The Promise of Treatment Advances
“The good news is that we've made a ton of advancements in diabetes management and medications, so not only do we have options with different classes of medications and technologies but the newest options of treatment,” said Matthew Palmer, PharmD, BCGP, director of clinical operations for PharMerica, adding, “While type 1 diabetics can still only use insulin, there are lots of options for kinds of insulin and insulin pump technology. At the same time, continuous glucose monitors (CGMs) are advancing at an astonishing pace. With type 2 diabetes, there's a plethora of options and newer medications that have some astounding secondary benefits such as cardiovascular protection, improved kidney function, and weight loss.”
Once a common treatment, sliding scale insulin (SSI) is discouraged for use in most instances. “it's inefficient and time-consuming for our nursing staff and caregivers and uncomfortable for patients,” Palmer said. Additionally, it is reactive versus proactive and has a higher risk for hypoglycemia.
CGMs
These have grown in popularity in recent years, as these devices – small sensors on the body replaced every 10-14 days – have several advantages. They provide more complete blood glucose levels through the day and nocturnal level tracking. Data is easily shared with providers, caregivers, and family, as appropriate; and some models integrate with insulin pumps. Possible barriers to use of CGMs include cost/coverage limitations and the potential for missed alarms.
Medications
Metformin
Metformin, in the biguanides class, is the first-line medication for many individuals:
- It is well-established
- It has a low side effect profile (GI upset is most common)
- It is contraindicated in eGFR <30 and cautioned in eGFR 30-45
- It is cost-effective
There are two newer classes of medications to treat diabetes – GLP1 receptor and GLP/GIP agonists and SGLT 2 inhibitors. “These drugs can act on many receptors throughout the body to not only help with dynamic control; but they also possibly have other beneficial effects as well,” said Van Amber.
GLP1 & GLP/GIP Agonists
These drugs are first-line treatment for those with high cardiovascular risk and/or chronic kidney disease:
They have a complex mechanism, slowing down gastric motility, inhibiting glucagon, and stimulating insulin production.
- They contribute to weight loss
- They are preferred agents before using insulin
- Administration is subcutaneous injection (mostly)
- Nausea/vomiting are common side effects
- Disadvantages include possible cost and supply barriers
- These medications should not be combined with DPP4 inhibitors
The labeled indications for these medications are diabetes, weight loss, and cardiovascular disease, with possible secondary benefits for liver disease, heart failure, chronic kidney disease, obstructive sleep apnea, COPD, and cholesterol.
SGLT2 Inhibitors
These are first-line treatment for individuals with high cardiovascular risk, heart failure, and chronic kidney disease:
- They inhibit glucose transport from urine back to the bloodstream in the kidney
- Administration involves oral tablets (no injections)
- Several have FDA approval for chronic kidney disease and heart failure treatment
- Adverse effects include fluid depletion, possibly UTIs/yeast infections. Ketoacidosis and Fournier’s gangrene are possible but rare. These drugs are on the American Geriatrics Society Beers Criteria of medications that may be inappropriate or pose risks for older adults.
- There is good evidence for renal protection and heart failure prevention with these drugs
Managing diabetes is a complex process for all patients. However, in populations like individuals with I/DD that complexity increases. One key, said Palmer, is to keep things as simple as possible. He noted, “We know that our I/DD population have complex medication regimens that can cause or worsen diabetes.” Therefore, it is essential to know each person’s medical history and medication regimen up front. “Then the first step is always to find out the goals of therapy, use our first-line agents, and avoid SSIs if we can.”
Ready to learn more?
For more information, including details on medications and insulin dosing, click here view our latest webinar, 2025 Diabetes Treatment Updates for Individuals with I/DD.
About Pharmacy Alternatives
One of the nation’s only I/DD-specific pharmacies, Pharmacy Alternatives provides comprehensive services for individuals with cognitive, intellectual, and developmental disabilities. Our pharmacy and account teams, many of whom have personal connections to the I/DD community, share a passion for caring for this unique population and understand their complex medication needs. With specialized consultant pharmacists and local account management support, we make medication management easy, so caregivers can focus on increasing independence and enhancing quality of life for the individuals they serve.