May 19, 2018 : Issue #938

• Very Low Carbohydrate Diet Equals Better Diabetes Control
• Intensive Blood Pressure Lowering in Patients With and Without Type 2 Diabetes
• Intensive BP Control Or Not For Those with Diabetes and CKD
• Variability of A1c Predicts All-Cause Mortality in Type 2 Diabetes
• Canagliflozin Vs. Dapagliflozin in Type 2 Diabetes
• Prediabetes Plus Hypertension Equals Coronary Artery Disease

Sometimes you wonder why logical thinking is often left out in medical care. Way back in the last century, when I was learning about diabetes, its causes, and solutions, it seemed logical that if you eat less sugar you will need less insulin if you are type 1, and less sulfonylureas if type 2. Then as I learned more about food, it was logical that if sugars are carbohydrates, then foods with low “sugars” and high carbohydrates would have the same effect as sugar. This logical thinking led me to believe that lowering carbohydrates would have a positive effect on blood sugar levels. As I looked for information on low carbohydrate food choices, I looked at many different plans, and for most of my patients I settled on 75-100 carbs a day, and have spent the last 20 years advising most patients to stay in that range. This did not preclude me from going lower in some patients. These patients usually require more attention and a dedicated track to follow, and for a lot of these dedicated patients, I would refer them to the Diabetes Solution.

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We can make a difference!

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Dave Joffe

Editor-in-chief

Important information regarding Accu-Chek Aviva Plus test strips with lot numbers 496947, 497291, 497296 and 497325: These affected test strips show an increased potential for strip errors prior to applying blood sample; strips not detected once inserted; or in a very limited number of cases, an inaccurate result may occur, which may not be detectable. Discontinue use of strips from these lot numbers and follow all instructions linked here.

What is your choice for a second drug after metformin for your type 2 patients with an A1c of 8 or above and 25 pounds overweight?

DPP-4
GLP-1
SGLT-2
Insulin
Other

Follow the link to share your opinion.

Toujeo Max SoloStar will launch later this year in the U.S. It holds 900 units of insulin and can dose up to 160 units in one injection, meaning fewer refills and possible co-pay savings. It can deliver twice as much insulin as the original SoloStar pen. The Toujeo Max SoloStar (insulin glargine U300) injection pen, which holds more basal (long-acting) insulin than any other pen available, has been approved in the U.S. by the Food and Drug Administration (FDA). Max SoloStar’s higher capacity means fewer injections for people who take more than 80 units of insulin at one time and fewer trips to the pharmacy.

Mrs. Hunter is a 36-year-old African-American who comes to your office for her annual wellness exam. She has excess weight (BMI 27 kg/m2), but is otherwise healthy. She jokes that she, “just can’t seem to lose that extra baby weight” after giving birth 3 years ago. However, her daughter recently started preschool so she has been able to go to her new gym several times per week. In fact, one of the added bonuses of her membership is that she has been participating in their free, weekly nutrition and exercise support groups. In addition to her routine labs, you order an A1C, which comes back elevated at 7.1%. This measurement is confirmed several days later.

Based on Mrs. Hunter’s profile, what would a reasonable next step be?

A. Encourage lifestyle modifications and start metformin with an A1C target of < 7.0%.
B. Encourage lifestyle modifications and start metformin with an A1C target of < 6.0%.
C. Encourage lifestyle modifications and do not initiate drug therapy at this time.
D. Encourage lifestyle modifications and start metformin and a sulfonylurea.

Follow the link for the answer.

In previous generations of Dexcom CGM systems (G4/G5), acetaminophen could affect your sensor readings, making them look higher than they really were. However, with the G6, you can take a standard or maximum acetaminophen dose of 1 gram (1,000mg) every 6 hours and still use the G6 readings to make treatment decisions. Taking higher than the maximum dose of acetaminophen (e.g. > 1 gram every 6 hours in adults) may affect the G6 readings and make them look higher than they really are. Follow G6 instructions. If you don’t, you could have a severe low or high glucose event. For other CGM systems you need to check with the manufacturer to see if there is other evidence of CGM interference with drugs such as lisinopril, albuterol, acetaminophen, atenolol, and even red wine, which in the past may have caused irregular readings on certain CGMs. Future studies are required to address interference with newer sensors being approved or in the process of approval.

Low carbs equals lower blood sugars and control, with less hypoglycemia, but how low do our patients need to go?

Pooled analysis from two randomized trials shows significant differences in effects on two groups.

Study looks at whether intensive BP lowering can increase the risk of CKD.

According to a recent published study, HbA1c variability is a better predictor of mortality in patients with type 2 diabetes compared with HbA1c averages.

First real-world study comparing SGLT2i therapies also showed patients taking INVOKANA 300 mg significantly less likely to discontinue treatment or switch to another diabetes medicine.

High blood pressure and prediabetes together may do more harm to the body than either one alone.

Quote of the Week!

“Don’t judge each day by the harvest you reap but by the seeds that you plant.”

…Robert Louis Stevenson

Diabetes in Control gratefully acknowledges the assistance of the following pharmacy doctoral candidates in the preparation of this week’s newsletter:

Vidhi Patel, Pharm. D. Candidate 2018, LECOM College of Pharmacy

Your Friends in Diabetes Care
Steve and Dave
Diabetes In Control
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Ewing, NJ, 08628
USA
www.diabetesincontrol.com