Diabetes

Chronic Condition Management

Tip of the Month

Message from the Medical Director

Over the past several years, and with extensive studies of glucose-lowering medications, the endocrine community now better understands the pathophysiology of diabetes. Accordingly, the American Diabetes Association (ADA) has made some major changes to their treatment algorithm recommendations.

This month we focus on the ADA recommendation that most patients with type 2 diabetes try glucagon-like peptide-1 receptor agonists (GLP-1 RAs) before insulin. GLP-1 RAs have a low risk of hypoglycemia, can help promote weight loss, and may be more cost-effective than insulin. If you do prescribe insulin, consider combination therapy alongside a GLP-1 RA for greater efficacy and benefit.

In this issue, you’ll find tips for counseling patients on GLP-1 RA therapy initiation, managing side effects, and information about medication formulation, dosing, contraindications and cautions for GLP-1 RA therapy.

Lastly, be sure to mark your calendar for our next chronic disease management CME event on managing diabetes and CKD. This virtual learning session will take place from 6 – 7:30 pm on Tuesday, September 12th. Registration details coming soon.

Thank you for your commitment to delivering high-quality care to our patients and in support of their health.

Kind regards,

X. Shirley Chen, MD, MS

In this Issue

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Counseling patients on GLP-1 receptor agonists
Managing side effects
Medication formulations and dosages
Contraindications and cautions for GLP-1 receptor agonists

*MSHP Care Management prioritizes patients in our MSSP and Healthfirst contracts and those patients with Medicaid

Counseling Patients Prior to Initiating Medication Therapy

Prior to beginning GLP-1 RAs, counsel patients on potential adverse effects and suggested dietary modifications

Side effects are typically temporary and often occur during initiation and titration

Most common GI side effects include nausea, vomiting, and diarrhea
May result in acute kidney injury (AKI) due to volume loss

Recommend reducing meal size and limiting higher-fat and liquid carbohydrate foods including alcohol

Managing Side Effects

Start treatment at the lowest dose (see medication table below)

Titrate based on tolerability, typically every 4 weeks to mitigate GI side effects

For vomiting and diarrhea, advise patients on increasing hydration and reducing volume of food intake

For patients with GI symptoms, try a slower dose escalation or lower the dose if unable to tolerate standard maintenance doses

Additional pharmacologic treatment such as GERD medications and anti-emetics should only be prescribed on a short term and case-by-case basis

Consider switching to an alternative GLP-1RA before labeling patient intolerant to the medication class

Medication Formulations and Dosages

Medication Class	Compounds	Common Trade Names	Dosage strength/ product	Starting dose (no renal/hepatic dysfunction)
GLP-1 RAs
	Exenatide	Byetta	5 mcg, 10 mcg pen	5 mcg bid
		Bydureon Bcise (ER	2 mg powder for suspension or pen	2 mg qweek
	Dulaglutide	Trulicity	0.75mg, 1.5 mg, 3.0 mg, 4.5 mg,	0.75 mg qweek
	Semaglutide	Ozempic	0.25 mg, 0.5 mg, 1 mg, 2 mg pens	0.25 mg qweek
		Rybelsus	3 mg, 7 mg, 14 mg (tablet)	3 mg qday
	Liraglutide	Victoza	6 mg/ml	0.6 mg qweek
GIP and GLP-1 RA
	Tirzepatide	Mounjaro	2.5 mg/0.5 mL; 5 mg/0.5 mL; 7.5 mg/0.5 mL; 10 mg/0.5 mL; 12.5 mg/0.5 mL;15 mg/0.5 mL	2.5 mg qweek

Contraindications/Precautions for

GLP-1 Receptor Agonists

Contraindications

Should not be used in combination with DPP-4 inhibitors
Contraindicated in patients with personal or family history of medullary thyroid cancer, multiple endocrine neoplasia 2A or 2B

Use with caution in patients with

History of acute pancreatitis
Gastroparesis
Severe gastroesophageal reflux disease
Inflammatory bowel disease
Established diabetic retinopathy due to potential risk of progression

Condition Management CME Course

Join us for our next condition management CME event!

Caring for Patients with Complex Chronic Disease: Key Components and Updates to Diabetes & CKD Management

Tuesday, September 12

6 – 7:30 pm | Live via Zoom

Registration coming soon

Find more on the Chronic Condition Management Hub

Mount Sinai Health System's Chronic Condition Management Hub is an online resource center for primary care physicians, specialists, and other care providers with resources and information to help them manage chronic health conditions

P: 877-234-6667

E: MSHP@mountsinai.org

Provider Engagement Team