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Getting to Goal: ‘ Practical Tricks of the trade‘ How to Achieve the ABCs

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 rgabbay@psu.edu. The ‘ABCs’. A 1C B P < 130/80 C holesterol (LDL<100, if CAD <70).

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Getting to Goal: ‘ Practical Tricks of the trade‘ How to Achieve the ABCs

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  1. 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 rgabbay@psu.edu

  2. The ‘ABCs’ • A1C • BP < 130/80 • Cholesterol (LDL<100, if CAD <70)

  3. 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

  4. 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

  5. How Low to Go?

  6. What’s the Problem? • Not Bad Patients or Bad Doctors • It’s the System • Acute Care vs. Chronic Care • Self-management • Clinical Inertia

  7. A1C < 7 Why? How?

  8. UKPDS: Hemoglobin A1C (HbA1C) Median HbA1C (%) 7.9 7.0

  9. UKPDS: Risk Reductions Any Diabetes- related Endpoint Microvascular Endpoints Laser Rx Cataract Albuminuria % Risk Reduction

  10. 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

  11. Really really important points: • Aggressive control early prevents complications. • Because of the log-linear relationship between control and complications, absolute benefits are greatest at high HbA1c values. • 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

  12. Sites of Drug Action Carbohydrate DIGESTIVE ENZYMES Alpha-glucosidase Inhibitors, Incretins Excessive lipolysis Glucose Sulfonlyureas Meglitinides Incretins Insulin Defective b-cell secretion Reduced glucose uptake Excess glucose production Metformin TZD Incretins Resistance to the action of insulin TZD, Metformin Dinneen SF. Diabet Med. 1997; 14 (Suppl 3): S19-24.

  13. 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

  14. Points to remember • Each oral agent lower A1C 1-2 • If A1C >9, start two agents • Follow SMBG, A1C, and Titrate!!!!!

  15. Diagnosis 9 8 HbA1c (%) 7 T2DM treatment strategies revisited Target-driven therapy* STEP 4 Basal plus prandial STEP 3 Basal insulin STEP 2 OHA combinations STEP 1 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

  16. Natural History of Type 2 Diabetes Postmeal glucose Plasma Glucose Fasting glucose 126 mg/dL Insulin resistance Relative -Cell Function Insulin secretion 20 10 0 10 20 30 Years of Diabetes Adapted from International Diabetes Center (IDC). Minneapolis, Minnesota. 6-6

  17. Over time,most patients will needinsulinto control glucose TYPE 2 DIABETES . . . A PROGRESSIVE DISEASE 6-7

  18. Uncontrolled A1C ~9% Correcting Fasting Hyperglycemia… Is Usually the First Task!! 300 “Controlled” A1C <7% 200 PG (mg/dL) 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

  19. Titrating Glargine or Detemir 2 units q 3 days until FPG < 100 Its that easy and it works!

  20. Physiologic Serum Insulin Secretion Profile 75 Breakfast Lunch Dinner 50 Plasma Insulin ( µU/mL) 25 4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00 Time

  21. Blood Pressure<130/80 Why? How?

  22. UKPDS: Effect of Intensive BP Lowering on Risk of Micro- and Macrovascular Complications Any Diabetes-relatedEndpoint Diabetes-relatedDeath RenalFailure Vision Deterioration MI Retinopathy Stroke HF 0 -10 -20 21P=.13 24P=.0046 -30 Risk Reduction (%) 32P=.019 34P=.0038 -40 42P=.29 44P=.013 -50 47P=.0036 56P=.0043 -60 Benefits of tight vs less tight BP control -70 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.

  23. 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.

  24. 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) Number of BP Medications 1Wright JT et al. JAMA. 2002;288:2421-2431. 2Bakris GL. J Clin Hypertens. 1999;1:141-147. 3Estacio 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.

  25. Evidence Based Guidelines • < 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?

  26. ALLHAT: Cumulative Event Rates for Fatal CHD or Nonfatal MI by Treatment 20 16 12 Chlorthalidone Amlodipine Lisinopril Cumulative Event Rate (%) 8 4 0 0 1 2 3 4 5 6 7 Years to Event Number at Risk: 15,255 14,477 13,820 13,102 11,362 6,340 2,956 209 Chlorthalidone 9,048 8,576 8,218 7,843 6,824 3,870 1,878 215 Amlodipine 9,054 8,535 8,123 7,711 6,662 3,832 1,770 195 Lisinopril 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.

  27. 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?

  28. Tashko and Gabbay, Integrated Blood Pressure Control (2010)

  29. 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?

  30. Cholesterol LDL control <100If CVD <70

  31. LDL Treat the water supply?

  32. 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 Follow-up (years) Benefit/1,000 -1 13 34 47 51 58 HPS Collaborative Group. Lancet. 2003;361:2005-2016.

  33. ASCOT-LLA: Primary End Point Atorvastatin 10 mg Placebo Number of events: 100 Number of events: 154 4 3 36%reduction Cumulativeincidence (%) 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.

  34. Statins for DM The question is: Who do we NOT treat?

  35. Putting it All together

  36. Community Health System Health Care Organization Resources and Policies ClinicalInfoSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes The Chronic Care Model

  37. 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

  38. 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

  39. Community Health System Health Care Organization Resources and Policies ClinicalInfoSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes The Chronic Care Model

  40. Decision support • Evidence based guidelines (ADA) • SHARE WITH YOUR PATIENTS

  41. Clinical Information systems Registry!!!! Track outcomes and ID those not at goal with a plan for intensification

  42. 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

  43. QUESTIONS?

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