Your Chart Your Chart Review Data Review Data Lara Zisblatt, MA Lara Zisblatt, MA Assistant Director Assistant Director Continuing Medical Education Continuing Medical Education Boston University School of Medicine Boston University School of Medicine
Participation Participation � 243 registered for the program � 243 registered for the program � 98 have completed the Practice 98 have completed the Practice � Assessment Assessment � 17 have completed their baseline chart 17 have completed their baseline chart � review review � 13 have implemented their action plans 13 have implemented their action plans � and are awaiting reassessment and are awaiting reassessment � 1 is completing follow 1 is completing follow- -up chart review up chart review �
PI Data: Gaps in Performance PI Data: Gaps in Performance � 49.57% (n=57) of patients had A1C � 49.57% (n=57) of patients had A1C values >7% at the last visit values >7% at the last visit � 47.37% (n=27) of patients with � 47.37% (n=27) of patients with A1C >7% did not have their therapy A1C >7% did not have their therapy intensified at the last visit intensified at the last visit
PI Data: Gaps in Performance (cont (cont’ ’d) d) PI Data: Gaps in Performance � 41.74% (n=48) of patients did not � 41.74% (n=48) of patients did not have self- -monitoring monitoring fasting fasting have self glucose levels collected at the last glucose levels collected at the last visit visit � 65.22% of patients did not have � 65.22% of patients did not have postprandial glucose levels glucose levels postprandial collected at the last visit collected at the last visit
PI Data: Gaps in Performance (cont (cont’ ’d) d) PI Data: Gaps in Performance � 31.25% (n=5) of patients with � 31.25% (n=5) of patients with A1C >9% are not currently taking A1C >9% are not currently taking more than 2 oral medications more than 2 oral medications
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The Ins and Outs The Ins and Outs of Insulin of Insulin In Patients With In Patients With Type 2 Diabetes Type 2 Diabetes John R. White, PA- -C, C, PharmD PharmD John R. White, PA Professor of Pharmacotherapy Professor of Pharmacotherapy Washington State University Washington State University College of Pharmacy College of Pharmacy Spokane, WA Spokane, WA
Case Study Case Study � 58 y.o. Native American female – Type 2 DM for 15 years � Medications: – Metformin 1000 mg bid (X 5 years) – Glimepiride 8 mg q AM (X 15 years) – Combination HCTZ 12.5 mg/losartan 100 mg q AM – Atorvastatin 20 mg daily
Case Study (cont Case Study (cont’ ’d) d) � BP 138/88 mm Hg � Height 5’3” � Weight 203 lb – BMI 36 – Currently not working – cares for parents who are home-bound – Not involved in any physical activity; poor diet – Gained 8 lb in 6 months � Self-monitoring blood glucose values have risen from 130s mg/dL fasting to always >170 mg/dL over the past year � No PP BG data � A1C value today is 9.2%
ADA Standards of Care ADA Standards of Care � Glycemia Glycemia: A1C <7.0%, : A1C <7.0%, � AACE goals – – A1C A1C AACE goals AACE goals – A1C FPG 90- -130 mg/dL, 130 mg/dL, FPG 90 6.5%, FPG 110 mg/dL, 6.5%, FPG 110 mg/dL, 6.5%, FPG 110 mg/dL, PP BG <180 mg/dL PP BG <180 mg/dL PP 140 mg/dL PP 140 mg/dL PP 140 mg/dL � Blood pressure: Blood pressure: � <130/80 mm Hg <130/80 mm Hg NCEP - - LDL LDL ≤ ≤ 70 mg/dL 70 mg/dL NCEP NCEP - LDL ≤ 70 mg/dL � Lipids: LDL <100 mg/dL; Lipids: LDL <100 mg/dL; � TG <150 mg/dL TG <150 mg/dL � Yearly: Yearly: � – Dilated eye exam; urinary Dilated eye exam; urinary – protein; foot exam; flu shot protein; foot exam; flu shot � Other: Other: � – Aspirin usage; pneumococcal Aspirin usage; pneumococcal – vaccine vaccine
Lowering A1C Reduces Risk Lowering A1C Reduces Risk of Complications of Complications United Kingdom Prospective United Kingdom Prospective Diabetes Study (UKPDS) Diabetes Study (UKPDS) 0 Any diabetes-related Reduction in risk (%)* endpoint -12 -10 -16 P =.029 Microvascular endpoint P =.052 -21 -20 -25 MI P =.015 P =.0099 -30 -34 Retinopathy P =.000054 Albuminuria at 12 years -40 -50 *Percent risk reduction per 0.9% decrease in A1C UKPDS. Lancet . 1998;352:837-853.
Cost of A1C lowering Cost of A1C lowering Intervention Intervention Cost per Cost per A1C lowering cost, A1C lowering cost, month ($)* $/mean- -lowering* lowering* month ($)* $/mean SU 14.00 9.00 SU 14.00 9.00 (glimepiride glimepiride 4 mg/day) 4 mg/day) ( Metformin 32.00 21.33 Metformin 32.00 21.33 (1000 mg bid) (1000 mg bid) Insulin 138.00 69.00* Insulin 138.00 69.00* ( (glargine glargine 50 U/day) 50 U/day) Glinide 132.00 105.60 Glinide 132.00 105.60 (nateglinide nateglinide 120 mg 120 mg tid tid) ) ( TZD 196.00 196.00 TZD 196.00 196.00 (pio pio 45 mg/day) 45 mg/day) ( Incretin Incretin 152.00 152.00 202.66 202.66 (exenatide 10 mcg bid) (exenatide 10 mcg bid) Gliptins Gliptins 181.00 181.00 241.33 241.33 (sitagliptin sitagliptin 100 mg/day) 100 mg/day) ( Adapted from White J, Campbell RK, eds, ADA/PDR Medications for the Treatment of Diabetes, 2 nd ed., In press. * Cost of supplies not included
Reasons for Inadequate Reasons for Inadequate Diabetes Care Diabetes Care � Many diabetes drugs—generally lower A1C 1%-1.5% � Treatment inertia – “Insulin Resistance” � Patient resistance – Cost, complexity, side effects Cost, complexity, side effects – – “ “I don I don’ ’t want insulin t want insulin” ” – � Progressive nature of disease Progressive nature of disease �
Clinical Inertia: Failure to Clinical Inertia: Failure to Advance Therapy When Required Advance Therapy When Required Percentage of subjects advancing when A1C >8% Percentage of subjects advancing when A1C >8% At insulin initiation, the average patient had: At insulin initiation, the average patient had: 100 100 • 5 years with A1C >8% 5 years with A1C >8% • • 10 years with A1C >7% 10 years with A1C >7% • 80 80 66.6% 66.6% % of Subjects % of Subjects 60 60 44.6% 44.6% 35.3% 35.3% 40 40 18.6% 18.6% 20 20 0 0 Diet Sulfonylurea Metformin Combination Diet Sulfonylurea Metformin Combination Brown JB, Nichols GA, Perry A. Diabetes Care. 2004;27:1535-1540.
Advancing Therapy- - Considerations Considerations Advancing Therapy � A1C delta needed? A1C delta needed? � � Patient acceptance Patient acceptance � � Complexity of regimen Complexity of regimen � � Cost Cost � � Side effects and secondary effects Side effects and secondary effects �
The Stages of Type 2 The Stages of Type 2 Diabetes Diabetes 350 Post-Meal Glucose 300 Glucose 250 Fasting Glucose 200 150 100 Relative Insulin 50 250 Function 200 Insulin Resistance 150 100 Insulin Level 50 α -cell failure 0 -10 -5 0 5 10 15 20 25 30 Years of Diabetes Adapted from RM. Bergenstal, International Diabetes Center
Approach to Combination Therapy Approach to Combination Therapy Intensifying Therapy metformin or glitazone sulfonylurea/glinide + + sulfonylurea/glinide or glucosidase inh metformin or glitazone FPG >130 mg/dL A1C >7% FPG <130 mg/dL A1C < 7% AGI, DPP-IV inhib, Exenatide, Continue Pramlintide, Insulin
Failing Sulfonylurea Failing Sulfonylurea and Metformin Metformin, Add , Add Troglitazone Troglitazone and 16 clinics in Canada, 200 patients A1C >8.5% Baseline A1C 9.7% A1C reduction from baseline -1.3% Reached target A1C <8% 43% Reached target A1C <7% 14% Yale JF, et al. Ann Intern Med. 2001;134:737-745.
Over time, Over time, most patients will most patients will need insulin need insulin to control glucose to control glucose
Insulin Therapy in Type 2 Diabetes Insulin Therapy in Type 2 Diabetes � More than half of patients with type 2 diabetes require insulin to reach A1C goal <7% � Insulin doses are usually higher in patients with type 2 diabetes (~1.2 U/kg) than in type 1 patients � Increasing use of insulin earlier in course of therapy for type 2 patients � Individualize insulin therapy for each patient: – Oral medications(s) + qd insulin or – Intensive insulin +/- other anti-hyperglycemic medications
Key Decision Points for Key Decision Points for Insulin Therapy in Type 2 Diabetes Insulin Therapy in Type 2 Diabetes � When to start insulin vs adding more oral agents – Exenatide and sitagliptin � What insulin program to start with: – Once-daily NPH, glargine, or detemir – Twice-daily pre-mixed � How to start insulin and optimize dosing � Continue or discontinue oral agents when insulin is started? � When to proceed to mealtime insulin
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