The Big 3
UIM Resources
Learning objectives
• Highlight 3 changes to the treatment of Type 2 DM in the 2013
ADA Guidelines
• Name two pharmacy chains offering free oral medications for
diabetes
• Outline the JNC-7 treatment algorithm for essential
hypertension
• Identify 3 UIM resources to assist with the management of
diabetes, hypertension and obesity
• Recognize that overweight and obesity are largely
undiagnosed in the US
• Assign appropriate follow-up intervals for patients with
uncontrolled diabetes and hypertension
Chronic diseases
8000
7000
6000
5000
4000
3000
2000
1000
0
UIM Chronic Diseases
Quality Measures
Systolic Blood Pressure
LDL
A1C
March 2013 SBP
March 2013 LDL
March 2013 A1C
# of visits
2621
# of visits
1724
Mean SBP:
133.28
Mean LDL:
100.54
Hydroxyurea
# of visits
1140
Mean A1C:
6.97
Mar-13
< 140
1758
67%
< 130
1403
81%
< 8%
906
79%
≥ 140
863
33%
≥ 130
321
19%
≥ 8%
234
21%
# patients on
Hydroxyurea
57
% increase
6%
*65 visits missing SBP not included
February 2013 SBP
February 2013 LDL
# of visits
2569
# of visits
1630
Mean SBP:
133.34
Mean LDL:
100.64
February 2013 A1C
# of visits
1051
Mean A1C:
6.94
Feb-13
< 140
1664
65%
< 130
1322
81%
< 8%
833
79%
≥ 140
905
35%
≥ 130
308
19%
≥ 8%
218
21%
# patients on
Hydroxyurea
54
% increase
8%
*29 visits missing SBP not included
January 2013 SBP
January 2013 LDL
# of visits
2857
# of visits
1896
Mean SBP:
133.31
Mean LDL:
100.60
January 2013 A1C
# of visits
1284
Mean A1C:
6.87
Jan-13
< 140
1926
67%
< 130
1544
81%
< 8%
1034
81%
≥ 140
931
33%
≥ 130
352
19%
≥ 8%
250
19%
# patients on
Hydroxyurea
50
% increase
19%
*43 visits missing SBP not included
December 2012 SBP
December 2012 LDL
December 2012 A1C
# of visits
2298
# of visits
1481
# of visits
990
Mean SBP:
133.68
Mean LDL:
98.36
Mean A1C:
6.94
Dec-12
< 140
1482
64%
< 130
1230
83%
< 8%
783
79%
≥ 140
816
36%
≥ 130
251
17%
≥ 8%
207
21%
# patients on
Hydroxyurea
42
% increase
14%
*53 visits missing SBP not included
November 2012 SBP
November 2012 LDL
# of visits
2529
# of visits
1568
Mean SBP:
133.29
Mean LDL:
101.05
November 2012 A1C
# of visits
1044
Mean A1C:
6.90
Nov-12
< 140
1689
67%
< 130
1280
82%
< 8%
836
80%
≥ 140
840
33%
≥ 130
288
18%
≥ 8%
208
20%
# patients on
Hydroxyurea
37
% increase
6%
*46 visits missing SBP not included
October 2012 SBP
October 2012 LDL
October 2012 A1C
# of visits
2618
# of visits
1641
# of visits
1121
Mean SBP:
131.92
Mean LDL:
99.32
Mean A1C:
7.02
Oct-12
< 140
1776
68%
< 130
1362
83%
< 8%
859
77%
≥ 140
842
32%
≥ 130
279
17%
≥ 8%
262
23%
# patients on
Hydroxyurea
35
% increase
13%
Case study
• 76 yo m with AODM x 20 years, HTN, dyslipidemia. He has
never smoked cigarettes, and there is no family history of
early coronary disease. A1C 9.4% at last visit 4 months ago Metformin increased from 500 mg bid to 1000mg bid. Two
weeks ago he woke up with diaphoresis and weakness, ate a
sandwich and felt much better.
• He is taking lisinopril and atorvastatin – BP 145/90; LDL 134,
BMI is 28. States that he had been seeing a doctor in
Walterboro for “years” and he does not think his diabetes has
ever been under good control. He did not bring in pill bottles.
States he has been out of the metformin for “about a week”.
Case study
What is this patient’s A1C goal?
1.
2.
3.
4.
<6%
<7%
<8%
<10%
ADA Guidelines
Lowering A1C to below or around 7%
has been shown to reduce microvascular
complications of diabetes, and
if implemented soon after the diagnosis
of diabetes is associated with
long-term reduction in macrovascular
disease. Therefore, a reasonable A1C
goal for many nonpregnant adults is
7%.
ADA Guidelines
Providers might reasonably suggest
more stringent A1C goals (such as
6.5%) for selected individual patients,
if this can be achieved without
significant hypoglycemia or other adverse
effects of treatment. Appropriate
patients might include those with short
duration of diabetes, long life expectancy,
and no significant CVD.
ADA Guidelines
Less stringent A1C goals (such as
8%) may be appropriate for patients
with a history of severe hypoglycemia,
limited life expectancy, advanced microvascular
or macrovascular complications,
extensive comorbid conditions,
and those with long-standing diabetes
in whom the general goal is difficult to
attain despite diabetes self-management
education (DSME), appropriate glucose
monitoring, and effective doses of
multiple glucose-lowering agents including
insulin.
Case Study, cont.
You discuss the patient’s A1C goal, and stress the importance of
taking his metformin every day. He states he is having trouble
buying this and all of his testing supplies.
Which of the following pharmacies has many free oral diabetes
medications?
1.
2.
3.
4.
Walgreen’s
Walmart
Harris Teeter
CVS
Free Oral Diabetes Med
(metformin and XR, glipizide)
• Harris-Teeter
• Publix
• Bi-Lo
Case Study, cont.
According to the 2013 ADA guidelines, how often should
he be checking fingerstick glucoses at home?
1. Every morning fasting
2. 2-3 times per day
rotating times
3. Only when symptomatic
4. Every evening before
bed
ADA 2013 Guidelines
“When prescribed as part of a broader
educational context, SMBG results may
be helpful to guide treatment decisions
and/or patient self-management for
patients using less frequent insulin injections
or noninsulin therapies. ”
What is this patient’s BP goal?
1.
2.
3.
4.
5.
6.
Systolic <120
Systolic <140
Diastolic <80
Diastolic <90
1 and 3
2 and 3
ADA BP Guidelines
People with diabetes and hypertension
should be treated to a systolic blood
pressure goal of <140 mmHg. (B)
Lower systolic targets, such as < 130
mmHg, may be appropriate for certain
individuals, such as younger patients, if
it can be achieved without undue
treatment burden. (C)
Patients with diabetes should be treated
to a diastolic blood pressure < 80
mmHg. (B)
Lifestyle Modification and
Hypertension
• What diet recommended by JNC-7 has been shown to effect
reductions in blood pressure similar to single drug therapy?
1.
2.
3.
4.
5.
Weight Watchers
Atkin’s diet
DASH diet
Southbeach diet
Jenny Craig
DASH diet
•
•
•
•
Dietary Approaches to Stop Hypertension eating plan
www.nhlbi.nih.gov
64 pages of instruction
Vegetables, lean meat, lowfat dairy, nuts and seeds
JNC-7 Treatment
• In general, what should be the first choice of medication class
for most patients with Hypertension?
1. ACE-I
2. Beta blockers
3. Calcium channel blockers
4. Thiazide diuretics
5. Spironolactone
JNC-7 Treatment
• “Thiazide-type diuretics should be used as initial therapy for
most patients with hypertension, either alone or in
combination with one of the other classes (ACEIs, ARBs, BBs,
CCBs) demonstrated to be beneficial in randomized controlled
outcome trials.”
Case Study
When would you bring the patient
back to be seen?
1.
2.
3.
4.
1 month
3 months
6 months
PRN
JNC-7
• “Once antihypertensive drug therapy is initiated, most
patients should return for follow-up and adjustment of
medications at approximately monthly intervals until the BP
goal is reached. More frequent visits will be necessary for
patients with stage 2 hypertension or with complicating
comorbid conditions.”
Adherence
• In patients with chronic medical conditions, what percent is
non-adherent after 1 year of treatment?
1. 10%
2. 20%
3. 30%
4. 50%
5. 70%
Patient Barriers to Adherence
• Complexity: “There are so many pills, I can’t keep them straight!”
• High cost: “I can’t afford my medicine so I will only take half a pill
today.”
• Difficulty remembering schedules: “I forget to take them.”
• Lack of understanding: “Why do I need them?”
• Not feeling sick: “I feel fine. I don’t need them.”
• Side effects: “The yellow pills make me feel sick and I heard the blue
pills give you liver problems.”
• Embarrassment/Stigma: “I don’t want my friends to know that I’m
sick.”
• Depression: “I don’t care…. What’s the point?”
• Health literacy: “I can’t understand these instructions!”
• Belief systems: “My sister took insulin, then had her leg amputated.”
Perceptions of
Overweight/Obese
• According to NHANES data from 16,720 American patients,
what percentage of overweight women perceived themselves
as having the right weight?
1. <5%
2. 5-10%
3. 10-20%
4. 20-30%
5. 30-40%
International Journal of Obesity (2011) 35, 1063–1070;
published online 2 November 2010
NHANES Data
• A large proportion of overweight individuals (23% women,
48% men) perceived themselves as having the right weight.
International Journal of Obesity (2011) 35, 1063–1070; published
online 2 November 2010
NHANES, cont.
• What percentage of overweight patients had ever received a
diagnosis of being “overweight” from a health care
professional?
1. 10%
2. 20%
3. 30%
4. 50%
5. 90%
International Journal of Obesity (2011) 35, 1063–1070; published
online 2 November 2010
Healthcare Advice Matters
• Also, 74% of overweight and 29% of obese individuals never
had an HCP diagnosis of overweight/obesity.
• Among overweight/obese adults, those with an health care
provider diagnosis of overweight/obesity were more likely to
diet (74 versus 52%), exercise (44 versus 34%), or pursue
both (41 versus 30%, all P<0.01) than those who remained
undiagnosed.
• Conclusion: HCPs have unused opportunities to motivate
their patients to control and possibly lose weight by
correcting weight perceptions and offering counseling on
healthy weight loss strategies.
• International Journal of Obesity (2011) 35, 1063–1070; published online 2 November
2010
Weight Loss Goals
• What percent of the patient’s body weight does he need to
lose to reduce the severity of his hypertension and diabetes?
1. 5%
2. 10%
3. 15%
4. 20%
5. 25%
Weight Loss Goals
• “The rationale for the initial 10-percent goal is that a
moderate weight loss of this magnitude can significantly
decrease the severity of obesity associated risk factors.”
Consistent Message
•
•
•
•
•
•
Cut out sugary beverages
Reduce the “white” on your plate
Walk every day
Eat more vegetables
Stop smoking
Take your medicines as they are prescribed
UIM Resources
• Aging Q3 – Clinical Tools: ADA 2013 Guidelines
• PharmD/CDE – adjust prescribed oral meds/insulin without
orders; start new meds/insulin with MD
• RN and PharmD/CDE – can teach glucose testing, insulin,
complications, goals
• RN Case Manager – phone follow-up of glucoses, lifestyle, etc.
• Dietician – referral - Carb counting
• MSW – help for medications and supplies, insurance,
counseling
• Patient Assistance – next to RT pharmacy; medications for
uninsured /underinsured patients
Other Resources
•
•
•
•
•
•
•
•
•
•
•
MUSC Weight Management (free studies)
Quit for Keeps, SC Tobacco Quitline
Work Programs
Weight Watchers (meeting or online)
Overeaters Anonymous
YMCA
Recreation Departments
Lighten Up Charleston
Lowcountry Senior Centers
211 United Way (Diabetes Education)
WIC Program can be used at Farmer’s Markets (Downtown,
MUSC, Mt Pleasant, Summerville)