <6.5% (ADA) or ≤6.5% (DC), to further reduce the risk of microvascular complications when the benefit outweighs the risk of hypoglycemia.1,2

Diabetes Canada has an online tool providers can use to individualize your patient’s A1C target at http://guidelines.diabetes.ca/reduce-complications/a1ctarget.

Read about A Personalized Approach for A1C Goals.


Choose the most appropriate agent(s) to achieve the A1C target.

Start with metformin in most patients with type 2 diabetes without severe renal impairment.1,2 (U.S.: do not start if eGFR <45 mL/min/1.73 m2).1 Metformin has negligible risk of hypoglycemia, does not cause weight gain, and may reduce cardiovascular risk.1,2

  • See our commentary, Clinical Use of Metformin in Special Populations, for details on metformin use in renal impairment, heart failure, and liver impairment.
  • Metformin is associated with B12 deficiency. Consider checking levels periodically (every two to three years), especially in patients with anemia or neuropathy (Canada: check every one to two years).1,13,14 For details on monitoring, diagnosis, and treatment, see our commentary, Management of Vitamin B12 Deficiency.

Add meds to metformin for patients with type 2 diabetes based on A1C lowering, side effects, and cost.1,2


Drug Class

Consider for…9,19

Avoid or Use Caution in…1,2,4,9,19

SGLT2 inhibitor

CV disease risk,* heart failure, overweight

Renal impairment, diuretic use, risk factors for amputation, history of genital fungal infections, fracture risk

GLP-1 Agonists

CV disease risk,* overweight

Personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type 2

Sulfonylurea

Cost concerns

Hypoglycemia risk, overweight

Insulin

High A1C

Hypoglycemia risk, overweight9

Glitazone

High triglycerides, CV risk

Heart failure, risk of bladder cancer, patients on insulin

DDP-4 Inhibitor

Post-prandial effect desired, overweight

Heart failure (saxagliptin, alogliptin)

α-glucosidase inhibitor

Post-prandial effect desired, overweight

A1C ≥8.5%

*In patients with clinical cardiovascular disease, consider empagliflozin, canagliflozin, liraglutide, or semaglutide.1,2 They reduce major CV events when added to standard care in patients with CV disease or high CV risk (liraglutide, canagliflozin, semaglutide),1 including all-cause and CV mortality (empagliflozin, liraglutide).1 See our chart, Diabetes Medications and Cardiovascular Impact, for details on study outcomes for each agent.

When goals aren’t met, scrutinize the patient’s med list for Drugs That Significantly Increase Blood Glucose.

For more information on drug therapy for type 2 diabetes, see our resources:


Ensure safe use of diabetes meds.

New insulin concentrations and products can create confusion. For strategies and resources to help prevent errors with insulin, see our chart, Tips to Improve Insulin Safety.

Give patients our patient education handout, How to Handle Low Blood Sugar (U.S. subscribers, Canadian subscribers).

For notable adverse effects of flozins, glitazones, and more, see our charts, Drugs for Type 2 Diabetes (U.S. subscribers) and Stepwise Treatment of Type 2 Diabetes (Canadian subscribers).


Use a statin when appropriate.

Use a statin for primary prevention for most diabetes patients 40 years of age and older.5,6

  • AHA/ACC:5
    • Statins are indicated for adults 40 to 75 years of age with diabetes and an LDL ≥70 mg/dL
    • In adults 20 to 39 years of age with diabetes that is longstanding (≥10 years for type 2 or ≥20 years for type 1), albuminuria (≥30 mcg/mg creatinine), eGFR <60 mL/min/1.73 m2, ABI <0.9, retinopathy, or neuropathy, starting a statin may be reasonable.
    • In patients >75 years of age with diabetes, continuing or even starting a statin may be reasonable after a risk/benefit discussion.
  • CCS: statins are indicated for diabetes and age ≥40 years, or diabetes >15 years’ duration and age ≥30 years, or diabetes with microvascular disease.6

A statin is indicated for secondary prevention in patients with diabetes and ASCVD.5,6

For a complete list of statin indications, see our charts, 2018 ACC/AHA Cholesterol Guidelines (U.S. subscribers) or Canadian Cardiovascular Society Dyslipidemia Recommendations (Canadian subscribers).

For more information on choosing and using a statin, see our charts:

To help promote safe statin use, give patients our patient education handout, What You Should Know About Statins.


Meet an appropriate blood pressure goal.

Aim for a BP <140/90 mmHg in most diabetes patients (JNC 8, ISH, ADA).1,7 The ADA states that a target of <130/80 mmHg may be suitable for patients with CV disease or 10-year CV risk >15% if it can be safely achieved.1 ACC/AHA guidelines recommend a BP of <130/80 mmHg for most patients in general,7 and Canadian guidelines (DC, CCS) recommend a goal of <130/80 mmHg for most patients with diabetes.2,8

Pharmacotherapy should include an antihypertensive shown to reduce CV events in diabetes patients: ACEI, ARB, thiazide-like diuretic, or dihydropyridine calcium channel blocker.1,2,8 (ISH guidelines give preference to ACEI or ARB in non-black patients.7)

For more information about blood pressure goals and choosing appropriate antihypertensives, see our resources:

Help pharmacy technicians brush up on treatment of high blood pressure with our technician tutorial, Hypertension 101.

Give patients our patient education handout, Blood Pressure Medications and You.


Choose safe and effective treatment for patients with concomitant heart failure.

Choose metformin first for most heart failure patients with type 2 diabetes.1,2,4 Hold if patient becomes unstable (e.g., acute heart failure exacerbation), or eGFR <30 mL/min/1.73 m2, due to rare risk of lactic acidosis.1,4 Preliminary evidence suggests that metformin may improve outcomes (e.g., reduced hospitalization and mortality).1,20

SGLT2 inhibitors are second-line agents.1,2 Empagliflozin, canagliflozin, and dapagliflozin have been shown to reduce heart failure hospitalization in patients with CV disease (and high CV risk [canagliflozin]).1,15,16

  • Studies are underway to determine SGLT2 inhibitor benefits specifically in patients with heart failure with reduced ejection fraction and heart failure with preserved ejection fraction.4
  • Be aware that SGLT2 inhibitors may cause volume depletion in patients taking a diuretic.1 Do not start an SGLT2 inhibitor if eGFR <45 mL/min/1.73m2 (canagliflozin, empagliflozin) or <60 mL/min/1.73m2 (dapagliflozin, ertugliflozin).1,2,17,18

GLP-1 agonists can be used in heart failure, but do not seem to specifically benefit heart failure (i.e., neutral effect).1,2 Concerns have been raised about increased heart rate in heart failure patients in some studies.4

Sulfonylureas and insulin appear to have a neutral effect.1,4

Saxagliptin, and alogliptin have been associated with heart failure hospitalization.4 For more on gliptins and heart failure, see our commentary, DPP-4 inhibitors (Gliptins) and Risk of Heart Failure.

Glitazones are associated with fluid retention and increased risk of heart failure and heart failure hospitalization, and should be avoided in patients with (symptomatic [ADA]) heart failure .1,2,4

Patients with diabetes are at increased risk of renal impairment and hyperkalemia due to renin-angiotensin-aldosterone system blockade. In patients with eGFR <60 mL/min/1.73 m2 and/or using spironolactone or eplerenone, consider starting their ACEI or ARB at half-dose; checking electrolytes, renal function, blood pressure, and heart failure symptoms within seven to ten days of initiation or dosage increase; and increasing the dose cautiously.2

Beta-blockers reduce morbidity and mortality in patients with heart failure with reduced ejection fraction and diabetes.4 They do not seem to worsen glycemic control, and hypoglycemic unawareness was not reported in clinical trials.4


Start low-dose aspirin if appropriate.

Use low-dose aspirin (e.g., 81 mg/day) in diabetes patients for secondary prevention in patients with a history of atherosclerotic cardiovascular disease (e.g., heart attack, stroke).1,2

Aspirin’s benefit for primary prevention in patients with diabetes appears similar to that of the general population, and is controversial.1,10 Low-dose aspirin could be considered for primary prevention in diabetes patients ≥50 years of age with at least one major risk factor (family history, hypertension, smoking, kidney disease, dyslipidemia) and low bleeding risk, after a risk/benefit discussion (ADA).1 Patients >70 years of age, risk appears greater than benefit.1 Similarly, Diabetes Canada does not recommend routine use.2

Give patients our handout, Aspirin and Your Heart.


Make sure patients are up-to-date on vaccines.

People with diabetes should receive immunizations per the latest immunization schedule recomendations.1,2 Encourage administration of pneumococcal vaccine, influenza vaccine, hepatitis B (ADA), and herpes zoster (DC) vaccine to patients with diabetes.1,2

  • ADA: Annual vaccination against influenza is recommended for all persons ≥6 months of age.1 Vaccination against pneumonia with pneumococcal polysaccharide vaccine (PPSV23; Pneumovax 23) is recommended for people with diabetes two through 64 years of age. In children, complete the pneumococcal conjugate vaccine (PCV13; Prevnar 13) series before age two years.1 For immunocompetent patients ≥65 years give one dose of PCV13 (if not previously given and 1 year has passed since any previous PPSV23 dose), then PPSV23 ≥1 year after PCV13 and ≥5 years after the last dose of PPSV23.3 Give the hepatitis vaccine series to unvaccinated adults with diabetes who are age 19 to 59 years. Also consider the hepatitis B vaccine series for unvaccinated adults with diabetes who ≥60 years of age.1
  • Diabetes Canada: For adults, give influenza vaccine annually.2 Vaccination against pneumonia with pneumococcal polysaccharide vaccine (PPSV23) should be offered to adults 19 to 64 years of age.2 For those ≥65 years give one dose of PPSV23, provided five years have elapsed since any dose given at age <65 years.2 For patients ≥65 years of age, PCV13 can also be considered (if not previously given) at least one year after any previous PPSV23 dose, then a one-time PPSV23 dose ≥8 weeks after PCV13, allowing five years to elapse since any PPSV23 dose given at age <65 years.2 Give the herpes zoster vaccine to adults ≥60 years of age.2

Immunization schedules can be found at http://www.cdc.gov/vaccines/schedules/hcp/adult.html (U.S.; adults ≥19 years of age), https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html (U.S.; ages ≤18 years), and http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-chroni-eng.php#a7 (Canada immunizations for persons with chronic diseases).


Ensure patients stay on appropriate medications through transitions of care.

Use our Transitions of Care Checklist at admission, at transfer between units at the same facility, and at the patient’s first post-admission outpatient visit to keep patients on track with their medications and out of the hospital.

For tips of reducing bouncebacks, see our toolbox, Reducing Hospital Readmissions.

Use the toolbox from AHRQ to optimize medication reconciliation (http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/match/match.pdf).

Pharmacy technicians can learn to assist patients with med lists using our technician tutorial, Mastering Medication Lists and Histories.


Help improve medication adherence.

Tailor medication regimens and educate patients with diabetes to help them adhere.

See our resources on improving adherence:

When patients are part of the decision-making process, they are more likely to be adherent. Most conditions have several reasonable treatment options, each carrying a different balance of risks and benefits. In these situations, “shared decision making,” which involves providing balanced information on the benefits and risk of each option, can be used.11

Use our resources to help educate diabetes patients about the need to tailor their medication regimens in specific situations:


Prevent and manage diabetes complications.

See our resources:


Use self-monitoring of blood glucose appropriately.

Recommend self-monitoring of blood glucose for patients who can benefit, such as those with type 1 diabetes, those with type 2 diabetes treated with insulin, or those with poorly controlled type 2 diabetes.1,2

In type 2 patients not taking hypoglycemic agents, multiple daily self-monitoring is not necessary except when therapy adjustments may be needed (e.g., acute illness, poor control, new meds, etc).12

For more information about self-monitoring of blood glucose, see our resources:

Give patients our handout: Understanding Your Blood Sugar Numbers (U.S. subscribers, Canadian subscribers).


Educate patients about diet, exercise, and other lifestyle changes.

Encourage beneficial lifestyle changes such as maintaining a healthy weight, smoking cessation, and regular physical activity for diabetes patients.1,2

Diabetes is best-managed by a multidisciplinary care team.1.2 To find an accredited diabetes education program, go to https://www.diabeteseducator.org/living-with-diabetes/find-an-education-program (U.S.)

Consider referral to a registered dietitian.1,2 To find a registered dietitian, go to http://www.eatright.org/programs/rdfinder/.

For more information on beneficial lifestyle changes for patients with diabetes, see our resources:

Give patients our patient education handouts to take home:


Help schedule screenings as appropriate.

Encourage adults with type 2 diabetes to schedule eye exams at least every two years (or at least every year if there is evidence of retinopathy), get screened for nephropathy annually, get screened for neuropathy annually, and get comprehensive foot exams at least annually.1,2


Learn about quality measures.

Learn more about quality measures for patients with diabetes from our toolbox:


Use medication therapy management (MTM) to optimize treatment for patients with diabetes (U.S. pharmacists).

Medicare Part D patients with diabetes are eligible for MTM.

U.S. pharmacists can use our conversation starter, Improving Diabetes Care, as a guide when talking with diabetes patients during medication reviews or other patient interactions.

For more information on MTM, see our resources:

Use our technician tutorials to engage pharmacy technicians in the process of MTM:


Project Leader in preparation of this clinical resource (350304): Melanie Cupp, Pharm.D., BCPS

References

  1. Standards of medical care in diabetes – 2019. Diabetes Care 2019;42(Suppl 1):S1-193.
  2. Diabetes Canada Clinical Practice Guidelines Expert Committee. Diabetes Canada 2018 practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2018;42(Suppl 1):S1-S325.
  3. Kobayashi M, Bennett NM, Gierke R, et al. Intervals between PCV13 and PPSV23 vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2015;64:944-7. Erratum in: October 30, 2015;64:1204.
  4. Lehrke M, Marx N. Diabetes mellitus and heart failure. Am J Cardiol 2017;120(Suppl):S37-47.
  5. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018. doi: 10.1016/j.jacc.2018.11.003.
  6. Anderson TJ, Gregoire J, Pearson GJ, et al. 2016 Canadian Cardiovascular Society guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol 2016;32:1263-82.
  7. Clinical Resource, Treatment of Hypertension. Pharmacist’s Letter/Prescriber’s Letter. January 2018.
  8. Nerenberg KA, Zarnke KB, Leung AA, et al. Hypertension Canada’s 2018 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Can J Cardiol 2018;34:506-25.
  9. Clinical Resource, Drugs for Type 2 Diabetes. Pharmacist’s Letter/Prescriber’s Letter. July 2017.
  10. Clinical Resource, Aspirin for CV Primary Prevention and More. Pharmacist’s Letter/Prescriber’s Letter. November 2018.
  11. Clinical Resource, Medication Adherence Strategies. Pharmacist’s Letter/Prescriber’s Letter. March 2018.
  12. Choosing Wisely. Endocrine Society. Updated July 2, 2018. http://www.choosingwisely.org/societies/endocrine-society/. (Accessed December 29, 2018).
  13. Product information for Glucophage and Glucophage XR. Bristol-Myers Squibb Company. Princeton, NJ 08543. May 2018.
  14. Product monograph for Glucophage. Sanofi-Aventis Canada. Laval, QC H7V 0A3. March 2018.
  15. Wiviott SD, Raz I, Bonaca MP, et al. Dapagliflozin and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2019;380:347-57.
  16. Neal B, Perkovic V, Matthews DR, et al. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med 2017;377:2099.
  17. Product information for Steglatro. Merck & Co. Whitehouse Station, NJ 08889. October 2018.
  18. Product monograph for Steglatro. Merck Canada. Kirkland, QC H9H 4M7. May 2018.
  19. Clinical Resource, Stepwise Treatment of Type 2 Diabetes. Pharmacist’s Letter/Prescriber’s Letter Canada. June 2018.
  20. Eurich DT, Weir DL, Majumdar SR, et al. Comparative safety and effectiveness of metformin in patients with diabetes mellitus and heart failure: systematic review of observational studies involving 34,000 patients. Circ Heart Fail 2013;6:395-402.

Cite this document as follows: Clinical Resource, Improving Diabetes Outcomes. Pharmacist’s Letter/Prescriber’s Letter. March 2019.