7/20/2009




Diabetes: Overcoming Barriers
and Achieving Excellence With
 Evidenced-based Guidelines

                Edw...
7/20/2009




Excellent evidence documents that when
patients achieve control of their HbA1c,
LDL and Blood pressure throu...
7/20/2009




                   More Diabetes Facts
• 20% of Medicare population has diabetes
• 30% of the Medicare Budge...
7/20/2009




Saves
Clinician 5
minutes




Empower
  the
 Patient
 P ti t




                     4
7/20/2009




Diabetes Master Clinician Program as of June 9, 2009




                                                   ...
7/20/2009




   Towers Perrin actuarial evaluation
      2006 Bridges to Excellence
ADA Quality          Yearly Cost
Indi...
7/20/2009




                                    CASE
• 42 Year old man comes to your office for routine
  physical. No c...
7/20/2009




                                               Metabolic Syndrome           Diabetes


              Insulin...
7/20/2009




ACE/AACE Diabetes Road Maps to achieve glycemic control in type 2 Diabetes Mellitus    17
Endocrine Practice...
7/20/2009




   June 2009 National ADA Meeting
• If newly diagnosed or in the first 10 years after diagnosis attempt
  to...
7/20/2009




21




22




           11
7/20/2009




                                                             23




    Case 2 Choosing Diabetes Medications...
7/20/2009




                                                    ADA guideline




Nathan et al Medical Management of Hyp...
7/20/2009




                                                              27




   Case 3 Multiple lipid abnormalities
...
7/20/2009




                                   Non-HDL Cholesterol
                • Non-HDL represents all the bad ugly...
7/20/2009




                      Case 3 more ?
• What goal do you attempt to achieve with LDL?
  Is there t d d
  I th ...
7/20/2009




                         Case 3 more ?
• What goal do you attempt to achieve with LDL?
  Is there t d d
  I ...
7/20/2009




 What if AST and ALT Are ↑ (Cont.)

• No supporting direct data that statins worsen hepatic
  histology 1 st...
7/20/2009




Kathiresan et al Framingham Heart Study Circulation 2006;113:20-29
                                         ...
7/20/2009




         Recommendations For Niacin
• May have 5%–10% incidence of flushing that ↓ with use.
  New formulati...
7/20/2009




        Recommendations for fish oil
   Rigorous purification processes in fish oil manufacturing
   reduces...
7/20/2009




Comments
  and
Questions
            43




                       22
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Diabetes Overcoming Barriers And Achieving Excellence

  1. 1. 7/20/2009 Diabetes: Overcoming Barriers and Achieving Excellence With Evidenced-based Guidelines Edward Shahady MD Medical Director Diabetes Master Clinician Program Florida Academy of Family Physicians Foundation Clinical Professor of Family Medicine 1 Objectives • Use diabetes registries to overcome the barriers to t reaching standards of diabetes care hi t d d f di b t • Understand the metabolic defects in Diabetes and which medications address which defects • Understand how to accomplish Diabetes standards of care in your office office. • Incorporate the above principles though case presentations 2 1
  2. 2. 7/20/2009 Excellent evidence documents that when patients achieve control of their HbA1c, LDL and Blood pressure through life style changes and medication, obtain recommended immunizations, eye exams, foot exams, urine microalbumin and t k aspirin d il significant d take i i daily, i ifi t reduction in complications will be achieved. Practices that measure individual and practice achievement of these evidenced based activities and share that information with clinicians, staff and patients achieve better diabetes control and reduce costs and complications.” 4 2
  3. 3. 7/20/2009 More Diabetes Facts • 20% of Medicare population has diabetes • 30% of the Medicare Budget is spent on diabetes • Leading cause of blindness is diabetic retinopathy and it is 90% preventable- National Eye Institute • Diabetic nephropathy is the leading cause of end stage renal disease- most is preventable-NIDDKD disease preventable NIDDKD • Diabetes accounts for 60% of all non-traumatic amputations-85% preventable- ADA CDC Sklar J, Atlas of Type 2 diabetes Preface Springer Science Philadelphia PA 2008 Registry Reports (tools) • FAFP registry is internet based-used by over 200 clinicians in Fl id 17 000 patients,59,000 visits li i i i Florida-17,000 ti t 59 000 i it • Point of Care Reports for the Clinician and the Patient- report cards • Population based Reports that identify– • Patients at increased risk because of increased HbA1c, LDL, B/P, Non-HDL, Triglycerides Non- • Patients who do not have documented annual recommendations or daily ASA 3
  4. 4. 7/20/2009 Saves Clinician 5 minutes Empower the Patient P ti t 4
  5. 5. 7/20/2009 Diabetes Master Clinician Program as of June 9, 2009 5
  6. 6. 7/20/2009 Towers Perrin actuarial evaluation 2006 Bridges to Excellence ADA Quality Yearly Cost Indicator Savings if indicator achieved HBA1C ≤ 7 $279.00 LDL ≤ 100 $369.00 Syst BP ≤ 130 $474.00 Total yearly $1122.00 savings http://www.bridgestoexcellence.org http://www.bridgestoexcellence.org Yearly Cost Savings using Bridges to Excellence data as of June 2009 # Patients reaching Yearly Cost Savings if goal for quality indicator achieved indicator above national average in 2002 HbA1c 1079 patients $301,041.00 LDL 3582 patients p $ , $1,321,758.00 , BP 3938 patients $1,866,612.00 Total yearly savings $3,489,411.00 www.bridgestoexcellence.org 6
  7. 7. 7/20/2009 CASE • 42 Year old man comes to your office for routine physical. No complaints • Family Hx of diabetes and Father MI age 44 • BMI 28, Waist 42 in, B/P 142/90 • Total Chol (TC)=180, Triglycerides=250, LDL (calculated)=100 HDL=30 and FBS=132 • You obtain an A1C and it is 6.0 • How would you treat him? What is your A1C goal? What about the Lipids? 13 Natural History of Type 2 Diabetes 100 75 50 25 Phase III Postprandial IGT Hyperglycemia Phase I Phase II 0 ‐12 ‐10 ‐6 ‐2 0 2 6 10 14 Years From Diagnosis IGT = impaired glucose tolerance; Lebovitz H (1999), Diabetes Reviews 7:139-153 14 7
  8. 8. 7/20/2009 Metabolic Syndrome Diabetes Insulin sensitivity Insulin secretion Associated risk factors— hypertension, dyslipidemia Atherogenesis Microvascular complications ↑ blood glucose Age (Years) Type 2 Diabetes Iosmma B, Diabetes Care 2001; 24(4):683-689 24(4):683- 15 Pre-Diabetes Treatment With Metformin (Level E) • ADA Panel recommends lifestyle modification and metformin (850 mg twice per day) if patient has IFG (FPG≥100 and <126 mg/dL) or IGT 2 hour post prandial (≥140 and <200 mg/dL) 2-hour and any 1 of the following: – <60 years of age – BMI ≥35 kg/m2 – Family history of diabetes in first-degree relatives – Elevated triglycerides – Reduced high-density lipoprotein – Hypertension – A1C >6.0% Nathan DM et al. (2007), Diabetes Care 30(3):753-759 16 8
  9. 9. 7/20/2009 ACE/AACE Diabetes Road Maps to achieve glycemic control in type 2 Diabetes Mellitus  17 Endocrine Practice 2007;13:261‐268 A1C ADA Recommendations • The A1C goal for patients in general is an A1C goal o %( ) of <7% (B) • The A1C goal for the individual patient is an A1C as close to normal (6%) as possible without significant hypoglycemia (E) • Less stringent treatment goals may be appropriate for patients with a history of severe hypoglycemia, p y yp g y , limited life expectancies, very young children or older adults, and individuals with comorbid conditions (E) (2009), ADA Clinical Practice Recommendations Diabetes Care. Available at: www. diabetes.org. Accessed 2-20-2009 2-20- 18 9
  10. 10. 7/20/2009 June 2009 National ADA Meeting • If newly diagnosed or in the first 10 years after diagnosis attempt to reach as close to 6% A1C as possible. UKPDS, Sub-analysis of ACCORD and VADTVADT. • If they have had a CV event, are older?, prone to hypoglycemia 7 to 7.5% more appropriate • Keeping the A1C as close to 6% as possible associated with – Pancreatic function survives longer period of time – Healthy endothelium –LLess f f tt acid released from adipocye, so l free fatty id l df di less t i l triglyceride id and less small dense LDL to penetrate the endothelium – Platelets less sticky – Less Inflammation 19 Ideal Medication sustains decrease 20 10
  11. 11. 7/20/2009 21 22 11
  12. 12. 7/20/2009 23 Case 2 Choosing Diabetes Medications • Mary is a 62 year old diabetic. She was diagnosed 3 years ago and treated with lifestyle changes and Metformin. Her A1C was 7.3 at diagnosis and decreased to 6.2. Recently she noticed her blood sugars are higher and her A1C is now 8.3. • What would you do at this time? time? – Would you go back over the lifestyle issues to be sure she understands them? – Would you add another oral medication? If so which one? y – Would you consider adding Insulin? – What about Byetta? (GLP-1 Agonist) (GLP- – What would you do if a second oral agent did not help her achieve goal? What goal did you try to achieve? 24 12
  13. 13. 7/20/2009 ADA guideline Nathan et al Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus  Algorithm for the Initiation and Adjustment of Therapy Diabetes Care 2009;32:‐193‐203 Algorithm for the Initiation and Adjustment of Therapy Diabetes Care 2009;32:‐193‐ 25 ACE/AACE Diabetes Road Maps to achieve glycemic control in type 2 Diabetes Mellitus  26 Endocrine Practice 2007;13:261‐268 13
  14. 14. 7/20/2009 27 Case 3 Multiple lipid abnormalities • Sam is a 55 year old man with diagnosed diabetes of 6 months. • His initial lab values 6 months ago revealed an A1C of 7.5, Cholesterol 200, LDL 100, Triglycerides 350, HDL 30, Non-HDL gy 170. His blood pressure was 150/95. You treated the diabetes with lifestyle changes and Metformin and his blood pressure with an ACE inhibitor. • He returns 6 months later and he has lost some weight, is exercising some and his B/P is now 125/78. His lab values now reveal an A1C of 6.5, Cholesterol 200, LDL 118, Triglycerides , , , gy 250, HDL 32, Non-HDL 168. – Why did his LDL go up? – How would you treat this man? – Would you consider adding medications like a statin, fibrate, fish oil, or Niacin? 28 14
  15. 15. 7/20/2009 Non-HDL Cholesterol • Non-HDL represents all the bad ugly small dense atherogenic LDL • Non HDL C = TC HDL = 200 25=175 TC-HDL 200-25=175 • LDL is calculated TC-HDL- (Trigs/5) = LDL • 200-25 = 175 - (350/5 = 70) • Calculated LDL is therefore 175-70 which = 105 • C not use LDL as only target when the triglycerides Can D l h h i l id over 200 • HDL C goal is LDL goal + 30 * *Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (2001), JAMA 285(19):2486-2497 29 Non–HDL- Non–HDL-C Is Superior to LDL-C LDL- in Predicting CHD Risk-especially in Diabetes Risk- 2.5 2 lative CHD Risk 1.5 1 Rel 0.5 ≥190 160‐189 Non–HDL‐C  160‐ Non–HDL‐ 0 <160 <130 130‐ 130‐159 ≥160 LDL- LDL-C Liu J, et al. Am J Cardiol. 2006;98:1363‐1368. Liu J, et al. Am J Cardiol. 2006;98:1363‐ 15
  16. 16. 7/20/2009 Case 3 more ? • What goal do you attempt to achieve with LDL? Is there t d d I th a standard or recommendations we can d ti follow. 31 Diabetes Care April 2008 ADA & ACC recommendations for Lipid goals in diabetes. 32 16
  17. 17. 7/20/2009 Case 3 more ? • What goal do you attempt to achieve with LDL? Is there t d d I th a standard or recommendations we can d ti follow. • Do you obtain an AST and ALT before your start a statin? • Do you sometimes stop statins if the AST and ALT go above a certain level? 33 What if AST and ALT Are ↑ • Nonalcoholic Fatty Liver Disease (NAFLD)/Nonalcoholic Steatohepatitis (NASH) is common in patients with p ( ) p hyperlipidemia and type II diabetes • NAFLD/NASH may increase risk of CVD, so treat • Liver enzymes are often normal in NAFLD/NASH; many hyperlipidemic patients with unsuspected NAFLD have likely been treated with statins without significant toxicity1 1Chalasani N (2005), Hepatology 41(4):690-695; 2Rallidis LS et al. (2004), Atherosclerosis 174(1):193-196; 3McKenney JM et al. (2006), Am J Cardiol 97(8A):89C-94C 34 17
  18. 18. 7/20/2009 What if AST and ALT Are ↑ (Cont.) • No supporting direct data that statins worsen hepatic histology 1 studies indicate statins may improve liver histology in patients with NASH2 • If ALT or AST exceeds 3x UNL during statin therapy, follow the patient and repeat the measures; there is no need to D/C the ; statin; consider using a fractionated bilirubin to detect liver dysfunction (rather than ALT/AST)3 1Chalasani N (2005), Hepatology 41(4):690-695; 2Rallidis LS et al. (2004), Atherosclerosis 174(1):193-196; 3McKenney JM et al. (2006), Am J Cardiol 97(8A):89C-94C 35 Case 3 more ? • What goal do you attempt to achieve with LDL? Is there t d d I th a standard or recommendations we can d ti follow. • Do you obtain an AST and ALT before your start a statin? • Do you sometimes stop statins if the AST and ALT go above a certain level? • What about Triglycerides and HDL? 36 18
  19. 19. 7/20/2009 Kathiresan et al Framingham Heart Study Circulation 2006;113:20-29 2006;113:20- 37 Kathiresan et al Framingham Heart Study Circulation 2006;113:20-29 2006;113:20- 38 19
  20. 20. 7/20/2009 Recommendations For Niacin • May have 5%–10% incidence of flushing that ↓ with use. New formulation Niaspan combined with NSAID or ASA decreases chances to <5%. 5%. • Niaspan start with 500 mg at night and increase by 500 mg a month up to 1500-2000mg may be enough • Be aware of “creep effect” keeps improving • Minor increases (4%–5% on average) in glucose levels often clinically insignificant insignificant. • Niacin co-administration with a statin does not potentiate statin-related myopathy. • Active gout is a contraindication to niacin use National Lipid Association Recommendations for Fibrates • Measure serum creatinine before starting fibrates-If impaired renal function is present, consider Gemfibrozil (Lopid) or a lower starting dose of Fenofibrate (Tricor)(48 mg) • Creatinine monitoring if taking metformin, which may need to be discontinued for creatinine elevations 1.4 mg/dL in women and 1.5 mg/dL in men, • When combined with a statin use fenofibrate not gemfibrozil to decrease risk for myopathy and or rhabdomyolysis • Fib t therapy elevates homocysteine but not sure is Fibrate th l t h t i b t t i clinically relevant • Fibrates may increase the risk for cholelithiasis National Lipid Association 20
  21. 21. 7/20/2009 Recommendations for fish oil Rigorous purification processes in fish oil manufacturing reduces risk of environmental toxins. The efficacy of fish oil therapy is most dependent on the amount of omega-3 fatty acids (such as EPA and DHA) in each capsule, not the total amount of fish oil concentrate Fish oil supplements are not subject to FDA approval requirements. So amount of EPA DHA varies Patients P ti t may need 11 capsules of fi h oil supplements to d l f fish il l t t match the amount of omega-3 fatty acid in 4 capsules of prescription fish oil (Lovaza). National Lipid Association Potential Dose Responses and Time Courses for Altering Clinical Events of Physiologic Effects of Fish or Fish Oil Intake Mozaffarian, D. et al. JAMA 2006;296:1885-1899. 21
  22. 22. 7/20/2009 Comments and Questions 43 22

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