ADA guidelines 2023:
Pharmacologic Approaches to Glucose Management
The American Diabetes Association (ADA) has released its Standards of Care in Diabetes 2023. The Pharmacologic Approaches to Glycemic Management section contains changes that align it with the ADA and the European Association for the Study of Diabetes (EASD) consensus statement published in 2022 and featured in a previous Diabetes Pharmacy Newsletter.
Medication Choices for Type 2 Diabetes
The glycemic management of type 2 diabetes should include agents with proven cardiorenal effects in people with, or at high risk for atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or chronic kidney disease (CKD) regardless of A1c levels. Other agents for glycemic control should possess adequate efficacy to achieve goals, be less likely to cause hypoglycemia, and be helpful in weight management.
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 Other Key Points
- Pharmacotherapy should be started in people with type 2 diabetes at diagnosis unless contraindicated.
- In most cases a GLP-1 RA should be the first injectable, and if insulin is indicated it should be combined with a GLP-1 RA to increase efficacy and durability and to attenuate weight gain.
- Continue metformin when adding insulin.
- Consider starting insulin early if the A1c is greater than 10%, there is extreme hyperglycemia (>300 mg/dL), or significant ongoing catabolism (weight loss).
- Combination therapy with either oral or injectable agents may increase efficacy and durability. Each additional agent added to metformin decreases the A1c by 0.7-1%.
 3 Minute Extra Mile: Take 3 minutes to:
- Help to avoid clinical inertia by reminding patients that therapy may need to be revised if goals are not met after 3-6 months.
- With metformin therapy, recommend vitamin B-12 levels or a non-prescription B-12 supplement at 1-2 mg daily.
- Suggest glucagon for patients on insulin therapy and furnish ADA or similar hypoglycemia patient handout. Remind them that they may qualify for CGM.
- Review medications to assess use of guideline directed therapy and make recommendations if needed.
- When counseling patients, recognize elements of social determinants of health (SDOH) such as health literacy, numeracy, cultural aspects, food security, and financial barriers.
James Bennett BsPharm, BCGP, CDCES
Bozeman, MT
Chronic Obstructive Pulmonary Disease Guideline
The Chronic Obstructive Pulmonary Disease (COPD) guideline was recently updated and it has a few notable changes. The 2023 GOLD Report has key changes including vaccine recommendations, inhaler device choices, and the ABCD Assessment Tool.
The diagnosis of COPD should be considered in a patient with chronic cough or sputum production, shortness of breath, and FEV1/FVC < 0.7. A patient may also have risk factors including smoking or environmental exposure from chemicals, gases, or air pollution.
Once a diagnosis of COPD has been made, establishing severity, symptoms, and a treatment plan should be next. The GOLD grades and severity have not changed as seen in table 2.6.
 The COPD Assessment Test (CAT) and modified Medical Research Council (mMRC) are both validated assessment tools that can be used to identify COPD symptoms. The ABCD Assessment Tool has been replaced with the ABE Assessment Tool which makes a treatment plan and inhaler choice more straightforward (see figure 2.3).
 Now, patients that fall into group B or E have one to two inhaler combination options. The treatment of choice would be a LABA plus a LAMA inhaler or in patients with a blood eosinophil count > 300, a LABA plus LAMA plus ICS could be considered (see figure 4.2).
 Vaccine recommendations for people with COPD include pneumococcal (one dose of PCV20 or one dose of PCV15 followed by one dose of PPSV23), COVID-19, influenza, Tdap, and Zoster (for those 50 year of age and older).
Pharmacists should:
- Counsel the patient on proper inhaler technique
- Assess the patient for appropriate medication therapy
- Assess the patient’s COPD symptoms
- Recommend appropriate vaccines
Rachael Zins, Pharm D, AE-C
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