You will be asked to complete a pre-assessment at the start of the - PowerPoint PPT Presentation

You will be asked to complete a pre-assessment at the start of the program .

Before We Begin Using the camera app on your smartphone or tablet, please complete the brief pre-assessment which can be accessed by scanning the QR code below or By clicking the pre-assessment link provided by your chapter representatives. The data collected will be used in evaluating the program goals and objectives and to ensure we’ve provided a useful educational activity.

Sponsorship and Support This educational activity is jointly provided by the North Carolina Academy of Family Physicians (NCAFP) and Spire Learning. This activity is supported by an educational grant from Novo Nordisk Inc.

Instructions to Receive Credit To receive credit for your participation in this educational activity: • Read the objectives and other introductory CME information • Complete the preassessment prior to the start of the activity • Participate in the CV risk reduction in type 2 diabetes presentation • Complete the postassessment and evaluation at the conclusion of the activity

Faculty and Disclosures (cont’d) Faculty Educator: Jeffrey S. Freeman, DO, FACOI, FNLA Professor of Internal Medicine Chairman, Division of Endocrinology Philadelphia College of Osteopathic Medicine Philadelphia, PA Endocrine Associates Crozer-Chester Medical Center Upland, PA Disclosure Statement: Promotional Speaker: Amarin Corp; Novo Nordisk Inc; Zealand Pharm

Off-Label and Disclaimer Statements If the faculty discuss off-label or investigational uses of products or devices, they will inform you that the use is off-label during the discussion. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. Further, participants should appraise the information presented critically and are encouraged to consult appropriate resources for any product or device mentioned in this program.

Learning Objectives Upon completion of this activity, learners should be better able to: • MANAGE CV risk factors in patients with diabetes according to current clinical practice recommendations. • INDIVIDUALIZE diabetes treatment based on comorbidities, patient preferences, and CV risk reduction goals. • EDUCATE patients/caregivers regarding CV risk, medication use and adherence, and lifestyle management.

Why Are We Still Talking About Diabetes? 34.2 million 88 million Americans Americans (9.4% of US population) (34.5% of US population) have diabetes 1 have prediabetes 1 90 % of all diabetes management occurs within the primary care setting 2 1. National Diabetes Statistics Report, 2020; Estimates of Diabetes and Its Burden in the United States. Available at: https://www.cdc.gov/diabetes/pdfs/data/statistics/national- diabetes-statistics-report.pdf; 2. Davidson JA. Mayo Clin Proc. 2010;85(Suppl 12):S3-S4.

Costs of Diabetes in the US Healthcare costs for Americans with diabetes Diagnosed diabetes costs America $327 billion each year , are 2.3x greater than those without diabetes: $12,000/year for diabetes , including $237 billion in direct medical costs $4000/year without diabetes. and $90 billion in lost productivity. The largest components of medical expenditures $1 in every $7 include hospital inpatient care (30%), spent on health care in the US is prescription medications to treat used to treat diabetes and its diabetic complications (30%), complications. antidiabetic agents and supplies (15%), and physician office visits (13%). ADA. The Cost of Diabetes. Available at: https://www.diabetes.org/resources/statistics/cost- diabetes#targetText=The%20American%20Diabetes%20Association%20(Association,the%20cost%20was%20last%20examined.

Good News: Diabetes-Related Complications in the US 150 Acute myocardial infarction Stroke 125 Events per 10,000 overall 10 100 adult population 8 75 Overall population 6 Population with diabetes 50 4 25 2 Overall population 0 1990 1995 2000 2005 2010 Gregg EW, et al. N Engl J Med. 2014;370(16):1514-1523.

Bad News: The Diabetes Epidemic Number and Percentage of US Population With Diagnosed Diabetes, 1980-2015 1 8 25 7 20 6 Number (in millions) 5 Percentage 15 By Year 2050, 1/3 of All Adults 4 in the US Will Have Diabetes 2 10 3 2 5 1 0 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Percentage with diabetes Number with diabetes 1. CDC. Long-term Trends in Diabetes; April 2017. Available at: https://www.cdc.gov/diabetes/statistics/slides/long_term_trends.pdf; 2. Boyle JP, et al. Popul Health Metr . 2010;8:29.

Type 2 Diabetes Mellitus Time: Insulin Resistance 30 Years Prediabetes Type 2 Diabetes Mellitus Vascular Complications Mechanick JI, et al. Endocr Pract . 2018;24(11):995-1011.

Consequences of Delayed Intervention Patients with A1c ≥7% not receiving At 5.3 years (median follow-up), IT within 1 year significantly increased risk of: 8.5 - MI 67% (CI 39%-101%) Patients with A1c - Stroke 51% (CI 25%-83%) <7% who received - HF 64% (CI 40%-91%) IT within 1 year of 8.0 - Composite CVE 62% (CI 46%-80%) diagnosis A1c, % 7.5 7.0 Bad glycemic Drive risk for 6.5 “legacy” complications 6 48 54 60 12 Months A1c, glycated hemoglobin; CVE, cardiovascular endpoint; HF, heart failure; IT, intensification of treatment; MI, myocardial infarction. Khunti K, et al. Prim Care Diabetes . 2017;11(1):3-12.

Bill – 67 Years Old • Type 2 diabetes for 12 years • Hyperlipidemia, hypertension, and stage 3B CKD (eGFR=41 mL/min/1.73 m 2 ) • Had STEMI 2 years prior • Drug-eluding stent placed in LAD artery • Often fails to refill prescribed medications • Medications – Losartan 50 mg, atorvastatin 40 mg, metformin 500 mg BID, sitagliptin 100 mg, aspirin 81 mg, clopidogrel 75 mg • Covered under Medicare BID, twice daily; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; LAD, left anterior descending; STEMI, ST-elevation myocardial infarction.

Bill’s Social History • Exercise “Golf and walking my dog Lucky” • Diet: Favorite restaurant is Golden Corral. “I get the senior discount” • Employment: Trucking company executive; frequent domestic travel • Alcohol use: “Only when playing golf. Don’t you?” • Sleep schedule: “Four to 5 hours a night. I can’t make money when I sleep.” • Epworth score: 15 (sleepy) Angiogram: 90% occlusion of LAD artery

Bill’s Physical and Labs Physical Labs • Blood pressure: 130/74 mm Hg HbA1c 8.4% (elevated) • BMI: 33 kg/m 2 eGFR 41 mL/min/1.73 m 2 (low) • Pertinent physical findings Vitamin B 12 221 mg/dL (low) – Peripheral sensory neuropathy with loss of vibratory sense and hot/cold LDL 124 mg/dL (elevated) sensation in both feet – Loss of ankle jerks bilaterally HDL 33 mg/dL (low) – 2+ pitting edema in ankles TG 224 mg/dL (elevated) – Left carotid bruit HS-CRP 5.2 (elevated) Apo-B 112 (elevated) ACR, albumin to creatinine ratio; Apo-B, apolipoprotein B; BMI, body mass index; HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; HS-CRP, high-sensitivity C-reactive protein; LDL, low-density lipoprotein; TG, triglycerides.

Your Action Plan for Bill – Points to Consider • How would you determine your strategy for intensifying Bill’s therapy? • How do you get Bill to commit to his health and his care plan? • What kind of glucose monitoring would you recommend, if any?

What I Would Do • Ask him what are his biggest concerns about Week 1 having diabetes • Remind him that he is the “captain” of his health care, whereas the clinician is the “coach” • Do NOT scare him into believing he is going to die if he doesn’t heed your professional advice • Ask if he would consider wearing a flash Week 2 (after medication change) glucose sensor for 2 weeks so that his glycemic patterns can be evaluated and intensified • After placing the sensor, have him return in 1 week to download the data • Intensify therapy at 1 week and download again after 7 days

Glucose Monitoring SMBG 1 Moment HbA1c 3 Months CGM Continuous CGM, continuous glucose monitoring; SMBG, self-monitored blood glucose.

HbA1c Only Provides a 90-Day Average Patient B Patient C Patient A HbA1c=7% HbA1c=7% HbA1c=7% 18% 29% 58% 24% 63% 8% 100% In Range Hypoglycemic Hyperglycemic