Effective Solutions To Common DM Care Challenges Paul Aoun, D.O., Ph.D. Clinical endocrinologist, PBDES Affiliate Assistant Professor, Univ Miami
Disclosure • Speaker for Astra-Zeneca • I do not have any financial relationships relative to the content of this program
In 1980: 108 Million Adults had diabetes
Prevalence of Diabetes and Prediabetes in the United States 140 Undiagnosed DM Diagnosed DM 120 Prediabetes 8.1 Diabetes 7 Persons (millions) 100 21.0 9.1% of US population 18.8 80 5.7 17.9 60 Prediabetes 86 40 79 37% of US population 57 20 0 2007 1 2011 2 2014 3 1. CDC. National diabetes fact sheet, 2008. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2008.pdf. 2. CDC. National diabetes fact sheet, 2011. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. 4 3. CDC. National diabetes statistics report, 2014. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf
HOW ARE WE DOING?
A1C Achievement by Individualized Target NHANES 2007-2010 (N=1444) 100 90 Patients with diabetes (%) 74.6 80 69.4 70 57.1 57.1 60 52.0 50 39.4 37.0 40 30 20 10 0 Age (years) 18-44 45-64 ≥65 ≥65 18-44 45-64 ≥65 Target A1C (%) ≤6.5 ≤7.0 ≤7.0 ≤7.5 ≤7.0 ≤8.0 ≤8.0 Without complications With complications NHANES, National Health and Nutrition Examination Survey. 10 Ali MK, et al. N Engl J Med . 2013;368:1613-1624.
WHY?
1 in 3 MEDICARE $ People with Diagnosed Diabetes ADA AACE
S. 586/H.R. 1192
Are 50%+ not reaching Treatment goals AND/OR Are we NOT reaching them?
Are novel therapies needed AND/OR Need to make better use of existing modalities?
OBJECTIVES The 4 Cs to improve Diabetes care outcomes
OBJECTIVES The First “C”
Is it Compliance??
Compliance Concordance COMPREHENSION -Diabetes - Patient’s preference -Treatment: -Set of values Dietary choices -Living conditions Physical Activity -Socioeconomic status Medications -Psychosocial barriers -Ramifications
OBJECTIVES: The First �C� -Comprehension • Diabetes • Treatment: – Dietary choices – Physical Activity – Medications
The First “C” -Comprehension Why do you think you developed diabetes?
The genes set the stage, the behavior tells the tale…
OBJECTIVES: The First �C� -Comprehension • Diabetes • Treatment: – Dietary choices – Physical Activity – Medications
Almost all diets (and diet pills) work initially Almost all diets (and diet pills) fail eventually
As A Medical Community: We Must Aim for Long-Lasting SUSTAINABLE Results
Portion Control & Restrict refined carbs and simple sugars
Mayo Clinic
Total Calories : 350 vs. 1400 Mayo Clinic
200 calories WiseGeek.com
NUTRITION HEALTH = CALORIES Furhman, J 2003
Physical Activity Altering the perception
Physical Activity Exercise
• Exercise: a structured form of activity for a defined purpose, often to compete in a sport or strength-training to maintain a certain fitness level. • Physical activity: Any bodily movement that involves muscle contraction.
James A .Levine, 2007
James A .Levine, 2007
OBJECTIVES: The First �C� -Comprehension • Diabetes • Treatment: – Dietary choices – Physical Activity – Medications
Comprehension: Incentive You are _____ lbs away from coming off _____________
Simplicity Improves Adherence
OBJECTIVES the 4Cs -Comprehension -Complexity
CASE-1 • 72 y.o. F Medically-complicated obesity (BMI 36); DM-2 since 1982; HTN; Dyslipidemia, CKD (eGFR-60s) • Was on Metf, believes stopped due to CKD and changed to insulin only 10-15 yrs prior • New consultation early 2015 for DM-2: A1C 8.6%; Cr-1.0; BMI-36 • Glargine 34 HS; Lispro up to 28 ac TID • Lives w/ husband who assists with insulin administration & treatment of hypoglycemia • �frustrated� w/ BG variability and hypos
CASE-1 BASELINE: Glargine 34 HS; Lispro up to 28 ac TID PROGRESS: -Added Metformin; Reduced Insulin requirements by 40%; lost 8 lbs -Added GLP-1A (Transient), stopped Prandial insulin (Lispro); lost addt’l 10 lbs, reduced GLP-1A dose -C-pep; GAD; ICAs all reassuring: Stopped GLP-1A (Fall 2015); Changed basal insulin to Glim 2 mg ½ AM and one tab PM -By late 2015, off all insulin, on Metf+Glim. Stable CKD
A1C-8.6% A1C-6.5% Wt: 188 lbs Wt: 164 lbs
Simplicity improves adherence • AVOID OVERINSULINIZATION – Revisit the need for insulin – Minimize/eliminate complex regimens, ESPECIALLY IN THE ELDERLY
Effects of Wt loss on B-cell parameters Insulin Sensitivity Insulin Secretion Obese non-DM Obese Diabetics Kelley DE et al, JCEM 1993 Ferrannini E et al, Diabetes 2004 Robertson SP et al, Diabetes 2004
• B cell failure: – Dysfunction (“stunned”) – De-differentiation – Death? Halban PA et al. JCEM 2014
• “Interestingly, the greatest HbA 1c reduction was the fall of 2% during the first 3 months with intensive diet and 5% weight loss” R. Holman, Oxford, U.K (Chief Investigator-UKPDS)
Simplicity improves adherence • AVOID OVERINSULINIZIATION – Revisit the need for insulin – Minimize/eliminate complex regimens, ESPECIALLY IN THE ELDERLY • Minimize OADs associated with HYPOGLYCEMIA
Meds associated with Hypoglycemia • LOWmeperide • LOWpizide • LOWburide
OBJECTIVES the 4Cs -Comprehension -Complexity -Cost
Medscape, 2016
COST Medscape, 2016
Treat-to-target Trial Riddle MC et al, Diabetes Care , 2003
Treat-to-target Trial 6.9% vs 4% events per pt-yr Riddle MC et al, Diabetes Care , 2003
LANMET Study Jarvinen YH et al, Diabetologia , 2006
LANMET Study WKS 0-12 13-24 25-36 Jarvinen YH et al, Diabetologia , 2006
LANMET Study Jarvinen YH et al, Diabetologia , 2006
NPH B L D HS B
Cost • If insulin indicated, Basal+Metformin or other OADs often sufficient • REINTRODUCE METFORMIN: whenever feasible
FDA & Metformin
DESIGN & FINDINGS • MEDLINE and Cochrane databases search for English- language articles pertaining to metformin, kidney disease, and lactic acidosis in humans between 1950 and June 2014. • 65/818 articles met criteria • FINDINGS: Estimated incidence of LA similar to those not treated with Metformin
Phenformin Metformin
Phenformin’s lactogenic effect >140x Metformin. 2 1. Tahrani AA et al. BMJ. 2007;335(7618):508-12 2. Wang DS et al. Mol Pharmacol 2003
OBJECTIVES the 4Cs -Comprehension -Complexity -Cost -Connotation
Positive Connotation “To me, marketing is about values” Steve Jobs
Positive Connotation “Who knows the most, lives the longest” (and lives the best) Elliott P Joslin
VALUES CONNOTATION COMPREHENSION COST COMPLEXITY EBM
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