practice: A multidisciplinary approach Richard Hobbs, MD Oxford, - - PowerPoint PPT Presentation

Managing diabetes in daily cardiovascular practice: A multidisciplinary approach Richard Hobbs, MD

Oxford, United Kingdom

Cardio Diabetes Master Class

February 22-23, 2019 - Barcelona, Spain

Managing diabetes in daily clinical practice: a multi-disciplinary approach

Richard Hobbs Nuffield Professor and Head, Nuffield Department of Primary Care Health Sciences University of Oxford, United Kingdom

Speaker or sponsorship disclosures in past 5 years: Amgen, Bayer, BMS, Boehringer Ingelheim, Medtronic, Merck, Novartis, Pfizer, Roche

Type 2 Diabetes Mellitus healthcare burden

Over 29 million people in the US currently have diabetes1 There are approximately 1.7 million new cases

• f diabetes in the

US every year1 CV disease is the leading cause of morbidity and mortality in patients with T2D2 CV disease contributes up to 49% of total direct costs of treating T2D3

Prevention or delaying onset of Diabetes becomes increasingly important

Why ?

• CV risk is incompletely

explained by conventional risk factors

• Prognosis is worse with

duration How ?

• Tackling Obesity/ sedentary

lifestyle/ caloric intake

• Legislation
• CV risk factor and CV

prevention medications

Adult (aged 16+) obesity: BMI ≥ 30kg/m2

Trend in obesity prevalence among adults

Health Survey for England 1993 to 2015 (3yr av)

Adult (aged 16+) overweight including obese: BMI ≥ 25kg/m2

Trend in excess weight among adults

Health Survey for England 1993 to 2015 (three-year average)

Trend in severe obesity among adults

Health Survey for England 1993 to 2015 (three-year average)

Adult (aged 16+) severe obesity: BMI ≥ 40kg/m2

Prevalence of overweight and obesity by age: men

Health Survey for England 2015

Adult (aged 16+) BMI thresholds: overweight: 25 to <30kg/m2; Obese: ≥30kg/m2

Adults aged 16+. Using combined waist circumference and BMI classification, as recommended by NICE

1993‐1994 2014‐2015

Change in prevalence of health risk categories

Using both BMI and waist circumference: Health Survey for England

Food energy from non-milk extrinsic sugars Men and women aged 19-64 and 65+ years:

National Diet and Nutrition Survey (2012/13 to 2013/14)

Estimated daily salt intake Men and women aged 19-64 and 65+ years;

National Diet and Nutrition Survey (2008/09-2011/12) & Assessment

• f dietary sodium (2014)

Consumption of oily fish Men and women aged 19-64 and 65+ years;

National Diet and Nutrition Survey (2012/13 to 2013/14)

Relative risk of type 2 diabetes

Relative Risk of BMI for type 2 diabetes 84,941 nurses: 16 years follow-up

10 20 30 40

15

38.8 20.1 7.6 1.0

20 25 30 35 40

Body mass index

Hu FB. N Engl J Med. 2001; 345:790-7.

Obesity in children

BMI status of children by age

National Child Measurement Programme 2016/17

This analysis uses the 2nd, 85th, 95th and 99.6th centiles of the British 1990 growth reference (UK90) for BMI to classify children as underweight, healthy weight, overweight , obese or severely obese.

Reception

Obese 9.6%

Year 6

Obese 20.0%

Prevalence of overweight and obesity

Children aged 2-10 and 11-15 years; Health Survey for England 2014-2016

Child overweight BMI between ≥ 85th centile and <95th centile, child obesity BMI ≥ 95th centile of the UK90 growth reference

Food energy from non-milk extrinsic sugars

Children aged 4-10 and 11-18 years: National Diet and Nutrition Survey (2012/13 to 2013/14 combined)

Estimated daily salt intake Children aged 4-6, 7-10 and 11-18 years: National

Diet and Nutrition Survey (2008/09 to 2011/12)

Data not available for NDNS Years 5 & 6 (2012/13 to 2013/14)

Consumption of oily fish Children aged 4-10 and 11-18 years:

National Diet and Nutrition Survey (2012/13 to 2013/14)

BMI during adolescence and CV mortality

Twig G et al, NEJM 2016;374:2430-40

Potential solutions to diabetes/CVD prevention?

Public health population primary prevention strategies

Use of taxation to change lifestyle behaviours

Pooled estimates of effects of lifestyle interventions on primary prevention of T2DM

• 50%

BMJ 2007

What are effective public health tobacco control policies?

• Reduce affordability of tobacco (tax and illicit)
• Mass media and social marketing campaigns
• Enforcement to restrict youth access
• Smokefree places
• Smoking cessation support

– Programme administration and management – Monitoring and surveillance

Best Practices for Comprehensive Tobacco Control Programs — 2014.Atlanta: U.S. Department of Health and Human Services, Centers for Disease

Cornerstone of tobacco control strategy: Do what is known to work and do it efficiently

Patient-level lifestyle intervention strategies

Lifestyle vs Metformin vs placebo in primary prevention of T2DM

DPP : N Engl J Med 2002; 346: 393-403.

Diabetes Prevention Program

• 58%
• 31%

Parallel

Pragmatic trials in weight behaviour

Pragmatic trials in weight behaviour

Management priorities to reduce CV risk of Diabetes

• Prevent diabetes

– Public health strategies – Population strategies in those at risk (obese and

• verweight) in community and primary care
• Identify and treat diabetes early

– Primary care case finding

• patients presenting with any CV risk factor

– Elevated BP, lipids, smokers, overweight

Management priorities to reduce CV risk of Diabetes

• Prevent diabetes
• Identify and treat diabetes early
• In established diabetes, use guideline recommended

strategies – Multifaceted risk reduction – Achieve targets – Consider lower targets

EUROASPIRE IV: Proportions at LDL-C targets in patients on lipid lowering at interview.

2012-13, EUROASPIRE VJ Prev Cardiolog 23, 636-648.

% Initiated A % Discontinued B % Changed to high C % Returned to low D

Gender Men 68.3% (233/341) 10.7% (380/3548) 13.0% (306/2358) 31.4% (480/1531) Women 61.2% (79/129) 12.6% (134/1067) 11.5% (89/775) 38.7% (163/421) Age <60 years 66.4% (85/128) 9.8% (143/1456) 14.5% (126/866) 30.6% (220/718) ≥60 years 66.4% (227/342) 11.7% (371/3159) 11.9% (269/2267) 34.3% (423/1234) A No statin at discharge: % statin at interview. B Statin at discharge: % no statin at interview. C No or low/moderate intensity statin at discharge: % high intensity LDL-C lowering at interview. D High intensity LDL-C lowering at discharge: % low/moderate intensity statin or no statin at interview.

EUROASPIRE IV: Action taken regarding statin use

Persistence with lipid-lowering drugs at

• ne-year

10 20 30 40 50 60 70 80 90

CAVE: Various methods to define discontinuation have been used.

• Caspard. Clin Ther. 2005; Perreault. Eur J Clin Pharmacol. 2005; Ellis. J Gen Intern Med. 2004; Abraha. Eur J Clin Pharmacol. 2003; Yang. Br J Clin
• Pharmacol. 2003; Larsen. Br J Clin Pharmacol. 2002; Catalan. Value Health. 2000; Mantel-Teeuwisse AK, et al. Heart. 2004.

Caspard Ellis Catalan Perreault Abraha Sturken- boom Mantel- Teeuwisse Yang Larsen

Various methods to define discontinuation have been used

% Persistence with LLD at One-Year USA CA ITA NL UK DK

Persistence with lipid lowering drugs

US data: Benner et al. JAMA. 2002;288:255-261. Other data from general practice databases in NL and Italy data on file Pfizer Inc, NY, USA.

Months After Starting Treatment % Fully Adherent: >80% PDC

10 20 30 40 50 60 70 80 90 100 3 6 9 12 18 24

USA Italy NL

Management priorities to reduce CV risk of Diabetes

• Prevent diabetes
• Identify and treat diabetes early
• Use guideline recommended strategies

– Multifaceted risk reduction – Achieve targets – Consider lower targets

• Critical role of primary care teams in CV risk management

Management priorities to reduce CV risk of Diabetes

• Prevent diabetes
• Identify and treat diabetes early
• Use guideline recommended strategies

– Multifaceted risk reduction – Achieve targets – Consider lower targets

• Critical role of primary care teams in all of the above

– Case finding of diabetes in all those with CV risk factors – Brief interventions for lifestyle factors and referral for support – Treat to CV risk factor targets, especially in those with diabetes

• Explicit clinical pathways defined, training on targets, time

for consultations (audit & feedback on performance)

Conclusions

• Prevention of diabetes strategies are needed
• Reducing obesity
• Early diagnosis of diabetes (role of screening?)
• Maximise traditional CV risk reduction
• Consider novel diabetes drugs in those with established CVD
• Important role for primary care teams

– explicit roles and clinical pathways