1. Medical Provider Meeting 5/3/2016
Community-University Health Care Center

2. • Long-acting insulins
• SGLT-2 inhibitors
• GLP-1 agonists
• The future

4. • Insulin degludec - human insulin analog
• Long-acting
• Half-life >24 hours, detectable for 96 hours
• Smooth, flat profile over 24 hours
• When compared to insulin glargine
• No difference in glycemic control
• Less variability
• Less nighttime hypoglycemia

5. • FlexTouch Pens
• U100 and U200 concentrations
• What you click is what you get
• Conversion from Lantus 1:1
• Lasts 56 days after opening

6. • U300 – more concentrated Lantus
• Flatter, longer profile than U100
• Duration of 24 hours, detectable for 36 hours
• Similar efficacy to U100 glargine
• Less hypoglycemia
• Both overall and nighttime
• Cost similar to U100 on a unit-per-unit basis

7. • Conversion from Lantus
• Start with 1:1 conversion
• DM2 patients typically need 11-15% more
• DM1 patients typically need 17.5% more
• May have a temporary increase in FBG
• Insulin naïve patients may take 5 days to
achieve full effect
• Use within 42 days

8. • Identical amino acid sequence to Lantus
• Available mid-December 2016
• Only in pens (KwikPen)

9. • Now available in a pen – increased safety
• Acts like regular/NPH mix
• Onset 30 minutes
• Lasts up to 24 hours
• 2-4 injections per day

12. • Names:
• Canagliflozin (Invokana)
• Dapagliflozin (Farxiga)
• Empagliflozin (Jardiance)
• A1c decrease 0.6-1%
• Modest weight loss in 12-week trials
• Can decrease blood pressure

13. INVOKANA
(CANAGLIFLOZIN)
FARXIGA (DAPAGLIFLOZIN)
JARDIANCE
(EMPAGLIFLOZIN)
STRENGTHS 100 mg, 300 mg 5 mg, 10 mg 10 mg, 25 mg
DOSING 1 tablet pre- breakfast 1 tablet QAM 1 tablet QAM
A1c REDUCTION (Alone) -0.77 to -1.16% -0.66 to -0.84% -0.85%
WEIGHT REDUCTION (Alone)
-2.8% (100 mg) -2.6% (5 mg) -2.8% (10 mg)
-3.9% (300 mg) -2.7% (10 mg) -3.2% (25 mg)
SBP REDUCTION -5.1 mmHg -4.5 to -5.3 mmHg -2.6 to -4.8 mmHg
COVERAGE
Blue Plus – Covered HealthPartners – Step therapy
UCare – Step therapy Medica – Step therapy
HealthPartners – Step therapy
Medica – Step therapy

14. • Names:
• Canagliflozin (Invokana)
• Dapagliflozin (Farxiga)
• Empagliflozin (Jardiance)
• A1c decrease 0.6-1%
• Modest weight loss in 12-week trials
• Can decrease blood pressure

15. • Dosage adjustments
• Do not use if eGFR <45 mL/min/1.73m2
• Can use Invokana and Jardiance use if eGFR 45-60
mL/min/1.73m2
• Do not use Invokana in hepatic impairment
• Adverse effects
• Increased urinary frequency/urgency
• Genital mycotic infection
• UTI
• Ketoacidosis

16. SGLT-2
Inhibition
Decreased
CHO
availability
Increased
lipolysis, lipid
oxidation and
glucagon
Increased
mobilization
of FFAs and
TGs
Increased
ketogenesis
Worsened by
decreased
insulin/CHO
intake
Increased
ketones
Increased
nausea
Decreased
caloric intake,
volume
depletion
BG mildly
high,
increased
insulin dose
Euglycemic
DKA

17. • Prevention of euglycemic DKA
• Contraindicated in Type 1 DM
• Caution in patients where T1 vs T2 is in question
• Caution in patients making little endogenous insulin
• Educate on symptoms and situations of DKA
• Nausea, vomiting, malaise
• BG may be normal or slightly elevated
• Insulin dose reductions, alcohol intake, illness

19. • Increased glucose-dependent insulin secretion
• Decreased glucagon secretion
• Slowed gastric emptying
• Increased satiety
• Modest weight loss
• A1c decrease 1-1.5%

21. • Mechanism of action:
• Increased glucose-dependent insulin secretion
• Decreased glucagon secretion
• Slowed gastric emptying
• Increased satiety
• Modest weight loss
• Less hypoglycemia than other agents
• A1c decrease 1-1.5%
• Adverse effects
• Nausea
• Risk of pancreatitis
• Risk of thyroid c-cell tumors?

22. GLP-1 AGONIST
FREQUENC
Y
TARGETS
A1C
REDUCTIO
N
WEIGHT
LOSS (KG)
SPECIAL FEATURES
BYETTA 5 AND 10 mg BID POSTPRANDIAL 1% 2 ADMINISTER WITH MEALS
VICTOZA 0.6-1.8 mg DAILY MIX 1.5% 2.5 DIAL OUT
BYDUREON 2 mg PEN/VIAL WEEKLY FASTING 1.5% 2.5 VIAL REQUIRES MIXING
TANZEUM WEEKLY FASTING 1% 1 DIFFICULT TO USE
TRULICITY WEEKLY FASTING 1.5% 2.5 AUTOINJECTOR

24. • Mix of Tresiba and Victoza
• Mix of Tresiba and rapid-acting insulin
• Novolog in a FlexPen

25. • Rosenstock, J., & Ferrannini, E. (n.d.). Euglycemic Diabetic Ketoacidosis: A
Predictable, Detectable, and Preventable Safety Concern With SGLT2
Inhibitors.Diabetes Care., 38(9), 1638-1642.
•
• Fineman, M., Cirincione, B., Maggs, D., & Diamant, M. (n.d.). GLP-1 based
therapies: Differential effects on fasting and postprandial glucose. Diabetes, Obesity &
Metabolism, 14(8), 675-688.
•
• Simonson, Greg. Highlights of what’s new in diabetes. Presentation. 1.25.2016
•
• Pharmacist’s Letter: GLP-1 agonists. Accessed 4.29.2016.
•
• Pharmacist’s Letter: SGLT-2s. Accessed 4.29.2016.
•
• Package inserts: Tresiba, Toujeo, Invokana, Jardiance, Farxiga