sign in sign up
<<
Home , Phenformin

3/29/2017

What Managed Care Needs to Know About Novel Therapies in the Evolving Management of Type 2 Diabetes For Audio Please call 866‐206‐0240, Participant Code 64953949# If you are having difficulties logging in or calling in, please contact Jeremy at [email protected].

To Receive your certificate, please be sure to complete the online evaluation survey. Please email Katie at [email protected] for the survey link.

Faculty Disclosure: Dr. Reid serves as a consultant and on an advisory board for Boehringer Ingelheim, Janssen, Lilly USA, Novo Nordisk and Sanofi. His presentation has been peer reviewed.

Planning Committee Disclosure: Bill Williams, MD has no real or perceived financial relationships to disclose. Jacquelyn Smith, RN, BSN, MA, CMCN has no real or perceived financial relationships to disclose. Katie Eads has no real or perceived financial relationships to disclose. Will Williams has no real or perceived financial relationships to disclose.

Accreditation: The National Association of Managed Care Physicians (NAMCP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. NAMCP designates this enduring material for a maximum of 1 AMA PRA Category I creditsTM. Each physician should claim credit commensurate with the extent of their participation in the activity.

The American Association of Managed Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Nurses who complete this activity and complete an evaluation form will receive 1 hour in continuing nursing credit.

This activity has been approved by the American Board of Managed Care Nursing for 1.0 contact hour toward CMCN recertification requirements.

This activity is supported by an educational grant from Lilly USA, LLC

What Managed Care Needs to Know About Novel Therapies in the Evolving Management of Type 2 Diabetes

TIMOTHY S. REID, M.D. MERCY DIABETES CENTER JANESVILLE, WI

1 3/29/2017

The Cost of Diabetes

29.6 Million Americans with Diabetes

$245 Billion Spent for Diabetes

1 in 5 Health Care Dollars spent on patients with diabetes

1 in 3 Medicare Dollars spent on patients with Diabetes

Diabetes Medical Expenditures are 2.3x higher

3835 People will be diagnosed with

diabetes today http://www.diabetes.org/diabetes-basics/statistics/infographics/adv- staggering-cost-of-diabetes.html (Accessed 4 March 2017) http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html

Rank Cause of Death US Total Cost 1 Heart Disease $190 Billion 2 Cancer $227 Billion 3 Chronic Lung Disease $65 Billion 4 Stroke $34 Billion Accidents 5 $308 Billion

6 Alzheimer’s Dse $70 Billion 7 Diabetes $112 Billion 8 Renal Disease $61 Billion 9Pneumonia and Flu $40 Billion 10 Suicide $34 Billion Total Cost: $1.1 Trillion

http://247wallst.com/special-report/2012/01/18/1-1-trillion-what-the-10-leading-causes-of-death-cost-the-u-s-economy/3/

2 3/29/2017

Objectives:

1. Discuss methods to enable optimal cost management of novel therapies to be realized by multiple T2DM stakeholders including managed care organizations 2. Analyze strategies used by managed care organizations to facilitate high quality care for members with T2DM, and how newer therapies affect those strategies 3. Discuss how newer therapies have affected managed care professionals in the T2DM arena 4. Role of medical directors and payers in Type 2 Diabetes management

Two of the Major Diabetes Management Guidelines:

1. American Diabetes Association:1 1. Widely distributed 2. Primary Care Aware 3. Referenced by many organizations 2. Am. Association of Clinical Endocrinologists:2 1. Well Know to Diabetes Specialists 2. Comprehensive 3. Detailed Strength of Recommendations 1. Effectiveness 2. Side Effects

1. http://professional.diabetes.org/content/clinical-practice-recommendations 2. https://www.aace.com/publications/algorithm

3 3/29/2017

Start with Monotherapy unless:

A1c is greater than or equal to 9%, consider Dual Therapy

A1c is greater than or equal to 10%, blood glucose is greater than or equal to 300 mg/dl, or patient is markedly symptomatic, consider Combination Injectable Therapy. (See Figure 8.2) Monotherapy Lifestyle Management Efficacy* high Hypo Risk low risk Weight neutral/loss Side Effects GI/lactic acidosis Costs* low If A1c target not achieved after approximately 3 months of monotherapy, proceed to 2‐drug combination (order not meant to denote any specific preference –choice dependent on a variety of patient ‐ & disease‐specific factors): Dual Therapy Metformin + Lifestyle Management

Sulfonylurea DPP‐4 Inhibitor SGLT‐2 Inhibitor GLP‐1 receptor agonist (basal) Efficacy* high high intermediate intermediate high highest Hypo Risk moderate risk low risk low risk low risk low high risk Weight gain gain neutral loss loss gain Side Effects hypoglycemia edema, HF, fxs rare GU, dehydration, fxs GI hypoglycemia Costs* low low high high high high

If A1c target not achieved after approximately 3 months of monotherapy, proceed to 3‐drug combination (order not meant to denote any specific preference –choice dependent on a variety of patient ‐ & disease‐specific factors):

Triple Therapy Metformin + Lifestyle Management Thiazolidinedione DPP‐4 Inhibitor SGLT‐2 Inhibitor GLP‐1 receptor agonist Insulin (basal)

TZD SU SU SU SU TZD

or DPP‐4 ‐i or DPP‐4 ‐i or TZD or TZD or TZD or DPP‐4 ‐i or SGLT‐2‐i or SGLT‐2‐i or SGLT‐2‐i or DPP‐4 ‐i or SGLT‐2‐i or SGLT‐2‐i

or  or or or GLP‐1‐RA or GLP‐1‐RA Insulin or GLP‐1‐RA Insulin GLP‐1‐RA or Insulin or Insulin or Insulin

Combination Injectable Therapy (See Figure 8.2) Copyright ©2017 American Diabetes Association Diabetes Care2017 Jan; 40(Supplement 1): S64‐S774

Reprinted with permission from American Association of Clinical Endocrinologists © 2016 AACE. Garber AJ, Abrahamson MJ, Barzilay JI, et al. AACE/ACE comprehensive type 2 diabetes management algorithm 2016. Endocr Pract.2016;22: 84‐113

4 3/29/2017

Two Diabetes Management Guidelines:

1. They both speak to the comprehensive nature of diabetes management 1. Lifestyle modifications 2. Dietary recommendations 3. Medication initiation and combinations 4. Referrals and Screenings

1. http://professional.diabetes.org/content/clinical-practice-recommendations 2. https://www.aace.com/publications/algorithm

Two Diabetes Management Guidelines:

1. Implementation: 1. Used Largely as Medication Roadmap 2. Many times not encultured into the actual point of care experience 3. Can lead to poly-pharmacy

1. http://professional.diabetes.org/content/clinical-practice-recommendations 2. https://www.aace.com/publications/algorithm

5 3/29/2017

What Does This Mean For Managed Care?

 Large Population with Diabetes  Chronic and Progressive Disease State  Best Practices requires a hands on approach for both provider and Care organizations  Expensive to treat effectively  Expensive to ignore

Federal/Medicare/CMS

 Diabetes is one of the significant focus areas:  Value-Based Programs  Better Health Care for Individuals  Better Health for Populations  Lower Cost  Quality Payment Program  Advanced Alternative Payment Models  Merit-based Incentive Payment System  8 Diabetes Specific Measures

https://qpp.cms.gov/measures/quality

6 3/29/2017

Managed Care Approach

 Case Management  Chronic Care Model

 Physician Education and Incentives  P4P  Education  Formulary Management  Primarily Managing High Cost Medications  Drug:Drug Issues

Managed Care Approach

 Case Management  Chronic Care Model  Self-Management Support  Decision Support  Delivery System Design  Clinical Information Systems  Organization of Health Care  Community

E.H. Wagner, C. Davis, J. Schaefer, M. Von Korff, B. Austin, “A survey of leading chronic disease management programs: are they consistent with the literature,: Managed Care Quarterly 7(1999):(3)56-66.

7 3/29/2017

Managed Care Approach

 Case Management

Patient Heroism Persistent Determination

A Hero or Heroine is a person or main character of a literary work who, in the face of danger, combats adversity through impressive feats of ingenuity, bravery or strength, often sacrificing his or her own personal concerns for some greater good.1

1. Wikipedia, Hero Definition

Managed Care Approach

 Case Management

Patient Heroism Persistent Determination

Are we there to support their heroism in a meaningful way?

8 3/29/2017

Managed Care Approach

 Case Management Government Workplace Community

Social Patient Workers Family

Care Managers Providers

Managed Care Approach

 Case Management

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf p. S53 Copyright ©2017 American Diabetes Association Diabetes Care2017 Jan; 40(Supplement 1): S11-S24”

9 3/29/2017

Managed Care Approach

 Case Management:  Adherence – How well a patient’s behavior corresponds to a health care provider’s recommendation1  Compliance - The proportion of administered doses/prescribed doses over a period to time1  Concordance – involvement of patients in decision-making to improve patient compliance with medical advice2

1. Garcia-Perez L, Alvarez M, et. Al. Adherence to Therapies in Patients with Type 2 Diabetes. Diabetes Therapy 2013 4:175-194. 2. Wikipedia: Concordance

Managed Care Approach

 Case Management:  Adherence – How well a patient’s behavior corresponds to a health care provider’s recommendation  Medications/Therapy  Lifestyle  Exercise  Dietary  Many Factors  Age  Information  Perception and Duration of Disease  Dosing Complexity  Poly-therapy  Psychological factors  Safety  Tolerability  Cost

Garcia-Perez L, Alvarez M, et. Al. Adherence to Therapies in Patients with Type 2 Diabetes. Diabetes Therapy 2013 4:175- 194.

10 3/29/2017

Managed Care Approach

 Case Management:  Adherence – How well a patient’s behavior corresponds to a health care provider’s recommendation  Medications/Therapy  Lifestyle  Exercise  Dietary  Many Factors  Age  Information  Perception and Duration of Disease  Dosing Complexity  Poly-therapy  Psychological factors  Safety  Tolerability  Cost

Garcia-Perez L, Alvarez M, et. Al. Adherence to Therapies in Patients with Type 2 Diabetes. Diabetes Therapy 2013 4:175- 194.

Managed Care Approach

 Case Management:  Adherence  Oral Agents:  1966-2003 Patients on therapy for 6-24 months, 90% adherence was noted at 36-93%  EMR Data: 61-85% adherence with 39.6% persistence at 24 months and 4% never filled script  Insulin:  Retrospective studies • 62% long term • 64% new starts • 4.5% never filled • 25.5% never refilled

Garcia-Perez L, Alvarez M, et. Al. Adherence to Therapies in Patients with Type 2 Diabetes. Diabetes Therapy 2013 4:175- 194.

11 3/29/2017

Managed Care Approach

 Physician Education and Incentives  P4P  Educational Pieces  Contact with Case Managers

Managed Care Approach

 Formulary Management  Primarily Managing High Cost Medications  Adherence  Drug:Drug Issues  Communication

12 3/29/2017

HTN and Diabetes Drug Classes in the US over the past 90 Years

12 SGLT-2 Renin Inhibitors Inhibitors

11 Angiotensin II Dopamine Agonists Receptor Blockers 10 Bile Acid Sequestrants ACE Inhibitors 9 DPP-4 Receptor Antagonists 8 Amylinomimetics Calcium Channel Peripheral -1 Blockers 7 GLP-1 Receptor Blockers Agonists -blockers 6

5 Diuretics Central -2 Adrenergic Agonists 4 -glucosidase Inhibitors neuronal blockers (Phenformin) 3 Withdrawn

Number of Medication Classes Number of Medication 1978 2 Insulin 1 Vasodialators

1920’s 1950’s 1960’s 1970’s 1980’s 1990’s 2000’s 2010’s

Where Diabetes Medications Work

GLP‐1 GLP‐1 Insulin Insulin

GLP‐1 Insulin Insulin

GLP‐1 GLP‐1 Insulin Insulin Insulin

DeFronzo RA. Diabetes. 2009;58 (4): 773-795.

13 3/29/2017

Medications for Diabetes:

 Tried and True:  Newer Choices:  Biguanides (metformin)  DPP-4i (,others)  Sulfonylureas (,  GLP-1RA , others) (,,  Thiazolididiones , other) ()  SGLT-2i (,  Α-glucosidase inhibitors , others) (, others)  U-100 Human & Analogue Insulin(rDNA) (various)  U-500 Human Insulin

The

 Tried and True:  Newer Choices:  Long Acting:  Long Acting:  U-100 (glargine, detemir)  U-100 glargine (follow-along)1  Intermediate:  U-100 (degludec)  Neutral Protamine Hagedorn (NPH)  U-200 (degludec)  U-300 (glargine)  Short Acting:  Short Acting:  (Human )  U-200 (lispro)  U-100 Analogues (lispro, aspart,  (U-100 lispro (follow-along)) glulisine)  (Ultra-Short Acting:2)  Concentrated:  (FIAsp NN-1218)  U-500 Human Regular Insulin  (70/30 combination of and FIAsp NN-1218)

1. https://www.diabetesdaily.com/learn-about-diabetes/insulin-101/biosimilar-insulin/ 2. http://blog.diabeteslab.org/2016/01/the-future-of-insulin-new-insulin-formulations-under-development/

14 3/29/2017

The Insulins

 The New Insulins In General  Similar A1c and BGM reductions to existing insulin products  Concentrating insulin results in smaller volume infused with changing pharmacokinetic and pharmacodynamics properties  Flatter action curves  Longer Durations of Action  For the Patient  Typically more predictable insulin  May allow more dosing flexibility  May require more total units of insulin for similar results  10% more glargine U-300 vs U-1003-4  1.08:1 more degludec U-100 vs glargine U-1005

1. https://www.diabetesdaily.com/learn-about-diabetes/insulin-101/biosimilar-insulin/ 2. http://blog.diabeteslab.org/2016/01/the-future-of-insulin-new-insulin-formulations-under-development/ 3. Riddle M. et al. New 300 Units/mL vs. Gargine 100 Units/mL in People with Type 2 Diabetes Using Basal and Mealtime Insulin: Glucose Control and Hypoglycemia in a 6-month Randomized Controlled Trial (EDITION-1). Diabetes Care 2014; 37:2755-2762. 4. Yki-Jarvinen H, et. Al. New Insulin Glargine 300 Units/mL vs. Glargine 100 Units/mL in People with Type 2 Diabetes Using Oral Agents and Basal Insulin: Glucose Control and Hypoglycemia in a 6-Month Randomized Controlled Trial (EDITION-2) Diabetes Care 2014;37:3235-3243. 5. Garber A, et. Al. Insulin degludec, an ultra-longacting basal insulin, versus insulin glargine in basal-bolus treatment with mealtime in type 2 diabetes (BEGIN Basal-Bolus Type 2): a phase 3, randomized, open-label, treat-to-target non-inferiority trial Lancet 2012;379:1498-1507.

The Insulins

 The New Insulins In General  Similar A1c and BGM reductions to existing insulin products  Concentrating insulin results in smaller volume infused with changing pharmacokinetic and pharmacodynamics properties  Flatter action curves  Longer Durations of Action  For the Patient  Typically more predictable insulin  May allow more dosing flexibility  May require more total units of insulin for similar results  10% more glargine U-300 vs U-1003-4  1.08:1 more degludec U-100 vs glargine U-1005

1. https://www.diabetesdaily.com/learn-about-diabetes/insulin-101/biosimilar-insulin/ 2. http://blog.diabeteslab.org/2016/01/the-future-of-insulin-new-insulin-formulations-under-development/ 3. Riddle M. et al. New Insulin Glargine 300 Units/mL vs. Gargine 100 Units/mL in People with Type 2 Diabetes Using Basal and Mealtime Insulin: Glucose Control and Hypoglycemia in a 6-month Randomized Controlled Trial (EDITION-1). Diabetes Care 2014; 37:2755-2762. 4. Yki-Jarvinen H, et. Al. New Insulin Glargine 300 Units/mL vs. Glargine 100 Units/mL in People with Type 2 Diabetes Using Oral Agents and Basal Insulin: Glucose Control and Hypoglycemia in a 6-Month Randomized Controlled Trial (EDITION-2) Diabetes Care 2014;37:3235-3243. 5. Garber A, et. Al. Insulin degludec, an ultra-longacting basal insulin, versus insulin glargine in basal-bolus treatment with mealtime insulin aspart in type 2 diabetes (BEGIN Basal-Bolus Type 2): a phase 3, randomized, open-label, treat-to-target non-inferiority trial Lancet 2012;379:1498-1507.

15 3/29/2017

Medications for Diabetes:

 Newer Choices:  GLP-1RA (liraglutide,lixisenatide, exenatide, , )  Five Important Actions:  Upregulates Beta-Cell activity (insulin)  Down-regulates α-cell activity (glucagon)  Slows Liver Production of glucose  Slows gastric emptying  Central hypothalamic satiety action  A1c Reduction of 0.6 to 1.6%  Fasting and Post-prandial activity  Different Preparations:  Twice Daily  Once Daily  Once Weekly  Oral investigational ()  Inplantable investigational (various)

Medications for Diabetes:

 Newer Choices:  GLP-1RA (liraglutide,lixisenatide, exenatide, dulaglutide, albiglutide)  Safety:  Early nausea, vomiting, diarrhea possible (usually mild, usually attenuates)  Hypersensitivity  Renal Impairment  Pancreatitis Risk  Medullary Thyroid Carcinoma (MTC) – nodules seen in rat and mice studies  Multiple Endocrine Neoplasia Type-2 (MEN-2)  Weight Loss is Common

16 3/29/2017

Medications for Diabetes:

 Newer Choices:  GLP-1RA (liraglutide,lixisenatide, exenatide, dulaglutide, albiglutide)  Patient Experience:  Choose Patient Wisely  Some experience with the oral medications  Not at goal  Side Effect Profile appropriate for patient  Capable of Managing Appropriate Device

Medications for Diabetes:

 Newer Choices:  SGLT-2i (canagliflozin, dapagliflozin, )  Removes excess glucose from circulation by blocking the re-uptake of glucose at the nephron  Can remove up to 100 gm of glucose daily from circulation  Compatible with other oral agents and insulins

17 3/29/2017

Medications for Diabetes:

 Newer Choices:  SGLT-2i (canagliflozin, dapagliflozin, empagliflozin)  Safety  Bladder infections  Yeast infections  Dehydration/volume depletion  Impairment of Renal Function  Euglycemic Diabetic Ketoacidosis  Long Bone Fractures  Hypersensitivity

Medications for Diabetes:

 Newer Choices:  SGLT-2i (canagliflozin, dapagliflozin, empagliflozin)  Patient Experience:  Choose Patient Wisely  Not the first oral medication to reach for  Encourage increased water intake  Recommend good genital hygiene  Use care with CKD patients  Caution with volume-fragile patients  Weight loss is possible  Elderly

18 3/29/2017

The Combinations:

 Insulin/GLP-1RA:  Lixisenatide/glargine (approved and on market)1  Liraglutide/degludec (approved, not yet on market)2

1. https://www.drugs.com/history/soliqua.html 2. https://www.drugs.com/newdrugs/novo-nordisk-receives-fda-approval-xultophy-100-3-6-insulin-degludec-liraglutide-type-2- diabetes-4458.html

The Combinations:

 Insulin/GLP-1RA:  Liraglutide/degludec (approved, not yet on market)2  Dual V RCT: Type 2 not controlled with glargine and metformin  Degludec/Lira vs glargine (baseline A1c 8.4 and 8.2) • A1c at wk 26 6.6 and 7.1% (non-inferior and superior) • Body Wt. -1.4 vs. +1.8 kg (superior) • Hypoglycemia 2.23 vs 5.05 events per PYE (superior)

1. Lingvay I, et.al. Effect of Insulin Glargine Up-titration vs Insulin Degludec/Liraglutide on Glycated Hemoglobin Levels in Patients with Uncontrolled Type 2 Diabetes, The DUAL V Randomized Clinical Trial JAMA 2016;315(9):898-907.

19 3/29/2017

The Combinations:

 Insulin/GLP-1RA:  Lixisenatide/glargine (approved and on market)1  LixiLan-L RCT (30 week trial)  Baseline A1c 8.5  8.1  iGlarLixi vs. iGlar A1c6.9% (-1.1%) vs. 7.5% (-0.6%)  Mean Body Weight  iGlarLixi vs. iGlar -0.7kg vs. +0.7kg  Hypoglycemia  iGlar Lixi vs. iGlar 3.03 vs. 4.22 events/pt. yr.  Severe Hypoglycemia  iGlarLixi 4 patients experienced 5 events vs iGlar 1Pt. 1 event. 1. Aroda V, et. Al. Efficacy and Safety of LixiLan, a Titratable Fixed-Ratio Combination of Insulin Glargine Plus Lisixenatide in Type 2 Diabetes Inadequately Controlled on Basal Insulin and Metformin: The LixiLan-L Randomized Trial Diabetes Care 2016;39:1972- 1980.

The Combinations:

 Insulin/GLP-1RA:  The overnight and fasting control of basal insulin combined with the GLP-1RA benefits previously described  Safety:  Early nausea, vomiting, diarrhea possible (usually mild, usually attenuates)  Hypersensitivity  Renal Impairment  Pancreatitis Risk  Medullary Thyroid Carcinoma (MTC) – nodules seen in rat and mice studies  Multiple Endocrine Neoplasia Type-2 (MEN-2)  Weight Loss is Common

1. https://www.drugs.com/history/soliqua.html 2. https://www.drugs.com/newdrugs/novo-nordisk-receives-fda-approval-xultophy-100-3-6-insulin-degludec-liraglutide-type-2- diabetes-4458.html

20 3/29/2017

The Combinations:

 Insulin/GLP-1RA:  Patient Experience:  Limited: as this is a new combination therapy  Individual components work well together  Consider for patients not at goal with either GLP-1RA or basal insulin therapy  Benefit vs. individual components would be adherence (1 vs. 2 or more injections)  Watch for transitioning basal insulin patients on larger insulin doses  Recommend reducing or deleting secretogogues when making this transition.

Managed Care Approach

Formulary Management

21 3/29/2017

Managed Care Approach

 Formulary Management  Cost In General  Complications and Hospitalizations  Medications and Expense  Medication that is purchased and never used  Medication that is used sub-therapeutically  Medication used for the wrong patient type  Medication that is not given to a patient that needs it  Inattention  Unfamiliarity  Prior Authorization or Non-Formulary

Managed Care Approach

 Formulary Management  Prior Authorization or Non-Formulary  Restricts access to higher cost medication  Possibly cost saving for health plan  Potentially re-directs patients to less costly alternatives

22 3/29/2017

Managed Care Approach

 Formulary Management  Prior Authorization or Non-Formulary  Interferes with patients receiving necessary medication  Fosters distrust in the patient:physician relationship  Contributes to physician stress/burnout  Added burden to patient care staff  Can lead to physician not choosing appropriate medication because of administrative burden

Managed Care Approach

 Recommendations:  Understand the wisdom of the Clinical Practice Guidelines/Recommendations  Understand the wisdom of the treating physician  Keep the patient’s well being central to your decision making  Use your Data

23 3/29/2017

Managed Care Approach

 Recommendations:  Use your Data  Physicians  Are they meeting recommended process goals  How frequently are at risk patients being seen/encountered  What medications are being used  Are appropriate referrals being made  Outcomes?  Share this information with physicians.  Don’t do a report card….annoying  Do present opportunities for improvement  Do recommend some behavioral cues that can be effective.

Managed Care Approach

 Recommendations:  Use your Data  Patients  Are they meeting recommended process goals  Duration of Diabetes  If at risk, are they being seen regularly  What important co-morbid conditions are present • CHF, Renal, GI, Pancreatitis, etc.  What medications are being used • Are the medications that are being used effective • Do the medications make sense with identified co-morbid conditions  Are appropriate referrals being made • Diabetes Education, Eyes, Dentist, Renal, etc  Outcomes?

24 3/29/2017

The Good, The Bad, and the Ugly of Diabetes Care

The Good: There is no better time in Human History to have the diagnosis of Diabetes Mellitus

The Bad: There are a lot more people with diabetes and it is expensive to treat

The Ugly: No treatment/under-treatment Complications

With apologies to Clint Eastwood……

Managed Care Plays a Role in Diabetes Management: 1. Larger portion of the population is involved in some form of Managed Care 2. Managed Care has access to data (claims/pharmacy/etc.) that can help all parties understand better how diabetes care is being delivered 3. Managed Care can also help us identify when care is not being delivered 4. Managed Care also has a responsibility in helping understand the longer term implications in the delivery of diabetes care

25 3/29/2017

Thank you

What Managed Care Needs to Know About Novel Therapies in the Evolving Management of Type 2 Diabetes

TIMOTHY S. REID, M.D. MERCY DIABETES CENTER JANESVILLE, WI [email protected]

26