Accreditation/Credit Designation

Physicians' Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Physicians' Education Resource®, LLC, designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physicians’ Education Resource®, LLC, is approved by the California Board of Registered Nursing, Provider #16669, for 1.0 Contact Hours.

Acknowledgment of Commercial Support

This activity is supported by an independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc. and Lilly USA, LLC.

Diabetes Consultations™: Beyond Insulin: The Role of SGLT-2 Inhibitors in Care of Patients with T1DM

Release Date: July 31, 2019
Expiration Date: July 31, 2020
Media: Internet - based

Activity Overview

Type 1 diabetes (T1D) has an extensive global presence and affects over 1.25 million Americans who live with the daily challenges of appropriate insulin dosing and glucose monitoring. Less than one-third of patients properly manage their diabetes and blood glucose levels and nearly half are either obese or overweight. However, escalating insulin doses carries many risks, including hypoglycemia and weight gain. Newer classes of antihyperglycemic agents used in type 2 diabetes offer a potential clinical option to effectively reach glycemic targets in patients with T1D. However, knowledge and competency among clinicians on risks and benefits, patient selection, and education on the use of SGLT-2 inhibitors as adjunctive therapy are crucial for effective clinical decision making and improving patient outcomes. Perspectives from an endocrinologist involved in clinical trials of these agents and a primary care physician with a diabetes center in their practice will offer learners well-rounded perspectives on best practices for optimizing treatment plans for patients with T1D.

Benefits of Participating

  • Review current gaps in care of patients with T1D
  • Understand the importance of appropriate patient selection and essential monitoring requirements for adjunctive treatment with an SLGT-2 inhibitor
  • Learn new evidence-based strategies for hyperglycemic management of patients with T1D to maintain glycemic goals

Acknowledgement of Commercial Support

This activity is supported by an independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc. and Lilly USA, LLC.

Instructions for This Activity and Receiving Credit

  • You will need to log in to participate in the activity.
  • Each presentation may contain an interactive question(s). You may move forward through the presentation; however, you may not go back to change answers or review video files/content until you finish the presentation.
  • At the end of the activity, educational content/video files will be available for your reference.
  • In order to receive a CME/CE certificate, you must complete the activity.
  • Complete the Posttest and pass with a score of 70% or higher, complete the Evaluation, and then click on “Request for Credit.” You may immediately download a CME/CE certificate upon completion of these steps.


Target Audience

This activity is intended for community endocrinologists, diabetologists, primary care clinicians, nurse practitioners, physician assistants, certified diabetes educators, and nurses involved in the treatment and management of patients with type 1 diabetes (T1D). This activity will provide education to a broad multidisciplinary team who will be invited to participate.

Learning Objectives

Upon successful completion of this educational activity, you should be better prepared to:

  • Identify patients with T1D who are not achieving their glycemic goals and who could benefit from adjunctive therapy to insulin
  • Examine new and emerging data on SGLT1/2 inhibitors for potential adjunctive therapy for T1D
  • Analyze risks and benefits associated with SLGT-2 inhibitor use in T1D
  • Incorporate shared decision making to individualize therapy and improve patient outcomes in T1D

Faculty, Staff, and Planners’ Disclosures

Faculty

Paul P. Doghramji
Paul P. Doghramji, MD, FAAFP
Attending Physician
Collegeville Family Practice
Medical Director of Health Services
Ursinus College
Collegeville, PA

Disclosures: Paul Doghramji has no relevant financial information of commercial interests to disclose.

Paresh Dandona
Paresh Dandona, MBBS, DPhil, FRCP, FACP, FACC
SUNY Distinguished Professor of Medicine, University at Buffalo
Chief, Division of Endocrinology, Diabetes and Metabolism
Founder, Diabetes-Endocrinology
Center of Western New York

Disclosures: Paresh Dandona has no relevant financial information of commercial interests to disclose.

The staff of Physicians' Education Resource®, LLC (PER®), have no relevant financial relationships with commercial interests to disclose.

Disclosure Policy and Resolution of Conflicts of Interest (COI)

As a sponsor accredited by the ACCME, it is the policy of PER® to ensure fair balance, independence, objectivity, and scientific rigor in all of its CME/CE activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME/CE activity to disclose all relevant financial relationships with commercial interests. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that creates a COI.

Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.

Off-Label Disclosure and Disclaimer

This CME/CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical and nursing education purposes only and is not meant to substitute for the independent clinical judgment of a physician or nurse relative to diagnostic or treatment options for a specific patient’s medical condition.

The opinions expressed in the content are solely those of the individual faculty members, and do not reflect those of PER® or any of the companies that provided commercial support for this program.

PER Pulse Recaps

1 of 3

PER Pulse™ Recap:
Diabetes Consultations™: Beyond Insulin: The Role of SGLT-2 Inhibitors in Care of Patients with T1DM

The online continuing medical education activity Diabetes Consultations™: Beyond Insulin: The Role of SGLT-2 Inhibitors in Care of Patients with T1DM features an engaging discussion on the potential role of sodium-glucose cotransporter 2 (SGLT-2) inhibitors in type 1 diabetes mellitus (T1DM). Paresh Dandona, MBBS, DPhil, FRCP, FACP, FACC, and Paul P. Doghramji, MD, FAAFP, exchanged perspectives on the current gaps in care of patients with T1DM; reviewed emerging evidence of adjunctive therapies, including SGLT-2 inhibitors; and identified which patients would be best candidates for add-on therapy. Faculty then shared best strategies for shared decision making to optimize patient outcomes and culminated their discussion with a range of patient cases.

This first of 3 PER Pulse™ Recaps will focus on gaps in current care of patients with T1DM, as explored in Diabetes Consultations™: Beyond Insulin: The Role of SGLT-2 Inhibitors in Care of Patients with T1DM.

Although newer insulin formulations, pump delivery, and continuous glucose monitoring have made a difference in maintaining glycemic control for patients with T1DM, Dr Dandona, State University of New York distinguished professor and chief of endocrinology at the University at Buffalo in New York, stated that 80% of these patients are still not under optimal control. The American Diabetes Association’s Standards of Medical Care in Diabetes recommend a glycated hemoglobin A1C of <7.0% in nonpregnant adults and <7.5% in children younger than 19 years.1

For patients ranging from the very young to elderly, management of T1DM is complex, with risk of hypoglycemia and weight gain from insulin, dietary and lifestyle adjustments, and a host of potential macrovascular and microvascular complications. Dr Doghramji describes it as overwhelming for the patient: “They must know how much insulin to give themselves and then administer a basal bolus if they don’t use an insulin pump. And if they do have an insulin pump, then they have to know how to operate it.”

Patients with T1DM may also have to manage hypertension, hyperlipemia, and weight gain. About half of patients with T1DM are obese.2 Additional comorbidities associated with T1DM include autoimmune thyroiditis, celiac disease, eating disorders, and depression, all of which require regular screening, evaluation, and treatment.3

Key Points

  • Patients with T1DM are not meeting glycemic goals established by the American Diabetes Association’s Standards of Medical Care in Diabetes.
  • Management of T1DM is complex and can be overwhelming for patients.
  • Numerous comorbidities add to the complexity of care for patients with T1DM.

References

  1. American Diabetes Association. 6. Glycemic targets: Standards of Medical Care in Diabetes-2019. 2019;42(suppl 1): S61-S70. doi: 10.2337/dc19-S006.
  2. Mottalib A, Kasetty M, Mar JY, Elseaidy T, Ashrafzadeh S, Hamdy O. Weight management in patients with type 1 diabetes and obesity. Curr Diab Rep. 2017;17(10):92. doi: 10.1007/s11892-017-0918-8.
  3. Kollipara S. Comorbidities associated with type 1 diabetes. School Nurse News. 2010;25(1):19-21. doi: 10.1177/1942602X09354117.

2 of 3

PER Pulse™ Recap:
Diabetes Consultations™: Beyond Insulin: The Role of SGLT-2 Inhibitors in Care of Patients with T1DM

As a follow-up to the online continuing medical education activity Diabetes Consultations™: Beyond Insulin: The Role of SGLT-2 Inhibitors in Care of Patients with T1DM, this second of 3 PER Pulse™ Recaps will focus on adjunctive therapies in T1DM.

Adjunctive antihyperglycemic agents that have been investigated for patients with type diabetes mellitus (T1DM) include amylin analogues, dipeptidyl peptidase 4 (DPP-4) inhibitors, glucagon-like peptide 1 (GLP-1) receptor agonists, and sodium-glucose cotransporter 2 (SGLT-2) inhibitors.1-4 Of these 4 classes, the SGLT-2 inhibitors have shown the most promising efficacy as adjunctive therapy to insulin. Amylin analogues require additional injections for patients, and efficacy of DPP-4 inhibitors has not been supported in clinical practice. Results of global studies of the GLP-1 receptor agonist, liraglutide, demonstrated a reduction of glycated hemoglobin A1C by just 0.34% to 0.54%, but with increased rates of symptomatic hypoglycemia and hyperglycemia with ketosis.5

Clinical trials of SGLT-2 inhibitors for adjunctive treatment of type 1 diabetes have demonstrated improved glycemic control and metabolic parameters, reduced body weight and a reduction in total daily insulin dose.4 In addition, SGLT-2 inhibitors have shown substantial cardiovascular benefits in persons with type 2 diabetes,6 although this has not yet been studied in T1DM.

However, before initiating treatment with SGLT-2 inhibitors in persons with T1DM, clinicians will need to proceed with caution and carefully select and educate these patients and their caregiver(s) because of an increased risk of diabetic ketoacidosis (DKA).7 Individuals on low-carbohydrate or ketogenic diets or those that skip meals or consume excess alcohol would not be good candidates for SGLT-2 inhibitors. Patients must be willing and able to follow prescribed regimens for monitoring ketones in blood and take action if levels are elevated. Additional potential adverse effects of SGLT-2 inhibitors include mycotic infections.

Key Points

  • Numerous adjunctive therapies to insulin have been evaluated, and SGLT-2 inhibitors hold promise for strong efficacy and potential cardiovascular benefits.
  • SGLT-2 inhibitors have demonstrated an increased risk of DKA.
  • Patient selection and education will be crucial before initiating treatment with SGLT-2 inhibitors for T1DM.

References

  1. Denroche HC, Verchere CB. IAPP and type 1 diabetes: implications for immunity, metabolism and islet transplants. J Mol Endocrinol. 2018;60(2):R57-R75. doi: 10.1530/JME-17-0138.
  2. Wang Q, Long M, Qu H, et al. DPP-4 inhibitors as treatments for type 1 diabetes mellitus: a systematic review and meta-analysis. J Diabetes Res. 2018;2018:5308582. doi: 10.1155/2018/5308582.
  3. Wang W, Liu H, Xiao S, Liu S, Li X, Yu P. Effects of insulin plus glucagon-like peptide-1 receptor agonists (GLP-1RAs) in treating type 1 diabetes mellitus: a systematic review and meta-analysis. Diabetes Ther. 2017;8(4):727-738. doi: 10.1007/s13300-017-0282-3.
  4. Chen J, Fan F, Wang JY, et al. The efficacy and safety of SGLT2 inhibitors for adjunctive treatment of type 1 diabetes: a systematic review and meta-analysis. Sci Rep. 2017;7:44128. doi: 10.1038/srep44128.
  5. Mathieu C, Zinman B, Hemmingsson JU, et al; ADJUNCT ONE Investigators. Efficacy and safety of liraglutide added to insulin treatment in type 1 diabetes: The ADJUNCT ONE treat-to-target randomized trial. Diabetes Care. 2016;39(10):1702-1710. doi: 10.2337/dc16-0691.
  6. Gallwitz B. The cardiovascular benefits associated with the use of sodium-glucose cotransporter 2 inhibitors - real-world data. Eur Endocrinol. 2018;14(1):17-23. doi: 10.17925/EE.2018.14.1.17.
  7. Wolfsdorf JI, Ratner RE. Commentary: SGLT inhibitors for type 1 diabetes: proceed with extreme caution. Diabetes Care. 2019;42:991-993. doi: 10.2337/dci19-0008.

3 of 3

PER Pulse™ Recap:
Diabetes Consultations™: Beyond Insulin: The Role of SGLT-2 Inhibitors in Care of Patients with T1DM

As a follow-up to the online continuing medical education activity Diabetes Consultations™: Beyond Insulin: The Role of SGLT-2 Inhibitors in Care of Patients with T1DM, this third of 3 PER Pulse™ Recaps will focus on shared decision making to individualize therapy and improve overall patient care.

Given the complexities of managing type 1 diabetes mellitus (T1DM) and the diverse characteristics of patients, employing the principles of shared decision making1 is essential. Alongside patient factors such as the ability to grasp the pump or glucose-monitoring technology and different learning styles, clinicians must consider patient needs and preferences, health literacy skills, and accessibility to health services.2 Then, in the 2-way flow of conversation, the patient’s experiential knowledge should be recognized to allow identification of any barriers to achieving treatment goals.

Paul P. Doghramji, MD, FAAFP, attending physician at Collegeville Family Practice in Pennsylvania, succinctly describes the clinician’s role: “Individualize your treatment, listen to your patients, see what their issues are, and make factored changes accordingly.”

Collaborating with primary care physicians, endocrinologists, and other specialists, diabetes educators play a central role in care of patients with T1DM. Potential factors that this multidisciplinary team might discuss with patients when individualizing treatment include:

  • Bolus insulin versus pump
  • Continuous glucose monitoring versus multiple self-administered glucose checks
  • Adjunctive therapy to insulin and any additional monitoring considerations
  • Engagement of school nurses and teachers for younger patients
  • Reduced insulin needs prior to exercise
  • Strategies to lessen weight gain, such as lowering the rate of insulin infusion in the pump
  • Management of comorbidities

Key Points

  • Shared decision making is fundamental to optimal management of patients with T1DM.
  • Diabetes educators are at the core of care for patients with diabetes, alongside other members of a multidisciplinary team.

References

  1. Legare F, Witteman HO. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff (Millwood). 2013;32:276-284. doi: 10.1377/hlthaff.2012.1078.
  2. Wiley J, Westbrook M, Greenfield JR, Day RO, Braithwaite J. Shared decision-making: the perspectives of young adults with type 1 diabetes mellitus. Patient Prefer Adherence. 2014;8:423-435. doi: 10.2147/PPA.S57707.

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