Learning Objectives:

• Review recommendations provided in the American Diabetes Association (ADA) Standards of Medical Care – 2020 addressing the pharmacologic approach to glycemic control for patients with type 2 diabetes
• Describe patient factors to consider when prescribing antihyperglycemic agents
• Understand the boxed warnings for antihyperglycemic agents

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Key Points:

• Diabetes is a complex illness requiring continuous chronic care. Glycemic control is one aspect of comprehensive care for patients with diabetes.
• The ADA recently published their annual Standards of Medical Care in Diabetes – 2020, which reviews the current evidence surrounding diabetes care, general treatment goals, and tools to evaluate the quality of care.
• Recent evidence demonstrates a benefit of adding sodium-glucose cotransporter 2 inhibitors (SGLT-2i) or glucagon-like peptide 1 receptor agonists (GLP-1 RA) to metformin in patients with preexisting cardiovascular disease (secondary prevention) or who are at increased cardiovascular risk.
• The Medi-Cal Fee-for-Service List of Contract Drugs includes therapy options from all categories of antihyperglycemic medications, including oral agents, combination products, non-insulin injectable products, and insulin vials and pens.

Background

Diabetes is a complex, chronic illness requiring continuous care in order to achieve glycemic control. In 2018, an estimated 8.2% of the population of the United States and 12.8% of adults between 18 and 64 years of age in the Medicaid population had a diagnosis of diabetes.^1,2 Uncontrolled diabetes can lead to poor general health, microvascular and macrovascular complications, hospital admissions, as well as higher out-of-pocket health care costs.³

Approximately 90 – 95% of people diagnosed with diabetes have type 2 diabetes, which most often develops in people over 45 years of age.¹ A type 2 diabetes diagnosis is based on the presence of classic symptoms of hyperglycemia (such as polydipsia or polyuria) and:

• a random plasma glucose ≥ 200 mg/dL, or
• fasting plasma glucose ≥ 126 mg/dL, or
• 2-hour postprandial glucose ≥ 200 mg/dL, or
• A1C ≥ 6.5%, which is the more common screening test.

Two abnormal test results are required if the patient does not present with documented hyperglycemia. Glycemic targets for patients with type 2 diabetes include A1C values from < 6.5% to < 8%.³ Each 1% drop in A1C down to 7% has been shown to reduce microvascular complications.^4,5 More stringent A1C goals are recommended in individuals with low risk for hypoglycemia, longer life expectancy, early diagnosis, fewer comorbidities, and existence of good support systems. Less stringent A1C goals may be considered for patients who have advanced vascular complications, history of severe hypoglycemia, limited life expectancy or when treatment risks outweigh the benefits. Individualized A1C goals must be a shared decision based on clinician judgement and patient motivation to adhere to the treatment regimen. The frequency of A1C testing may vary from quarterly to biannual measurements depending on treatment efficacy and patient ability to reach target A1C.³

The ADA annually publishes its Standards of Medical Care in Diabetes. This document provides clinicians, patients, researchers, payers, and other interested individuals with an overview of care for diabetes, general treatment goals, and tools to evaluate quality of care.³ The sections on the pharmacologic approach to glycemic control and cardiovascular risk and management offer guidance on the use of medications. As shown in Table 1, the Medi-Cal Fee-for-Service List of Contract Drugs includes therapy options from all categories of antihyperglycemic medications, including oral agents, combination products, non-insulin injectable products, and insulin vials and pens.

Download the full documente here: