This document summarizes the care of a 55-year-old male patient with type 2 diabetes who recently relocated. At his initial visit, his HbA1c was 11.2 and BMI was 31. The document outlines assessments done, treatment goals discussed, and a treatment plan involving lifestyle changes and medication adjustments. At a 3-month follow-up visit, some improvements were seen but challenges remained. The doctor discusses continuing treatment to further improve the patient's condition and manage his diabetes and related risks.

1. Patient Video
Dr. Gosmanov
01 Gosmanov Pt Video dr 2.18.14.pptx

2. Patient Case (webinar)
• New patient, recently relocated
• 55 year old male
• BMI = 31
• HbA1c = 11.2
• Other labs
– Kidney function? Is this an issue for the patient?
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Narrated by Dr. G in webinar format

3. Patient Case (webinar)
• Physical exam
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• Medications
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Narrated by Dr. G in webinar format

4. Patient Case (webinar)
• Medical history
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• Social history
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• Family history
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Narrated by Dr. G in webinar format

5. Assessing the Patient:
Stages of Change
(end of webinar section)
• Pre-contemplation (Avoidance/denial)
• Contemplation
• Preparation/Determination
• Action/Willpower
• Maintenance
Prochaska JO, et al. J Consult Clin Psychol. 1983;51(3):390-395.

6. Meeting the Patient
Readiness to Change (Patient Video: 5’)
• First interaction with patient
• Assessment of readiness to change
• Why are you here?

7. Assessing the Patient:
Stages of Change
(beginning of 2nd webinar section)
• Pre-contemplation (Avoidance/denial)
• Contemplation
• Preparation/Determination
• Action/Willpower
• Maintenance
Prochaska JO, et al. J Consult Clin Psychol. 1983;51(3):390-395.

8. What is this approach to this patient?
(webinar)
• Review patient interaction
• Current status
– Readiness to change
– Clinical presentation
– History
• Review of risk/benefit
– Diabetes complications
– CV risk
• Goals
– ABCs
– Weight
• Strategy

9. Type 2 Diabetes Risk Assessment
http://www.diabetes.org/are-you-at-risk/diabetes-risk-test/. Accessed February 2014.

10. Heart Attack Risk Assessment
http://cvdrisk.nhlbi.nih.gov/. Accessed February 2014.
Factor
Age years
Gender O Female O Male
Total cholesterol mg/dl
HDL cholesterol mg/dl
Smoker O No O Yes
Systolic BP mmHg
Current hypertension
medication?
O No O Yes
10-Year Risk of Heart Attack

12. Stroke Risk Assessment
1. Are you a female and over the age of 55, OR are you male and over the age of 45? YES NO
2. Do you have high blood pressure, or do you take medication for high blood pressure?
(Ideal Blood Pressure is 120/80) YES NO
Your Blood Pressure: _________________ Date Tested: _________________
3. Do you smoke or have a long history of smoking? YES NO
4. Do you have an irregular heartbeat? YES NO Don’t Know
5. Do you have high cholesterol, OR do you take medication for high cholesterol? YES NO
Don’t Know
6. Cholesterol Levels (if known) HDL: ________ LDL:______ Total:_________
Date Tested: ______________
7. Has your mother, father, siblings, or children had a stroke or heart disease? YES NO
8. Do you exercise less than 3 times per week for 20-30 minutes at a time? YES NO
9. Do you eat a diet high in saturated and/or animal fat? YES NO
10. Are you diabetic? YES NO
11. Are you overweight by 20 pounds or more? YES NO
www.hopeheart.org. Accessed February 2014.
3 or more “YES”  see your doctor

13. Treatment Goals: ABCs
• HbA1C
– < 7 % for many people
– Preprandial capillary plasma glucose 70–130 mg/dl
– Peak postprandial (1-2 hours) capillary plasma glucose < 180
mg/dl
• Blood pressure (mmHg)
– Systolic < 140 for most people
– Diastolic < 80 (< 90 per Joint National Committee-8 2014
guideline)
Inzucchi SE, et al. Diabetes Care. 2012;35(6):1364-1379.
http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=114. Accessed Nov 2013.
James PA, et al. JAMA. 2013 Dec 18. [Epub ahead of print]. http://jama.jamanetwork.com. Accessed Dec 2013.
American Diabetes Association. Diabetes Care. 2014; 37:S14-S80.

14. • Cholesterol – Lipid Profile (mg/dl)
– LDL Cholesterol < 100
LDL < 70 with overt CVD
– HDL Cholesterol Men > 40, Women > 50
– Triglycerides < 150
Inzucchi SE, et al. Diabetes Care. 2012;35(6):1364-1379.
http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=114. Accessed Nov 2013.
James PA, et al. JAMA. 2013 Dec 18. [Epub ahead of print]. http://jama.jamanetwork.com. Accessed Dec 2013.
American Diabetes Association. Diabetes Care. 2014; 37:S14-S80.
Treatment Goals: ABCs
(cont.)

15. Diabetes Patients at Goal
Stark Casagrande S, et al. Diabetes Care. 2013;36(8):2271-2279.
Ali MK, et al. N Engl J Med. 2013;368(17):1613-1624.
HbA1c 52%
LDL 56%
BP 51%
All 3
19%

16. Other Risk Factors
(end webinar section)
• Smoking
• Sedentary lifestyle
Education Must Be Ongoing

17. Overview of Current Medical Condition
(Patient Video—20’ for section?)
• Diabetes complications
– Consequences of continuing current path
• Diabetes comorbidities
• ABCs (current vs goal?)
– HbA1c
– BP
– Cholesterol
– BMI

18. Risk Assessment (Patient Video)
• Myocardial infarction
• Stroke
• Amputation
• Blindness
• Loss of limb

19. Action Plan
(Patient Video, concluding initial visit)
• Review current patient condition
• Lifestyle changes, specific tools
• Medication changes

20. ?3-Month Follow-Up Visit
(Patient Video)
• HbA1c change
• Body weight change?
• BP, lipids, etc.
• Self-reported lifestyle changes/smoking
cessation
• Medication adherence
• AEs
• Solicit patient feedback on treatment plan

21. Charting the Course (Patient Video)
• Reinforce positive accomplishments
• Review of risks in light of current values
• Areas for improvement
• Review of AEs
• Re-Assessing Goals
• Adjustments to medication?
• Set next visit

22. Case Summary (webinar)
• Initial state
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• Follow-up visit
– Improvements
– Challenges
• Next steps, likely course with this patient

23. What Happened at the Patient Visits?
(webinar)
• Readiness to change
• Initial visit
– Exam
– Lab values
– Goals vs current
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• 3 month visit
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• Treatment plan for this patient

24. Reduce
Hyperglycemia
Metformin
Insulin
Thiazolidinediones
Insulin
GLP-1 analogues
DPP-4 inhibitors
SGLT2 Inhibitors
Insulin
-glucosidase
inhibitors
Sulfonylureas
Glitinides
GLP = glucagon-like peptide;
DPP = didpeptidyl peptidase
Multiple Therapies for Type 2 Diabetes

25. Diabetes Drugs Impact Multiple Endpoints
Drug BW
Hyper-
tension
Dys-
lipidemia
Hypoglycemia
Risk
-glucosidase
inhibitors
Neutral Improved
Neutral/
Improved
Low
DPP-4 inhibitors Loss/Neutral Neutral Improved Low
GLP-1 agonists Loss Improved Improved Low
Insulin Gain Neutral* Improved High
Meglitinides Gain Neutral Neutral Moderate
Metformin Loss/Neutral Neutral Improved Low
SGLT2 inhibitors Loss Improved ? Low
Sulfonylureas Gain Neutral Variable Moderate
TZD Gain Improved Improved Low
Basile JN. J Diabetes Complications. 2013;27(3):280-286.
*Hyperinsulinemia is associated with hypertension

26. Therapeutic Options (webinar)
• Initial visit
– How did therapy match patient?
– Successes
– limitations
• Follow-up visit
– How was therapy adjusted?
– Expected impact
– Challenges

27. What Do Patients Want to Know?
(webinar)
• Benefits (long term avoidance of complications)
• Risks (short term adverse effects)
– Weight gain
– Hypoglycemia
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• Other issues
– Injection anxiety
– Adherence
– Self-image?
– Cost/insurance
– Impact of ACA on diabetes care

28. Key Messages (webinar)
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