Transcript Document

Getting to Goal:
‘Practical Tricks of the trade‘
How to Achieve the ABCs
Robert Gabbay MD, PhD
Director
Penn State Hershey Diabetes Institute
Penn State College of Medicine
[email protected]
The ‘ABCs’
• A1C
• BP < 130/80
• Cholesterol (LDL<100, if CAD <70)
Evidence based interventions that
reduce morbidly and mortality
•
•
•
•
•
•
•
HbA1C < 7
BP < 130/80
LDL cholesterol < 100 (or <70 if CAD)
Aspirin age > 50 men, 60 women with 1 risk factor
ACE -age >55
Statin use- age >40
Yearly screen for nephropathy, feet, and eye exams
Current Diabetes Care in US
• 71 % < 1 A1c measurements per year
– 18 % A1C > 9.5
– ½ A1C > 7
• ~64% blood pressure above goal
• 89 % LDL > 100
• 37 % no dilated eye exam
• 45 % no yearly foot exam
How Low to Go?
What’s the Problem?
• Not Bad Patients or Bad Doctors
• It’s the System
• Acute Care vs. Chronic Care
–Self-management
• Clinical Inertia
A1C < 7
Why?
How?
UKPDS: Hemoglobin A1C (HbA1C)
9
8.5
8
Median
HbA1C (%)
7.5
7
6.5
7.9
7.0
Conventional
Intensive
6
UKPDS: Risk Reductions
Any Diabetesrelated Microvascular
Endpoints
Endpoint
0
-5
-10
% Risk
Reduction
-15
-20
-25
-30
-35
-40
-45
-50
Laser
Rx
Cataract
Albuminuria
But I thought it was Bad to Lower A1C too
Much
• All recent studies aimed at A1C = 6.5 or lower
• No evidence that A1C = 7 is bad
• Data says to reduce CVD- its not so much
about Glucose
• It’s the Blood Pressure and Cholesterol
Really really important points:
1. Aggressive control early prevents complications.
2. Because of the log-linear relationship between control
and complications, absolute benefits are greatest at
high HbA1c values.
3. Pushing patients with advanced disease (particularly
macrovascular complications) to ‘tight’ control that they cannot
achieve probably increases mortality
•
attention to hypoglycemia and particularly nocturnal hypoglycemia
Sites of Drug Action
Carbohydrate
DIGESTIVE ENZYMES
Glucose
Sulfonlyureas
Meglitinides
Incretins
Insulin
Alpha-glucosidase
Inhibitors, Incretins
Excessive
lipolysis
Defective
b-cell secretion
Excess
glucose
production
Metformin
TZD
Incretins
Reduced glucose
uptake
Resistance to the action of insulin
TZD, Metformin
Dinneen SF. Diabet Med. 1997; 14 (Suppl 3): S19-24.
How to choose?
•
•
•
•
Pathophysiology – I resist or I secretion?
Cost
Rapid onset- avoid TZD
Co-morbidities
–
–
–
–
–
–
Renal – no metformin
Liver –no TZD
CHF – no TZD
CAD? – avoid TZD?
Weight- favor metformin, incretins
Concern hypo- avoid SU
Points to remember
• Each oral agent lower A1C 1-2
• If A1C >9, start two agents
• Follow SMBG, A1C, and Titrate!!!!!
T2DM treatment strategies revisited
HbA1c (%)
Diagnosis
Target-driven therapy*
9
8
7
STEP 4
STEP 3
STEP 2
STEP 1
Basal plus prandial
Basal insulin
OHA combinations
OHA monotherapy
Lifestyle modification
Adapted from Riddle M. Endo Metab Clin NA 1997;26:659―77.
Riddle M. Am J Med 2004;116:35―95.
*Individualise
Natural History of Type 2
Diabetes
Postmeal
glucose
Plasma
Glucose
Fasting glucose
126 mg/dL
Insulin resistance
Relative b-Cell
Function
Insulin secretion
20
10
0
10
20
30
Years of Diabetes
Adapted from International Diabetes Center (IDC). Minneapolis, Minnesota.
6-6
TYPE 2 DIABETES . . . A PROGRESSIVE DISEASE
Over time,
most patients will need
insulin
to control glucose
6-7
Correcting Fasting Hyperglycemia…
Is Usually the First Task!!
300
Uncontrolled A1C ~9%
PG (mg/dL)
“Controlled” A1C <7%
200
A1C ~6%
100
Normal A1C 5%–6%
0800
1200
1800
0800
Time of Day
…then, Tackle Postprandial Hyperglycemia if A1C still >7%!
Adapted with permission from Cefalu WT. In: Leahy J, Cefalu W, eds. Insulin Therapy.
New York: Marcel Dekker; 2002:1
2003 Aventis Pharmaceuticals Inc
Titrating Glargine or Detemir
2 units q 3 days until FPG < 100
Its that easy and it works!
Physiologic Serum Insulin Secretion
Profile
75
Breakfast Lunch
Dinner
50
Plasma
Insulin ( µU/mL)
25
4:00
8:00
12:00
16:00
Time
20:00
24:00
4:00
8:00
Blood Pressure
<130/80
Why?
How?
UKPDS: Effect of Intensive BP Lowering on
Risk of Micro- and Macrovascular
Complications
0
MI
Any
Diabetesrelated
Endpoint
Diabetesrelated
Death
Retinopathy
Renal
Failure
Stroke
Vision
Deterioration
HF
Risk Reduction (%)
-10
-20
21
-30
-40
-50
P=.13
24
P=.0046
32
P=.019
34
P=.0038
42
P=.29
44
P=.013
47
P=.0036
-60
56
P=.0043
-70
Benefits of tight vs less tight BP control
UKPDS (United Kingdom Prospective Diabetes Study) was a randomized, prospective trial in which 1,148 hypertensive
patients with type 2 diabetes were allocated to tight (<150/<85 mm Hg, n=758) or less tight (<180/<105 mm Hg, n=390)
BP control and followed for a median of 8.4 years. Microvascular endpoints included retionpathy requiring
photocoagulation, vitreous hemorrhage, and fatal or nonfatal renal failure.
UKPDS 36. BMJ. 2000;321:412-419. UKPDS 38. BMJ. 1998;317:703-713.
Consistency Across Guidelines on
BP Goal in Patients With Diabetes
• JNC 7:
• ADA:
BP Goal Is <130/80 mm Hg
• NKF:
Adapted from American Diabetes Association. Diabetes Care. 2003;26(suppl 1):S33-S50; NHBPEPCC. JNC 7
Express. 2003. NIH Publication No. 03-5233; NKF. Available at:
www.kidney.org/general/news/diabetic.cfm?id=64. Accessed March 9, 2004.
High-Risk Hypertensive Patients Require
Multiple Agents to Achieve Goal
Achieved
Systolic BP
AASK1
(134 mm Hg)
ABCD2,3
(132 mm Hg)
ALLHAT4 (135 mm Hg)
HOT2,5
(141 mm Hg)
IDNT6
(140 mm Hg)
RENAAL7 (140 mm Hg)
UKPDS2,8 (144 mm Hg)
1
2
3
4
Number of BP Medications
1Wright
JT et al. JAMA. 2002;288:2421-2431. 2Bakris GL. J Clin Hypertens. 1999;1:141-147.
RO et al. N Engl J Med. 1998;338:645-652. 4The ALLHAT Officers and Coordinators. JAMA. 2002;288:2981-2997.
5Hansson L et al. Lancet. 1998;351:1755-1762. 6Lewis EJ et al. N Engl J Med. 2001;345:851-860. 7Bakris GL et al. Arch
Intern Med. 2003;163:1555-1565. 8UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713.
3Estacio
Evidence Based Guidelines
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•
•
•
< 130/80 (you will report <140/90)
How about LOWER???
ACCORD looked at lower (120)- no better
What is the first line medication?
– Who cares?
ALLHAT: Cumulative Event Rates for
Fatal CHD or Nonfatal MI by Treatment
Cumulative Event Rate (%)
20
16
12
Chlorthalidone
Amlodipine
Lisinopril
8
4
0
0
1
2
3
4
5
6
6,340
3,870
3,832
2,956
1,878
1,770
7
Years to Event
Number at Risk:
Chlorthalidone
Amlodipine
Lisinopril
15,255
9,048
9,054
14,477
8,576
8,535
13,820
8,218
8,123
13,102
7,843
7,711
11,362
6,824
6,662
209
215
195
ALLHAT (The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack) participants were randomly
assigned to receive chlorthalidone, 12.5 to 25 mg/d (n=15,255); amlodipine, 2.5 to 10 mg/d (n=9,048); or lisinopril, 10 to
40 mg/d (n=9,054) for planned follow-up of approximately 4 to 8 years, mean follow-up 4.9 years.
ALLHAT Collaborative Research Group. JAMA. 2002;288:2981-2997.
Medication Treatment Algorithm?
• Start with ACE or ARB and/or HCTZ
– Either one - best might be early combo since all
will likely need it
• Third agent based on co-morbidity
– Beta blocker and/or Ca channel
• Add the 4th and hopefully you’ve reached
goal- if not call an expert +/- alpha blocker?
Tashko and Gabbay, Integrated Blood Pressure Control (2010)
Practical:
What can I do on when I get back to work?
•
•
•
•
Track BP
Don’t miss an opportunity to escalate
Shared goals
Standing Orders?
Cholesterol
LDL control <100
If CVD <70
LDL
Treat the water supply?
HPS Substudy: First Major Vascular
Event in Patients With Diabetes
30
22 %
P<0.0001
25
Placebo
20
%
15
Simvastatin
10
5
0
0
1
2
3
4
5
6
51
58
Follow-up (years)
Benefit/1,000
-1
13
34
47
HPS Collaborative Group. Lancet. 2003;361:2005-2016.
ASCOT-LLA: Primary End Point
Atorvastatin 10 mg
Placebo
4
Number of events: 100
Number of events: 154
3
36%
reduction
Cumulative
incidence
2
(%)
1
HR=0.64 (0.50-0.83) P=0.0005
0
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Follow-up (yr)
Nonfatal MI (including silent MI) and fatal CHD.
Sever PS et al. Lancet. 2003;361:1149-1158.
Statins for DM
The question is:
Who do we NOT treat?
Putting it All together
The Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Info
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
36
Self-management support
Increase adherence
• Education but most important
SUPPORT
• Use handouts, share goals
• Combo Rx for pill burden
– Who else on the team can help?
– Use Diabetes Educators where available
Delivery System Design
• Distribute tasks amongst team
– It takes a TEAM to manage a Chronic disease
• Care management of high risk
– Stratifying your population
• Regular f/u by team
• Planned Visits
• Dealing with CLINICLA INERTIA
The Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Info
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
39
Decision support
–Evidence based guidelines (ADA)
–SHARE WITH YOUR PATIENTS
41
42
Clinical Information systems
Registry!!!!
Track outcomes and ID those not
at goal with a plan for
intensification
Evidence based interventions that
reduce morbidly and mortality
•
•
•
•
•
•
•
HbA1C < 7
BP < 130/80
LDL cholesterol < 100 (or <70 if CAD)
Aspirin age > 50 men, 60 women with 1 risk factor
ACE -age >55
Statin use- age >40
Yearly screen for nephropathy, feet, and eye exams
QUESTIONS?