DMII Victoza med management

mbdRN · Aug 28, 2013

Hi there. I am an RN and diabetes educator. Although I obviously cannot prescribe, I make medical recommendations to our MD and NP based on my assessment/interaction with the patient. Like you said already, it will be different for each patient. Do you have your patients keep individual BG logs? I would look for trends in their blood glucose levels, not just the A1c. If there post-prandial BGs are still elevated, you can always push the Victoza to the max (1.8 mg), monitor further, and encourage positive lifestyle change including carb control and exercise. If PP BGs are at goal but fasting is still elevated, incretin therapies don't have a large impact there. I would suggest the basal insulin over the Victoza if that were the case.

If I had a patient who was already maximized on metformin, a sulfonylurea, and Victoza (or another incretin) whose A1c remained above goal, I would suggest a basal insulin (Levemir or Lantus) at 10 units (sometimes 15-20 units for morbidly obese patients) QHS and decrease the sulfonylurea by half with the ultimate goal of discontinuing. I am not a fan of sulfonylureas due to the potential side effects including weight gain and the possibility of hypoglycemia, particularly paired with insulin. I would continue the Victoza and metformin along with the basal insulin.

I have a couple patients on Bydureon, but I have not seen a significant difference between it and the Victoza. I tend to agree with the research showing the superiority of Victoza over Byetta/Bydureon based on the efficacy and side effect profile. Ultimately it comes down to the individual patient as to whether one agent is better than another. The Bydureon is not a simple pen to manipulate. It takes some getting used to, and for those that are injection naive, I would hesitate to recommend it. The larger needle and lump it leaves can be intimidating and scary. Plus preparing the shot can be difficult for those with poor manual dexterity. But some love only once shot per week! As I said, highly individualized.

Please let me know if you have any further questions. I'd be more than happy to answer them to the best of my ability.

allnurses Guide · Aug 28, 2013

From a primary care perspective:

I have had much better results with:

1. Max metformin

2. Add Lantus.

3. Add single largest meal bolus.

4. Add the new SLT2.

I now avoid all the other oral agents because of the ADR and the modest A1c reduction they offer.

coast2coast · Aug 28, 2013

From a primary care perspective:
I have had much better results with:
1. Max metformin
2. Add Lantus.
3. Add single largest meal bolus.
4. Add the new SLT2.
I now avoid all the other oral agents because of the ADR and the modest A1c reduction they offer.

Somewhat similarly, my preferred escalation is:

1. Max metformin. Hard & fast. No weenie 5 year slog at 500mg/day. You either need it or you don't.

2. Max glipizide ( and wait for the inevitable ).

3. Long acting insulin (lantus or levemir depending on formulary). Titrate up over a few weeks and then titrate off the glipizide.

4. Bolus with meals if/when the lantus becomes inadequate.

My DM2 mantras are K.I.S.S. (for providers)(ie don't waste time and money hand-wringing over 12 orals/injectable for anyone with A1C >10) and "insulin isn't the worst thing that can happen to you!" Repeated ad nauseum to patients until they believe me.

I don't have access to invokana (sp?) but am curious... I take it you have had a good experience w/it Boston?

allnurses Guide · Aug 28, 2013

Somewhat similarly, my preferred escalation is:
1. Max metformin. Hard & fast. No weenie 5 year slog at 500mg/day. You either need it or you don't.
2. Max glipizide ( and wait for the inevitable ).
3. Long acting insulin (lantus or levemir depending on formulary). Titrate up over a few weeks and then titrate off the glipizide.
4. Bolus with meals if/when the lantus becomes inadequate.
My DM2 mantras are K.I.S.S. (for providers)(ie don't waste time and money hand-wringing over 12 orals/injectable for anyone with A1C >10) and "insulin isn't the worst thing that can happen to you!" Repeated ad nauseum to patients until they believe me.
I don't have access to invokana (sp?) but am curious... I take it you have had a good experience w/it Boston?

I have about a dozen on it right now with a decent response, well tolerated. I have been overly cautious about GUI/UTIs but I have yet to see one. I am still not 100% sold on it, but I prefer it to all the other oral agents. I was concerned about LDL bumps but I haven't seen any significant changes as of yet.

We have become much more aggressive with our T2 management of late. I actually feel more comfortable with insulin than almost all the other oral agents with my patient panel.

And we all know that all paths lead to insulin at some point in the future.

coast2coast · Aug 31, 2013

We added levemir to formulary a few months ago (in addition to NPH and 70/30) and I have been pushing it pretty hard with my DM2's. It's amazing to see how fast A1C's normalize with a long-acting insulin + metformin after, in most cases, years of struggle and strife with 3 or more meds. It requires a few weeks of regular BG checks by the patient, but then they decrease to 2 or 3 fingersticks/week to monitor fasting BG's. And they feel SO much better when sugars finally normalize.

.... Now if I can just convince my colleagues to follow my lead ... I am convinced that half the issue w/ starting insulin in DM2 patients is provider resistance.