To Common DM Care Challenges Paul Aoun, D.O., Ph.D. Clinical - - PowerPoint PPT Presentation

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To Common DM Care Challenges Paul Aoun, D.O., Ph.D. Clinical - - PowerPoint PPT Presentation

May 15, 2023 359 likes •1.2k views

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

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Effective Solutions To Common DM Care Challenges

Paul Aoun, D.O., Ph.D.

Clinical endocrinologist, PBDES Affiliate Assistant Professor, Univ Miami

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Disclosure

  • Speaker for Astra-Zeneca
  • I do not have any financial relationships

relative to the content of this program

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In 1980: 108 Million Adults had diabetes

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Prevalence of Diabetes and Prediabetes in the United States

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  • 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.
  • 3. CDC. National diabetes statistics report, 2014. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

Prediabetes 37% of US population Diabetes 9.1% of US population 57 79 86 17.9 18.8 21.0 5.7 7 8.1 20 40 60 80 100 120 140 2007 2011 2014 Persons (millions) Undiagnosed DM Diagnosed DM Prediabetes

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HOW ARE WE DOING?

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A1C Achievement by Individualized Target

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NHANES, National Health and Nutrition Examination Survey. Ali MK, et al. N Engl J Med. 2013;368:1613-1624.

NHANES 2007-2010 (N=1444)

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 37.0 52.0 57.1 69.4 39.4 57.1 74.6 10 20 30 40 50 60 70 80 90 100 Patients with diabetes (%)

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WHY?

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1 in 3 MEDICARE $

People with Diagnosed Diabetes ADA AACE

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  • S. 586/H.R. 1192
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Are 50%+ not reaching Treatment goals AND/OR Are we NOT reaching them?

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Are novel therapies needed AND/OR Need to make better use

  • f existing modalities?
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OBJECTIVES The 4 Cs to improve Diabetes care

  • utcomes
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OBJECTIVES The First “C”

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Is it Compliance??

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Compliance Concordance COMPREHENSION

  • Diabetes
  • Treatment:

Dietary choices Physical Activity Medications

  • Ramifications
  • Patient’s preference
  • Set of values
  • Living conditions
  • Socioeconomic status
  • Psychosocial barriers
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OBJECTIVES: The First C-Comprehension

  • Diabetes
  • Treatment:

–Dietary choices –Physical Activity –Medications

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The First “C”-Comprehension Why do you think you developed diabetes?

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The genes set the stage, the behavior tells the tale…

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OBJECTIVES: The First C-Comprehension

  • Diabetes
  • Treatment:

–Dietary choices –Physical Activity –Medications

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Almost all diets (and diet pills) work initially Almost all diets (and diet pills) fail eventually

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As A Medical Community: We Must Aim for Long-Lasting SUSTAINABLE Results

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Portion Control & Restrict refined carbs and simple sugars

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Mayo Clinic

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Total Calories: 350 vs. 1400

Mayo Clinic

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200 calories

WiseGeek.com

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NUTRITION HEALTH = CALORIES

Furhman, J 2003

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Physical Activity Altering the perception

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Physical Activity Exercise

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  • 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.

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James A .Levine, 2007

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James A .Levine, 2007

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OBJECTIVES: The First C-Comprehension

  • Diabetes
  • Treatment:

–Dietary choices –Physical Activity –Medications

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Comprehension: Incentive

You are _____ lbs away from coming off _____________

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Simplicity Improves Adherence

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OBJECTIVES the 4Cs

  • Comprehension
  • Complexity
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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
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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

  • ne tab PM
  • By late 2015, off all insulin, on Metf+Glim. Stable CKD
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A1C-8.6% Wt: 188 lbs A1C-6.5% Wt: 164 lbs

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  • AVOID OVERINSULINIZATION

– Revisit the need for insulin – Minimize/eliminate complex regimens, ESPECIALLY IN THE ELDERLY

Simplicity improves adherence

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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

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  • B cell failure:

– Dysfunction (“stunned”) – De-differentiation – Death?

Halban PA et al. JCEM 2014

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  • “Interestingly, the greatest HbA1c 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)

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  • AVOID OVERINSULINIZIATION

– Revisit the need for insulin – Minimize/eliminate complex regimens, ESPECIALLY IN THE ELDERLY

  • Minimize OADs associated with HYPOGLYCEMIA

Simplicity improves adherence

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Meds associated with Hypoglycemia

  • LOWmeperide
  • LOWpizide
  • LOWburide
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OBJECTIVES the 4Cs

  • Comprehension
  • Complexity
  • Cost
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Medscape, 2016

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COST

Medscape, 2016

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Treat-to-target Trial

Riddle MC et al, Diabetes Care, 2003

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Treat-to-target Trial

6.9% vs 4% events per pt-yr

Riddle MC et al, Diabetes Care, 2003

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LANMET Study

Jarvinen YH et al, Diabetologia, 2006

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LANMET Study

WKS 0-12 13-24 25-36

Jarvinen YH et al, Diabetologia, 2006

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LANMET Study

Jarvinen YH et al, Diabetologia, 2006

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NPH

B L D HS B

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Cost

  • If insulin indicated, Basal+Metformin or
  • ther OADs often sufficient
  • REINTRODUCE METFORMIN:

whenever feasible

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FDA & Metformin

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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

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Phenformin Metformin

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1. Tahrani AA et al. BMJ. 2007;335(7618):508-12 2. Wang DS et al. Mol Pharmacol 2003

Phenformin’s lactogenic effect >140x Metformin.2

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OBJECTIVES the 4Cs

  • Comprehension
  • Complexity
  • Cost
  • Connotation
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Positive Connotation “To me, marketing is about values”

Steve Jobs

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Positive Connotation “Who knows the most, lives the longest” (and lives the best)

Elliott P Joslin

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VALUES EBM

COMPREHENSION COST COMPLEXITY CONNOTATION

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