Hi, I'm Jill Ellis, and today we're going to talk about the second diabetes presentation in this series, and this presentation is going to focus on diabetes management, including specifically cardiovascular disease complications. Here's my disclosures. And the instructional objectives for today's module is going to be to summarize the overall care of the diabetic patient, to identify acute and chronic complications of diabetes mellitus, to identify both microvascular and macrovascular complications of diabetes, and then we'll focus on the macrovascular complications and discuss the management of and screening for macrovascular complications in patients with diabetes, and then at the end we'll just talk a little bit about the management of diabetes in hospitalized patients because there are many patients who are hospitalized with diabetes or hyperglycemia, so that can be an important little add-on part there. So the overall care of the diabetes patients, we're going to put it together. In the last presentation, we talked about many different components. We talked about pharmacologic treatment options, we talked about non-pharmacologic options, but how do you really start with your patient with diabetes, and that's what we're going to kind of focus on here. So specific treatment recommendations focusing on type 2 diabetes, we want to consider those non-pharmacologic treatments, so that's going to include the healthy lifestyle behaviors, diabetes self-management education, diabetes self-management support, addressing social determinants of health, like we previously described, but then also pharmacotherapy. An important thing about pharmacotherapy, two kind of big principles, is that number one, pharmacotherapy should begin at the time of diagnosis. Once a patient reaches the diagnostic threshold for diabetes, they do qualify for pharmacotherapy at that time of diagnosis. We no longer wait for a period of lifestyle modifications to see if the patient can control the hyperglycemia without medications. We now start the medications at the time of diagnosis. And then another important pharmacologic principle is to avoid clinical inertia. So if you have a patient who has had an adequate trial of a pharmacologic agent, then when you follow up with them, if they're not meeting their glycemic targets, you do advance their therapy, either increasing the dose or adding on additional therapy, and you also want to continue to emphasize the non-pharmacologic treatment aspects as a complement, as a supplement to the pharmacologic treatment, but don't avoid increasing the pharmacotherapy to ignore that aspect. You want to make sure that you focus on both simultaneously. So focusing on approaches that provide efficacy to attain glycemic goals. So the American Diabetes Association guidelines for the first time in 2023 said that you now can consider other agents besides metformin as the initial therapy, but they still do put an emphasis on metformin because metformin oftentimes still is the most appropriate initial therapy for patients with type 2 diabetes. But the things that you want to consider are going to be the efficacy. So most oral agents will lower the glucose levels between 0.5 and 1.5 percentage of a hemoglobin A1c value. So trying to look at how much glycemic lowering the patient has to have, and then picking an agent that matches that need. Also looking at hypoglycemic risk. Some medications have a high hypoglycemic risk. For instance, sulfonylureas have an increased risk of hypoglycemia, whereas metformin, the GLP-1RAs, the DPP-4s, the SGLT-2 inhibitors, those have a reduced risk of hypoglycemia. Also looking at the effect on weight. So some agents are weight neutral. Metformin is predominantly a weight neutral medication. Some medications promote weight loss, GLP-1RAs is a classic one for that. And then some medications actually are associated with some weight gain, such as the TZDs. So looking at the patient's weight and selecting an option where you could obtain dual benefits, not only glycemic lowering therapy, but also weight benefits. Or looking at cardiovascular and renal effects. If you have a patient who has significant cardiovascular risk or renal effects, you may want to pick either the GLP-1RAs or the SGLT-2 inhibitors, because those have some beneficial effects, like we'll talk about in the upcoming slides here. Method of administration can also have an impact. So like we talked about in the last presentation, you want to individualize therapy for patients. So if you have a patient who is not willing to engage in injectable therapy at this point, that's going to take out some of your options. So then the GLP-1RAs, the GLP-1RA, and the GIP inhibitors, the insulin, are not going to be an option for the patient at this point. Maybe you have a patient who has a lifestyle that they, at this point, do not feel as conducive to multiple injections or multiple therapies. So then you might focus on medications that have once daily dosing as opposed to multiple day dosing. And there are even some of the new GLP-1RAs that can be dosed just once a week. And so that might be an option for patients to let that fit better into their lifestyle. So again, trying to combine the pharmacologic benefits of the medications with the patient's lifestyle to find a treatment that is best for your individual patient. And that, again, incorporates the patient preference. If you have somebody who has an entry hemoglobin A1c more than 1.5% above the glycemic target, remember that the entry, the glycemic target for most patients is going to be 7%. So if you have somebody upon diagnosis who has a hemoglobin A1c greater than or equal to 8.5%, you are going to want to consider dual combination therapy or a more potent agent if possible. So that could be like the GLP-1RAs or insulin. GLP-1RA are now preferred to insulin when possible. And the reason for that is they do have beneficial weight effects. So whereas GLP-1RA promotes weight loss, insulin actually promotes weight gain. Whereas GLP-1 has the demonstrated cardiovascular benefits, insulin does not. And GLP-1RAs don't have a risk of hypoglycemia, whereas insulin does. So if possible, GLP-1RAs are preferred, but sometimes they need to be added onto insulin therapy or sometimes there might be reasons that the GLP-1RAs are not a good option for your patient. Early introduction of insulin, if there's ongoing evidence of catabolism, symptoms of hyperglycemia, or if you have a hemoglobin A1c above 10% or a blood glucose level above 300, insulin is the most effective glycemic lowering therapy. So if you have a patient who has the need for profound glucose lowering, then insulin should be a part of that regimen. Now insulin can be combined with other options, for instance, the GLP-1RA, the metformin, the SGLT2, the DPP4, but if you have the severe hyperglycemia, insulin should at least be a component of that initial regimen. Other things to consider, like, and I kind of mentioned this on the last slide, adults that have established or adults who are at high risk for atherosclerotic cardiovascular disease, heart failure, and or chronic kidney disease should be treated with agents that reduce cardiorenal risk, and that's going to include the GLP-1RAs, the majority of which are injectable. There is one oral form or SGLT2 inhibitors, and the SGLT2s are the ones that are preferred for chronic kidney disease. And then another important thing to talk with your patients about is that many patients with type 2 diabetes eventually require and benefit from insulin. So even if you have a patient who at this point could be managed with monotherapy with metformin or one of the other oral agents, you don't want to tell them that they have the type of diabetes that is controlled with oral medications, because an underlying principle of diabetes is that it's a progressive disease. And so even if it can be controlled with one oral agent now, as the disease progresses, it will likely require more than one medication, and at the end of the course of diabetes, this includes insulin for many patients. So not using insulin as a threat for patients, but just kind of emphasizing the progressive nature of the disease, focusing on the things that the patients do have control over, such as lifestyle modifications, and then recognizing that you will supplement that non-pharmacologic treatment with pharmacologic treatment, which may include insulin as the disease progresses. For patients with type 2 diabetes that ultimately transition into insulin therapy, the most common way to do that is to start with basal insulin therapy. That's the most convenient initial insulin regimen to decrease nocturnal and fasting glucose levels. So you might have a patient that has been managed with non-insulin therapies, but now we are no longer able to control their glucose levels with those non-insulin therapies. So we add in insulin. The most common way to do that is with a fixed basal insulin-only dose. And then as that becomes less effective over time, because again, diabetes is a progressive disease, then we could consider adding in prandial insulin, which would be a rapid-acting or short-acting insulin, or using a GLP-1RA to supplement that basal insulin, or sometimes we can use pre-mixed insulin, which can allow patients to have twice-daily dosing and not have to have the calculations of the corrective and the nutritional insulin calculations. So those can be different options as well, but again, just emphasizing the progressive nature of the disease. Once you have a patient that you've kind of determined what their initial therapy is, whether it's metformin, insulin, or one of the other non-insulin, non-metformin therapies, then you still have to see these patients frequently to make sure that they're reaching their target. So how do you follow up with those patients with diabetes? Usually you're going to follow up with these patients every three to six months. And when you see these patients, you're going to do interval medical history, assessing their medication-taking behavior. Are they tolerating it? Are they having side effects? Are they having any complications? Specifically asking about hypoglycemia at every visit for patients with type 2 diabetes and type 1 diabetes. Asking them about their diabetes self-management behaviors. And this is a formal process. You're not expected as a general provider to provide the level of education that patients need for diabetes self-management education and diabetes self-management support. These are programs that you should be referring your patient to, and they consist of a minimum of 10 hours oftentimes to allow patients to have the amount of education and support that they need to manage their diabetes at home. And it's also not a one-and-done type of education. These are patients that, these are educations that should be repeated. So once yearly, and then if there's hospitalizations, if there's a change in the treatment. So if a patient had been having good control of their diabetes, and then for some reason they had deterioration in their glycemic control, that would be another time to consider the diabetes self-management education and support referrals. Asking them about their nutrition. Again, the referrals to the medical nutrition therapist is not a one-and-done thing either. You want to send the patients to nutrition at the time of diagnosis, but then again, throughout the course of their disease. Not only does their disease change, but their dietary preferences may change. They may need reminders about some of the things that they had forgotten. They may have questions that have come up over the course of their management. Asking about their psychosocial health, including screening for diabetes distress, which is a subtype of a psychosocial disorder that is specific to patients with diabetes. When patients have the overwhelming feeling of dealing with a chronic disease, the frequent blood glucose checks, the frequent referrals, the frequent doctor visits, the frequent medications, the dietary changes, the activity changes, that can become overwhelming, and it can lead to deterioration in glycemic control, and so we want to screen for how the patients are doing with their diabetes. Asking about sleep evaluation. Like I mentioned in the previous presentation, poor sleep has been a risk factor both for the development of diabetes, but also for glycemic control in patients with established diabetes, so finding out how they're sleeping, and then assessing for the presence of comorbidities, and there's a variety of comorbidities that occur with increasing frequency in patients with diabetes. Comorbidities can include cognitive impairment, nonalcoholic fatty liver disease, obstructive sleep apnea, fractures, low testosterone levels, periodontal disease, hearing impairment, other autoimmune diseases, pancreatitis, psychosocial disorders like we mentioned, a number of comorbidities that can occur with increased frequency in patients with diabetes, and we want to assess for the presence of these comorbidities because we want to treat the comorbidities for the presence of the risk factors, the comorbidities, but also because these comorbidities can lead to poor glycemic control, so if we address the comorbidities, that will help us to improve their glycemic control as well. On physical exam, we want to make sure that we do vital signs, including blood pressure measurement, BMI measurements for our patients with diabetes, skin assessments to evaluate for injection site complications, making sure that our patients have annual dilated fundoscopic eye exams, and that needs to be done by an eye care professional. Technology has allowed us to do some interesting things with this where they can do retinal photographs of patients that can't have access to ophthalmologic care, so they don't always have to see an ophthalmologist, sometimes those can be done remotely, however, if something is found, then the patient would need to follow up with that ophthalmologist for further care. Making sure that patients have routine foot exams, so screening for foot problems at every visit, a visual inspection of feet at each visit for high-risk diabetic patients, a comprehensive foot exam for all diabetic patients at least once a year, making sure that patients have their annual dental exams, if you have pediatric patients assessing their growth and their pubertal assessments to make sure that you adjust their diabetic needs as they grow and as their body is changing, as their hormone levels are changing, that you make sure that you kind of anticipate those changes and manage the diabetes appropriately through those periods. Some follow-up, so not only do we need labs at diagnosis, we also need to repeat these labs frequently, so a hemoglobin A1c should be obtained every three to six months to help us determine if the patients are meeting their glycemic targets. The urine albumin should be obtained annually, and that's a spot urinary albumin to creatin ratio, and that's to assess for the presence of diabetic kidney disease, so if it's present, we can identify it early, we can treat it by improving glycemic control, improving blood pressure control by possibly adjusting the diabetic medications to focus on agents that are beneficial for the kidneys, such as the SGLT2 inhibitors. We want to monitor the serum creatinine and extragrammellular filtration rate annually in adults. Previously, they recommended just the urine albumin annually, however, they have now recognized that with increased frequency, patients with diabetes are developing diabetic kidney disease without the presence of albuminuria. So now they recommend to screen for both the urinary albumin and the serum creatinine NGFR. A lipid profile should be performed periodically to assess the patient's overall ASCVD risk. The TS-8 should be performed periodically. It initially should be performed in all patients with dyslipidemia and women over the age of 50, as we mentioned in the previous presentation, but then it should be repeated periodically based on risk factors and or symptoms that the patient may have. Consider periodic vitamin B12 screening. That's predominantly for your patients that are on metformin. The majority of patients with type 2 diabetes are still on metformin and prolonged metformin use can lead to vitamin B12 deficiency. So they do recommend to periodically screen for that. And then ongoing management. So evaluate the need for referrals. When you're seeing a patient with diabetes for their preventive care, have they seen the dentist? Have they had a visit with the ophthalmologist? Have they gone to a podiatrist if they need to? Do they need to have any other specialty referrals? Administering their immunizations, making sure they're up to date on all the CDC recommended immunizations, remembering again that the pneumococcal vaccine is an indication for adults with diabetes. Performing routine health maintenance screening, making sure that patients are up to date on their cancer screening, making sure that they've been referred for their education self-management review annually. Transitioning of care from families to individual for pediatric patients. So as pediatric patients with diabetes grow, they will have increasing responsibilities for their diabetes. So if you have a younger diabetic patient, their management may have predominantly been performed by their parent or a guardian, but as they get older, they will start to assume more of that management. And so kind of assessing for that each year to find out where the family and the patient are at with that. Smoking cessation counseling at every visit, if applicable, and then aggressively treating all comorbid conditions. And now just a little bit more on the diabetic complications. We'll focus on the macrovascular disease complications of ASCVD, but we'll briefly mention the other ones as well. So when you think about diabetic complications, I like to divide it up into acute and chronic, and then for the chronic, both microvascular and macrovascular. So for the acute complications, we think about things like hypoglycemia, and then also the acute hyperglycemic complications like DKA and HHS. We're not going to focus on those today. There's also chronic microvascular complications, and those are the neuropathy, the retinopathy, and the diabetic kidney disease. We're also not going to primarily focus on those today, but we're going to talk about the chronic macrovascular complications. So atherosclerotic cardiovascular disease, heart failure is also a complication here, and we'll talk about how frequent these complications occur. The macrovascular complications actually are one of the leading causes of death related to diabetes, and so this is an appropriate area to focus on. So like I mentioned before, ASCVD is the leading cause of morbidity and mortality in patients with diabetes, so this is an appropriate area to discuss. Heart failure is another major cause of morbidity and mortality from coronary vascular disease. Lower extremity peripheral arterial disease is a common complication of diabetes, and the cardiovascular disease is the largest contributor to direct and indirect costs of diabetes. So costs are not only in terms of morbidity mortality, but also in dollars. Screening of cardiovascular disease is important. Patients with diabetes oftentimes present atypically, so they may not present with the crushing chest pain or the crescendo angina. They may have more atypical symptoms, so we want to make sure that we screen both to identify risk factors and if patients have symptoms. So annual assessment to identify risk factors, and that's going to include things like blood pressure, lipids, like it's mentioned below there. So assessment of the 10-year ASCVD risk at the time of diagnosis and then periodically thereafter to make sure that you're aggressively managing any of the comorbidity or comorbid risk factors for your patient. A blood pressure assessment at every visit. The periodic lipid screening like we mentioned. Consider ankle brachial index screening for patients that you feel that are at risk for peripheral arterial disease. So if they have a history of decreased walking speed, leg fatigue, claudication, if they have an abnormal exam for their pedal pulses, then you might want to consider getting the ankle brachial index screening for those patients. Routine screening for coronary artery disease itself is not recommended in asymptomatic patients, meaning that we don't do routine stress tests in patients. But if you have a patient that has any type of cardiac symptom or symptom that could be a cardiac symptom, remembering they present atypically, if they have signs or symptoms of associated vascular disease or if they have EKG abnormalities, then you could consider some type of cardiac workup, whether it be a stress test or ultimately a heart catheterization or whatever type of workup it has. But there's no routine recommendations to do that. We screen for the presence of cardiovascular disease by screening for the risk factors in patients with diabetes. And then for prevention of cardiovascular disease, we really think of kind of three different targets that we want to meet. We want to try and meet glycemic targets, blood pressure targets, and lipid goals. When you look at the success of providers and patients in meeting these glycemic goals, there is progress in patients in the United States with diabetes meeting their glycemic goals, but there is still a very small minority of patients who are meeting all three blood pressure, lipid, and glycemic goals together. So really trying to focus on setting all three of those goals and then meeting all three of those goals. So aggressive glycemic control, avoiding clinical inertia, emphasizing non-pharmacologic therapy. If your patients smoke, encouraging them to stop smoking. Aggressive blood pressure control. Like I mentioned in the previous presentation, we do now have alignment in the blood pressure goals between the American Heart Association, the American Diabetes Association, so that the majority of patients should have a blood pressure goal of less than 130 over 80. Emphasizing lifestyle modification. Home blood pressure monitoring should be recommended for patients with diabetes to monitor their control of the blood pressure at home. Pharmacologic therapy for patients if their blood pressure remains above goal, and that would include ACE inhibitor or ARB for first-line therapy in patients that have diabetes and coronary artery disease. Not both, but one or the other. So either an ACE inhibitor or an ARB is recommended as the first-line therapy. Other aspects of prevention for cardiovascular disease include aggressive lipid control. So lifestyle modifications for all patients with diabetes. Statin therapy for patients that are 40 to 75 or patients that are younger that have risk factors. And then the intensity of statin therapy will vary with the calculated risk, their side effects from the medications, how well they tolerate the medications, what their actual LDL levels are. In general, low-intensity statin therapy is not recommended for patients with diabetes. So it's either going to be moderate or high-intensity statin therapy. Consider the addition of non-statin therapies for very high-risk patients. So that could include things like a PKSK9 inhibitor, azetamide, those types of options. Consider aspirin for primary prevention in diabetic patients that are at increased cardiovascular risk and not at an increased risk of bleeding. Those recommendations have softened somewhat as they follow along with the United States Preventive Service Task Force recommendations for aspirin for primary prevention. And there is not as strong of a recommendation for primary prevention use of aspirin. But if you do have a patient that is at increased CVD risk and not at increased risk of bleeding, you could consider the low-dose aspirin for those patients. If you have a patient that has diabetes and established cardiovascular disease, their treatment is not going to differ significantly from treatment of established cardiovascular disease in patients without diabetes, with the exception of adding on the glycemic lowering therapy. So focusing on lifestyle modifications. Patients that have established cardiovascular disease and diabetes should be treated with aspirin and statin therapy if there's no other contraindications. You would consider the use of non-statin pharmacotherapy for prevention in these high-risk patients. ACE and ARB should be considered to decrease the risk of cardiovascular events. And patients that have a prior MI beta blocker should be continued for three or more years post-event. And then the other consideration for patients with established ASCVD and diabetes are the anti-hyperglycemic medication consideration. So we mentioned this previously, but there's even stronger recommendations. If you have a patient that has established heart disease, they should be on one of these diabetic medications with proven cardiovascular benefits. So the selected SGLT2 inhibitors have demonstrated CVD benefits in patients with type 2 diabetes and established ASCVD. And the same thing is true for the selected GLP-1RAs. So it is recommended to add on one of these medications, even if your diabetic patient is at their glycemic goals. Neither of these medications are associated with hypoglycemia, so they can be safely added on to glycemic lowering regimens, even if the patient is at the goal. So if for some reason you don't want to discontinue one of the other medications in the patient's glycemic lowering regimen, and you just want to add on the SGLT2 inhibitor or the GLP-1RA, that is fine. But your patients with the established heart disease and diabetes should be on one of these two glycemic lowering therapies. Other anti-hyperglycemic medication considerations for heart failure include the fact that SGLT2 inhibitors have been shown to reduce the risk of worsening heart failure and cardiovascular death. So if you have a patient that has type 2 diabetes and established heart failure, you would want to strongly consider the SGLT2 inhibitors because they have improved symptoms, improved physical limitations, and improved quality of life. You would want to avoid the TZD medications in patients with heart failure because there is an increased risk of heart failure. The relationship between DPP4 inhibitors and heart failure is unclear. There's been some studies that have shown beneficial effects, some studies that have shown adverse effects, so the effect there is really unclear. You want to avoid metformin in unstable or hospitalized patients with heart failure. So a couple of things to consider with heart failure as well. And then just shifting for a little add-on presentation here about diabetes care in the hospital because again diabetes is common in the hospital. Over a quarter of patients in the hospital will either have established diabetes or hyperglycemia, so it is important to consider the management of diabetes in the hospital. All patients that have hyperglycemia or have established diabetes should have a hemoglobin A1c if it has not been performed within the past three months. All patients with hyperglycemia or established diabetes should be assessed for their knowledge of diabetes, so finding out what their self-management knowledge is and educating them as appropriate. Glycemic goals are a little bit different for patients in the hospital. We've looked at over the years different glycemic goals, so you'll see there was more stringent goals of 110 to 140 when we used to use those goals for intensive care patients, but we found that that risk of hypoglycemia is significant, so they've now relaxed glycemic goals in the hospital to 140 to 180 milligrams per deciliter for most patients, so we want to avoid the hypoglycemia, but then we also want to avoid the hyperglycemia, so blood glucose levels above 180 can lead to spilling of glucose into the urine through the kidneys, and then that can lead to some fluid electrolyte imbalances, so we want to avoid any of the glucose urea, but we also want to avoid hypoglycemia, so that 140 to 180 is kind of within that range, and then we monitor glucose levels frequently for patients with diabetes in the hospital, so if a patient's eating, we'll check it before meals and at bedtime. If they're not eating every four to six hours, if they're on a continuous insulin infusion, we'll check their blood glucose every 30 minutes to two hours. If you have a patient who is on established continuous blood glucose monitoring, we can continue that in the hospital if there are appropriate resources and support to do so, so there would want to be coordination between the patient and the care team to record those measurements periodically, make sure the appropriate tools are there and the supplies that they would need to use the continuous glucose monitor. Other considerations for treatment of diabetes or hyperglycemia in hospitalized patients, you would want to consider consultation with a specialized diabetes or glucose management team. You want to consider appropriate medical nutrition therapy to see if you need to have any dietary modifications. In general, we discontinue oral glucose lowering agents and use insulin for management for all patients, even if they were managed with oral glucose agents as an outpatient. Correctional insulin can be used for patients that have diet or non-insulin dependent diabetes, and then if you have patients that have poor oral intake, NPO, or if they have higher glycemic needs, then you can add on the basal or the basal bolus insulin, so just kind of depending on what their glucose levels are, you would pick one of those options of insulin regimens that we had discussed in the previous presentation. And then IV insulin is preferred for most critically ill patients in the intensive care unit. Some additional treatment considerations for hospitalized patients with diabetes is that diabetes self-management in the hospital may be appropriate for some patients. So, you might have a patient who uses an insulin pump as an outpatient, and they're hospitalized for a condition where they will continue to have relatively stable oral intake, and they're able to mentate and appropriately manage their insulin pump. It may be most appropriate to continue their insulin pump, but it would have to be in coordination with the care team and ensuring that the patient has the appropriate resources for their individual insulin pump, because the hospital likely would not have the specific supplies for their pump. So, there may be certain patients who can participate in self-management in the hospital, just depending on their acute medical condition, depending on their level of awareness, and depending on the resources and support available for the hospital. It is critical to avoid hypoglycemia in the hospital, like I mentioned. And so, hypoglycemia management protocols should be used. So, there should be a formalized process that hospitals are using to treat hypoglycemia. And any time a hypoglycemic event occurs, and that would be defined as a blood glucose level less than 70, there should be a documentation in the medical record that the regimen was reviewed and then adjusted as needed based on that hypoglycemia, because we do want to avoid any hypoglycemic events in the hospital. And then, as you're getting ready to move that patient into discharge, you should have a comprehensive discharge plan for patients with diabetes to reduce the risk of complications, reduce the risk of readmission, and just to address their overall diabetic needs and ensure that they have someone to assist them with the management of their diabetes following discharge. Thank you for participating in this module, and we hope you learned a little bit about diabetes management. And that's the conclusion of the presentation. If anybody has any questions that they would like answered, please reach out to academy at medaxiom.com.

diabetes management

cardiovascular complications

individualized treatment

pharmacotherapy

glycemic targets

SGLT2 inhibitors