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Part 1

Part 1. Faculty/Presenter Disclosure. Disclosure of Commercial Support. This program has received financial support from AstraZeneca Canada Inc. in the form of an educational grant This program has received in-kind support from AstraZeneca Canada Inc. in the form of logistical support

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Part 1

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  1. Part 1

  2. Faculty/Presenter Disclosure

  3. Disclosure of Commercial Support This program has received financial support from AstraZeneca Canada Inc. in the form of an educational grant This program has received in-kind support from AstraZeneca Canada Inc. in the form of logistical support Potential for conflict(s) of interest: [Faculty/speaker name] has received [payment/funding] from [organization supporting the program AND/OR organization whose product(s) are being discussed in this program] AstraZeneca Canada Inc. markets or benefits from the sale of a product(s) that will be discussed in this program: exenatide (Byetta), saxagliptin(Onglyza)

  4. Mitigating Potential Bias Potential sources of bias identified in the preceding 2 slides have been mitigated as follows: Information presented is evidence-based Recommendations made are evidence- or guidelines-based rather than personal recommendations of the presenter Material has been reviewed by an Educational Committee responsible for overseeing the program’s Needs Assessment and subsequent content development

  5. Learning Objectives After completing this program, participants will be able to: Articulate overall approaches to CV risk reduction in patients with type 2 diabetes (T2DM); Describe the impact of glycemic control on CV risk; and Cite evidence describing CV risks and/or benefits of various antihyperglycemic agents.

  6. Case Study 1: Paul • 55-year-old male • Has been seen many times over past years but has been poorly compliant to follow-up • Last visit 3 years ago: – noted to have “pre diabetes” (A1C 6.3%) – dietician follow-up booked; patient did not follow through Today’s visit: wants to “get his heart checked out” after his 59-year-old brother suffered a fatal MI

  7. What investigations would you order in Paul’s case at this point?

  8. Paul: Investigations BP: 152/96 mmHg (confirmed on 2 office visits and HBP log) All other blood parameters: normal Lifestyle: sedentary, non-smoker Family history: mother with T2DM; brother with fatal MI at age 59 Fasting blood sugar: 9.8 mmol/L A1C: 8.6% TC: 5.6 mmol/L, TG: 4.7 mmol/L, HDL-C: 0.7 mmol/L LDL-C: unable to calculate BMI: 34 kg/m2

  9. Discussion Write a “problem list” for Paul. Is his risk for CV events low, medium or high? What tools do you use to establish risk? Do you use any tools to communicate CV risk to patients? What are your treatment priorities for Paul?

  10. Problem List

  11. How would you describe Paul’s risk for CV events?

  12. What are your treatment priorities for Paul?

  13. Metabolic Syndrome ≥ 3 risk determinants are present: • FBG: ≥ 5.6 mmol/L (or receiving treatment of elevated glucose) • BP: ≥ 130/85 mmHg (or receiving treatment of previously diagnosed hypertension) • TG: ≥ 1.7 mmol/L (or receiving treatment) • HDL-C: < 1.0 mmol/L (men) or < 1.3 mmol/L (women) • Abdominal obesity: WC ≥ 102 cm (men) or ≥ 88 cm (women) in Canada/U.S./European populations* • *Otherwaistcircumference (WC) cutoffs: ≥ 94 cm (men) or ≥ 80 cm (women) for Europids, whites, Sub-SaharanAfricans, Mediterranean and Middle East (Arab) populations; ≥ 90 cm (men) or ≥ 80 cm (women) for Asian and ethnic South and Central American populations. • Leiter LA, et al. Can J Cardiol 2011; 27(2):e1-e33.

  14. CV Risk Assessment Patient is at HIGH RISK for CV disease Not necessary to perform Framingham calculation to assess risk…

  15. 2013 CHEP Recommendations: Assessing Cardiovascular Risk to Improve Adherence • Use analogies that describe comparative risk, such as “Cardiovascular Age,” “Vascular Age” or “Heart Age” to inform patients of their risk status Inform patients of their global risk to improve the effectiveness of risk-factor modification

  16. What strategies would you use in discussing Paul’s CV risk with him?

  17. Informing Patients of Their Global Risk Improves the Effectiveness of Risk-factor Modification • GroverSA, et al. J Gen Intern Med 2009; 24(1);33-9.

  18. Case Study 1: Paul (cont’d) • Paul agrees to see the diabetes nurse educator and start on lifestyle changes • Adamant that he wants to reduce his CV risk, and comfortable with whatever therapies are necessary to achieve this What evidence-based medical therapies would you recommend?

  19. What evidence-based medical therapies would you recommend in Paul’s case?

  20. CDA 2013 Guidelines: Vascular Protection Checklist • CDA: Canadian Diabetes Association. • CDA 2013 ClinicalPractice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212. AA1C – optimal glycemic control (usually ≤7%) BBP – optimal blood pressure control (<130/80) CCholesterol – LDL ≤ 2.0 mmol/L if decided to treat DDrugs to protect the heart A – ACEi or ARB │S – Statin │A – ASA if indicated E Exercise / Eating healthily – regular physical activity, achieve and maintain healthy body weight SSmoking cessation

  21. CHEP Hypertension Recommendations: Vascular Protection • Male gender • 55 years or older • Smoking • T2DM • TC:HDL-C ratio ≥ 6 • Family history of premature CV disease • Previous stroke or TIA • LVH • ECG abnormalities • Microalbuminuria or proteinuria • Peripheral vascular disease Statins are recommended in high-risk hypertensive patients based on having established atherosclerotic disease or at least 3 of the following: • Hackam DG, et al. Can J Cardiol 2013; 29(5):528-42.

  22. 2012 CCS Dyslipidemia Guidelines Update: Recommendations in High Risk • High risk: clinical atherosclerosis; all persons with diabetes aged > 40 years as well as younger persons with diabetes with additional sources of risk (e.g., diabetes > 15 years duration and age > 30 years); or adjusted Framingham Risk Score ≥ 20% (Strong Recommendation, High-Quality Evidence) • now included in this category: abdominal aortic aneurysm, high-risk kidney disease (eGFR < 45) and high-risk hypertension (Strong Recommendation, Moderate-Quality Evidence) • Treatment target for LDL-C: ≤ 2.0 mmol/L or ≥ 50% reduction for optimal risk reduction (Strong Recommendation, Moderate-Quality Evidence) • ApoB (≤ 0.80 g/L) or non-HDL-C (≤ 2.6 mmol/L) considered as alternatives (Strong Recommendation, High-Quality Evidence) • Anderson TJ, GregoireJ, et al. Can J Cardiol2013; 29(2):151-67.

  23. Does This Patient Require Vascular Protective Medications? Statin + ACEi or ARB + ASA Clopidogrel if ASA-intolerant YES YES Statin + ACEi or ARB NO STEP 2: What is the patient’s age? ≥ 55 years OR 40-54 years YES YES Statin NO STEP 3: Does the patient… Have diabetes > 15 years AND age > 30 years? Warrant statin therapy based on the 2012 CCS Lipid Guidelines? YES STEP 1: Does this patient have end-organ damage? Macrovascular disease Cardiac ischemia (silent or overt) Peripheral arterial disease Cerebrovascular/carotid disease OR Microvascular disease Retinopathy Nephropathy (ACR ≥ 2.0) Neuropathy • Canadian Diabetes Association. guidelines.diabetes.ca

  24. CDA 2013 Guidelines: Individualizing Antihyperglycemic Agents After Metformin • CDA: Canadian Diabetes Association. • CDA 2013 ClinicalPractice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212. The CDA guidelines suggest individualization of therapy based on patient characteristics Complete the following table, looking at important characteristics of each class of antihyperglycemic agents.

  25. Individualizing Antihyperglycemic Agents After Metformin (1)

  26. What would be your approach to individualizing antihyperglycemic therapy in Paul’s case?

  27. Individualized T2DM Treatment Options After Metformin (CDA 2013) • *In alphabetical order. • CDA 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212.

  28. Key Messages Insulin resistance is progressiveand care should be taken to not lose patients with pre-diabetes to follow up. 2. Evaluate and treat all vascular risk factors in patients with DM. 3. Individualize the choice of antihyperglycemic agents based on patient characteristics 4. Recent evidence with saxagliptin and alogliptin reinforces the CV safety of DPP-4 Inhibitors

  29. Support Slides Additional resources for program facilitators

  30. 2012 CCS Dyslipidemia Guidelines Update Estimation of 10-year risk of total CVD in men (Framingham HeartStudy) • Canadian CardiovascularSociety, 2013.

  31. 2012 CCS Dyslipidemia Guidelines Update Estimation of 10-year risk of total CVD in men (Framingham HeartStudy) Multiplied by 2 whenfamilyhistory of premature CVD is positive • Canadian CardiovascularSociety, 2013.

  32. Cardiovascular Age Tables: Male Patients WITHOUT Diabetes Non-smokers Smokers Blood Pressure (mmHg) Blood Pressure (mmHg)

  33. Cardiovascular Age Tables: Male Patients WITH Diabetes Non-smokers Smokers Blood Pressure (mmHg) Blood Pressure (mmHg)

  34. Cardiovascular Age Tables: Male Patients WITH Diabetes Non-smokers Smokers 43.6 Example: 30-year-old male with diabetes who smokes, BP 150/95 mmHg, TC:HDL-C ratio 5 • CV age: 43.6 years • CV age vs. same profile but without diabetes: + 5 years • CV age vs. healthy 30-year-old male: + 13.6 years Blood Pressure (mmHg) Blood Pressure (mmHg)

  35. Cardiovascular Age Tables: FemalePatients WITHOUT Diabetes Non-smokers Smokers Blood Pressure (mmHg) Blood Pressure (mmHg)

  36. Cardiovascular Age Tables: FemalePatients WITH Diabetes Non-smokers Smokers Blood Pressure (mmHg) Blood Pressure (mmHg)

  37. Ongoing CV Outcome Trials: DPP-4 Inhibitors • Adapted from:1. Golden SH. Am J Cardiol 2011; 108(Suppl):59B-67B. 2. Fonseca V. Am J Cardiol 2011; 108(Supp):52B–58B. 3. www.clinicaltrials.gov

  38. Ongoing CV Outcome Trials: GLP-1 Agonists • Adapted from:1. Golden SH. Am J Cardiol 2011; 108(Suppl):59B-67B. 2. Fonseca V. Am J Cardiol 2011; 108(Supp):52B–58B. 3. www.clinicaltrials.gov

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