Jennifer Burkmar, MD, MBA Emory Family Medicine

1. Managing Type II Diabetes for the Family Medicine ResidentPart 1 – Roadmap, Behavior, Lifestyle, Nutrition, and Overcoming Barriers Jennifer Burkmar, MD, MBA Emory Family Medicine

2. Learning Objectives • Specify current ADA/EASD and AACE/ACE goals & guidelines for managing type II diabetes • List evidence-based data for appropriate glycemic control • Explain the problem of clinical inertia & why we need to change the course • Understand issues with behavior and compliance in patients with type II diabetes • Be able to count grams of carbohydrates for appropriate insulin therapy & review the Quick-Carb Count system • Describe current ADA nutrition recommendations for type II diabetes • List potential HbA1c reduction levels associated with medical nutrition therapy for diabetes • Learn methods to overcome barriers in care

3. 1994 2000 1994 2000 No Data <4.5% 4.5–5.9% 6.0–7.4% 7.5–8.9% >9.0% No Data <14.0% 14.0–17.9% 18.0–21.9% 22.0–25.9% 26.0% Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Aged 18 Years or Older Obesity (BMI ≥30 kg/m2) 2010 Diabetes 2010 CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

5. The UKPDS demonstrated that a 1% reduction in HbA1c results in …….% reduction in microvascular disease. • 12% • 19% • 31% • 37%

6. The UKPDS demonstrated that a 1% reduction in HbA1c results in …….% reduction in microvascular disease. • 12% • 19% • 31% • 37%

8. An epidemic that is only becoming worse

9. Prediabetes & Early Cardiovascular Disease • Compared with normoglycemic controls, asymptomatic patients with prediabetes have worse: • Diastolic blood pressure during exercise • Retinal score • EKG score • Elasticity of small & large arteries • Levels of BNP

10. What factor is associated with the greatest risk for CAD in type 2 DM? • Increased LDL cholesterol • Elevated HbA1c • Elevated systolic blood pressure • Smoking

11. What factor is associated with the greatest risk for CAD in type 2 DM? • Increased LDL cholesterol • Elevated HbA1c • Elevated systolic blood pressure • Smoking

12. Rank the order of risk factors for CAD in type 2 diabetes • Increased LDL • Decreased HDL • Elevated HbA1c • Elevated systolic blood pressure • Smoking

13. Rank the order of risk factors for CAD in type 2 diabetes • Increased LDL • Decreased HDL • Elevated HbA1c • Elevated systolic blood pressure • Smoking

14. Comprehensive Management of Diabetes • BLOOD GLUCOSE • But there is also: • Antiplatelet therapy • Blood pressure • Cholesterol • Dietary changes • Exercise changes

15. Comprehensive Management of Diabetes • And let’s not forget… • Smoking • Weight • Regular examination of: • Eyes • Mouth/teeth • Feet/skin • Kidneys

16. Recommended Targets for T2DM

17. Rationale for TLC as Initial Therapy • Weight loss • Effective in lowering blood glucose • Possible elimination of diabetes • Weight loss & exercise • Improved CVD risk factors • Safe, cost-effective with few difficulties • Support needed to promote long-term adherence • Benefits generally seen rapidly, often before substantial weight loss

18. What effect do statins have on glucose control? • ↑ glucose • No effect • ↓ glucose

19. What effect do statins have on glucose control? • ↑ glucose • No effect • ↓ glucose

20. Statins and Diabetes Risk • The use of high-dose statin therapy is associated with an ↑ risk of T2DM compared with moderate-dose statin therapy • FDA mandates statin label change in 2012 • Label change for statin class (except pravastatin), issuing a warning that they can raise blood sugar & A1c levels • JUPITER study showed 27% ↑ in risk of T2DM in patients taking rosuvastatin • Women’s Health Initiative showed 48% ↑ risk of diabetes among women • Multiple other studies showed ↑ risk of T2DM with high-dose statin

21. JUPITER Trial on CVD Risk Reduction with Statin Therapy • Justification for Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin • N = 17,603 • Studied patients without cardiovascular disease or diabetes • Treatment – Rosuvastatin 20mg daily or placebo • Followed for up to 5 years • Conclusion – CV benefits of statin therapy exceed the diabetes hazard

22. Disadvantages of Current Paradigm for T2DM Management • Few patients achieve glycemic targets • The stepwise approach is usually applied at a slow pace, with long delays between steps • When insulin is initiated, the average patient has spent 5yrs with an A1c >8% & 10yrs with an A1c > 7% • Prolonged hyperglycemia & resultant glucotoxicity may accelerate β-cell failure

23. Treatment of T2DM • Treat-to Failure Principle • “We continue the SAME treatment plan until the situation is disastrous & failing before we make changes in managing the patient.”

24. Treat-to-Failure Approach:Suboptimal Glycemic Control OAD = Oral Antidiabetic Drug A1c goal

25. Treatment of T2DM • INSTEAD we need to follow the Treat-to-Target Principle • “We need to design our management plan based on reaching TREATMENT TARGETS.” • If the fasting glucose is consistently 148, we need to alter our treatment plan

26. Treat-to-Target Approach to T2DM

29. ADA-EASD Position Statement: Management of Hyperglycemia in T2DM • Other considerations: • Weight • Majority of T2DM patients are overweight/obese • Intensive lifestyle program • Metformin • GLP-1 receptor agonists • ? Bariatric surgery • Consider latent autoimmune diabetes in adults (LADA) in lean patients

30. Intensive glycemic control may be beneficial in all of the following except: • Shorter duration T2DM • No established atherosclerosis • Long life expectancy • Extensive comorbid conditions

31. Intensive glycemic control may be beneficial in all of the following except: • Shorter duration T2DM • No established atherosclerosis • Long life expectancy • Extensive comorbid conditions

32. Implications of ACCORD, ADVANCE, & VADT Trials • Lack of significant CVD benefit with intensive glycemic control • HOWEVER • HbA1c < 7% still the general target • May be beneficial in patients with: • Shorter duration T2DM • Without established atherosclerosis • Long life expectancy

33. Implications of ACCORD, ADVANCE, & VADT Trials • Intensive glycemic control may NOT be beneficial in patients with: • Longstanding T2DM • Known history of severe hypoglycemia • Advanced microvascular/macrovascular complications • Extensive comorbid conditions • Advanced age/frailty • Limited life expectancy

34. Implications of ACCORD, ADVANCE, & VADT Trials • Affirmed need for treatment of all vascular risk factors – not just hyperglycemia • ↓ risk of new/worsening albuminuria when HbA1c lowered to 6.3% vs. 7.0% • Overall – intensive therapy decreases microvascular adverse outcomes • Does not significantly affect CVD or mortality

35. ADA-EASD Position Statement on Management of Hyperglycemia in T2DM • Glycemic targets • HbA1c < 7.0%  mean plasma glucose 150-160 • Preprandial PG < 130 • Postprandial PG < 180 • Individualization is key • Lower target (6.0 – 6.5%) – younger, healthier • Higher target (7.5 – 8.0%) – older, comorbidities, hypoglycemia prone, etc • Avoid hypoglycemia

36. Clinical Inertia • What is it??????

37. Clinical Inertia • “Failure of healthcare providers to initiate or intensify therapy when indicated.” • Are you doing anything? • Are you doing enough?

38. Clinical Inertia • Negative attitudes on the part of the patient and/or clinician about the: • Complexity of treatment • Anticipated complications • Disease severity • May apply to oral as well as injectable therapies • May have significant impact on: • Treatment adherence (patient) • Management plan (clinician)

39. Strategies to Overcome Clinical Inertia: Patient • Establish an “actionable” HbA1c goal for the patient • Establish time frame for achievement of HbA1c goal • Display progress toward achieving HbA1c goal • Keep results displayed in patient’s medical record (perhaps as a graph)

40. Strategies to Overcome Clinical Inertia: Primary Care Residents • 3yr trial with 345 IM residents managing 4,038 patients with T2DM • Computerized reminders at every visit • Performance feedback from endocrinologists/attendings • Feedback group intensified therapy and maintained this over 3 years better than other groups • Combination of feedback and reminders had best results

41. Overcoming Physician Concerns About Insulin Therapy in T2DM • Hypoglycemia severe hypoglycemia very uncommon • Worsening Atherosclerosis  no evidence of worsening CVD • Weight Gain  modest & controlled by diet & exercise, also controlled if metformin or GLP-1 receptor agonist is used • Patient’s Negative Perception of Insulin Therapy  patient needs assurance that insulin is a “positive” approach to achieving glycemic control & is most effective when dose properly

42. Overcoming Patient Concerns about T2DM • Ask the patient about their concerns! • Use your team to help the patient deal with their concerns • Multidisciplinary team requires: • Common goals • Supportive, nurturing approach • Commitment to principles of self-care • Good interpersonal skills of team members • Clear definition of specific & shared responsibilities of team • Effective leadership • Tailoring of team members according to setting & resources

43. Impact of a Multidisciplinary Team on Glycemic Control & Hospital Admissions

44. Behavior & Diabetes: Moving from Compliance to Collaboration • Case Study – Ms. S. • T2DM • A1c is 9.4% • BMI is 29 • Smokes • On metformin & glyburide • Rarely monitors glucose levels • Frequently does not keep appointments • Always promises to do better

45. Our plan for Ms. S. • STOP SMOKING! • LOSE WEIGHT! • FOLLOW YOUR DIET! • EXERCISE! • MONITORS BLOOD GLUCOSE 4X DAY!

46. What Ms. S. hears… • If you don’t change your behavior, you will have to go on the needle • You are a noncompliant, bad patient • You are a failure • You are a “diabetic”, not a person

47. The real Ms. S… • Works at a convenience store at varying times of the day • Recently separated from husband • Son has severe asthma requiring multiple medications • Handles stress by smoking & eating chocolate • Insurance does not cover diabetes supplies or medication

48. Behavior & Diabetes • Approach to behavior has historically been disease focused and didactic • Very little understanding or focus on the impact of diabetes on the patients’ lives • Message was “it’s easy to take care of and control your diabetes” • Doctors telling patients “You should…” • RNs telling patients “Do it for me…” • Failure is neither the fault of healthcare professionals nor patients

49. Behavior & Diabetes • Diabetes self-management is less than optimal • Self-management problems are due in large part to psychosocial problems • Psychological problems are common but rarely treated • 85% reported severe diabetes distress at diagnosis • 15yrs later, 43% continued to have these feelings • Access to team care & communication between patients and healthcare professionals is associated with better outcomes • Initiatives to address psychosocial needs must have a high priority to improve outcomes

50. Empowerment • Helping people discover and use their own innate ability to gain mastery over their diabetes • Diabetes is self-managed and I am the “self” • You can teach me, but you can’t make me. I have to make myself