Diabetes Management Day:
Living Well with Diabetes
May 27, 2015 0800-1200 Hours
This program has been approved for the following credits: • The College of Family Physicians of Canada - 3 Mainpro-M1 credits per session • Royal College of Physicians and Surgeons of Canada - 3 Section 1 credits per session
IN PARTNERSHIP WITH
SUPPORTED BY
Diabetes Management Day:
Living Well with Diabetes Table of Contents
What’s New in Oral Hypoglycemics Brenda Chamachourdijan, BScPhm
p. 7
Eat Move & Motivate: Clinical Myths & Pearls Interprofessional Panel on Lifestyle Management
Motivating Change Jane Bowman, OT Reg.
p. 13
Exercise Myths & Pearls of Wisdom Jacqueline Holloway, PT
p. 17
Diabetes & Nutrition Abby Langer, RD
p. 23
Bariatric Surgery: Impact on Diabetes
p. 27
Paul Sullivan, MD
Case Discussion
p. 33
Donna Arab-O’Brien, MD
2015 Continuing Medical Education Curriculum
p. 37
SGLT-2 INHIBITORS
Brenda Chamachourdjian, BScPhm Inpatient Pharmacy, St. Joseph’s Health Centre, Toronto
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NONE
Canagliflozin
Dapagliflozin
Participants will gain an understanding of the mechanism of action and efficacy adverse effects and contraindications advantages and disadvantages place in diabetes management
In the U.S.: Empagliflozin Empagliflozin/linagliptin Canagliflozin/metformin Dapagliflozin/metformin Chao EC et al. Nature Reviews Drug Discovery. 9: 551-9, 2010 Jul. http://www.nature.com/nrd/journal/v9/n7/fig_tab/nrd3180_F3.html
0.5-1.0% reduction in HbA1c 1.1-4.5mmol/L reduction in FPG 2-7mmol/L reduction in PPG Approximately 70g glucose excreted in urine per day (i.e. 280 kcal/day) Weight reduction of up to 4 kg, seems to be mainly body fat
Abdul-Ghani MA et al. Journal of Internal Medicine. 276(4):352-63, 2014 Oct. http://onlinelibrary.wiley.com/doi/10.1111/joim.12244/full#joim12244-fig-0001
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CANAGLIFLOZIN
Monotherapy in T2DM adults when cannot use metformin Add-on in T2DM adults to:
DAPAGLIFLOZIN
Monotherapy in T2DM adults when cannot use metformin Add-on in T2DM adults to:
Metformin SU
Metformin +/- SU or pioglitazone Insulin +/- metformin
Metformin SU Insulin +/- metformin
Dose-related mild increase in LDL and HDL Dose-related ↑SCr, ↑BUN and ↓eGFR (usually transient) – especially in hypovolemia or existing renal impairment ↑ potassium with canagliflozin
RFs: <60mL/min, potassium-sparing diuretics, ACEIs, ARBs
↑ phosphate ↓ uric acid with canagliflozin ↑ hemoglobin and hematocrit Genital mycotic infections UTI URTI/Nasopharyngitis Increased incidence of bladder CA with dapagliflozin???
metabolism is primarily via glucuronide conjugation (UGT) into inactive metabolites Substrate of drug transporters (eg. P-gp) Extensively protein-bound
Assess and correct volume status before starting RFs: > 75 yoa, < 60mL/min, hypotension, loop diuretics, ACEIs, ARBs, vomiting, diarrhea
↓ SBP approximately 0.1-7.9mmHg Falls Hypoglycemia – seems like less likely than SUs, more likely when added to a SU or insulin, more likely in renal impairment
Polyuria, pollakiuria, polydipsia
Hypovolemia → postural dizziness, orthostatic hypotension, hypotension
...along with diet and exercise
Glucosuria Osmotic diuresis (urine vol ↑ 375mL/day)
May need to decrease insulin or SU dose prior to starting
K (+/- PO4) SCr, BUN & eGFR Volume status BP Falls Hypoglycemic events LDL Hemoglobin, hematocrit Digoxin levels
Insulin, SUs ↑ risk of hypoglycemia Loop diuretics ↑ risk of hypovolemia ACEIs, ARBs, potassium-sparing diuretics ↑ risk of hyperkalemia with canagliflozin Digoxin with canagliflozin Rifampin?, phenytoin, phenobarbital, barbiturates, carbamazepine, ritonavir, efavirenz, St. John’s Wort with canagliflozin Note: this is not an exhaustive list
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Canagliflozin Dapagliflozin Start at
100 mg
5mg
If tolerating and need tighter glycemic control
300mg
10mg
decreased GFR decreased glucose filtration less significant amount of inhibition of glucose reabsorption by SGLT-2 inhibitors
eGFR
Canagliflozin
< 60mL/min/1.73m2 • Do not start
Dapagliflozin • Do not use
• If already on and decreases to < 60mL/min/1.73m2, decrease or maintain dose at 100mg PO daily < 45mL/min/1.73m2 • Do not use
Geriatrics (≥ 65)
Smaller decrease in A1c increased incidence of hypotension , orthostatic hypotension, syncope, dehydration
Especially > 75 yoa and with doses of 300mg canagliflozin
Pregnancy or lactation
Not as expensive as GLP-1 agonists (exenatide and liraglutide) Approximately similar cost as DPP-4 inhibitors
do not use (not studied)
Hepatic impairment
Paediatrics
do not use (animal studies suggest risk)
$3.04 /tablet or day (same price for different strengths, $ cana = $ dapa) Not covered by ODB Overall:
Dapagliflozin - increased levels, but no dosage adjustment necessary in mild to moderate impairment (no recommendations for severe) Canagliflozin – no dosage adjustment necessary in mild to moderate impairment, but do not use in severe
Oral Once daily dosing, with or without food Possible weight loss and SBP reduction A1c reduction similar to that of most other oral hypoglycemics Can be combined with some other hypoglycemics Efficacy not dependent on insulin production or sensitivity Overall, does not cause hypoglycemia unless added to a SU or insulin So far no CV risk found (time will tell)
Diuresis bothersome, hypovolemia, falls Not ideal in elderly/frail Cannot be used in renal impairment Not more effective than other hypoglycemics Genital mycotic infections Avoid dapagliflozin in bladder CA hx or fam hx and do not combine with pioglitazone Not cheap, not covered by ODB (yet)
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CDA 2013 Guidelines did not include them as they were not yet approved (already included in ADA 2015 Guidelines) Can potentially be used in longstanding DM that has low insulin production Should be able to combine with agents that work at other sites of action Possible future in T1DM??? Not ideal for frail, older, renally impaired, urinary incontinent, hypovolemic, hypotensive or hyperkalemic patients
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Motivating Change
Jane Bowman OT Reg.(Ont.) Urban Family Health Team/Family Medicine Advancing the Health of Our Community by being Canada’s Best Community Teaching Health Centre
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Empowerment Based Problem Solving Model
Presenter Disclosure • Relationships with commercial interests: None
• Explore the problem • “What is the hardest thing about caring for diabetes for you?” Group Education Strategies for Diabetes Self management, Tang, Funnel, Anderson, Diabetes Spectrum; Spring 2006; Proquest Nursing and Allied health Source, p. 99
•
Clarify Feelings and meaning • What are your thoughts about this? • How do you feel about this? • Are you feeling (insert feeling) about this?
Ask about willingness to develop a plan • What is working for the client? • What are the client's goals ( 1 month, 3 months, 1 year)? • What might happen if you don’t do anything about it?
Committing to Action •
*Behaviour Change Contract or Prescription – a copy for you and one for the patient (have the patient fill out the form to influence commitment) *roll with resistance (Motivational Interviewing approach)
•
Change I'd like to make:
•
Action steps I can take«(encourage patient to keep goals SMART)»:
•
Readiness Ruler: "On a scale of 0‐10, with 10 being very ready, how ready are you to make this change?“ 0___1___2___3___4___5___6___7___8___9___10___
•
Confidence Ruler: "On a scale of 0‐10, with 10 being very confident, how confident are you that you can make this change?“ 0___1___2___3___4___5___6___7___8__9__10__
•
Develop discrepancies. For example, "Why did you choose number 4 and not a lower one?"
• •
Did the patient find this exercise helpful? «Yes»«No» Did the provider find this exercise helpful? «Yes»«No»
•
What is one thing you will do when you leave here today?
How did it go? • • • •
What you notice about your plan? What barriers did you encounter? What would you do differently next time? What will you do when you leave here today?
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Your Goal and the Patient’s Goal • Start where the patient is at, not where you want them to be • Don’t work harder than the patient!
Reacting to unpleasant feelings and thoughts
Managing difficult Feelings or Resistance • Sit with it! • Acknowledge it and Accept it • Wait for it to pass, “Maybe there is no more for us to talk about today.”
3‐Minute Breathing Space
• our automatic reaction is Aversion • deliberately turning to face, investigate and recognize the unpleasant feelings and your reaction to them – a powerful affirmation that you don’t have to get rid of them (mindfulness) • Modeling this for the patient and recognizing it in yourself can be very powerful in allowing resistance to pass •
‐ The Mindful Way Workbook, by Teasdale, Williams and Segal
Individual and group participation
Thank you!
• 30% rate of attrition following the first session • Sustainability of behaviour change? • Possible solutions: front end load group materials, skills and education etc.; series of workshops versus groups; internet interventions; using general mindfulness groups versus groups specifically targeting diabetes self‐management; other ideas? • Qualitative research about why people drop out of psycho‐educational interventions? What people find helpful and unhelpful about groups
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Diabetes Management Day Living Well with Diabetes â&#x20AC;˘ Exercise Myths and Pearls of Wisdom Jacqueline Holloway Physiotherapist
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Presenter Disclosure
Myth 1: “Exercise” means the same thing to everyone
• Relationships with commercial interests: None
Myth 2: A general exercise prescription of 150 minutes weekly will suit everyone Pearl: Individualized exercise prescriptions with guidance for progressions will give optimal benefit. “There is a positive dose response of health benefits that result from increasing exercise intensity”(2014, American College of Sports Medicine’s Guidelines for Exercise Testing and Prescription, p 167)
Myth 1: “Exercise” means the same thing to everyone • Understand your patient’s concept of exercise and present activity level • Get to know a patient’s current activity
Pearl: Understand your patient’s concept of exercise and present level of activity/exercise experience
Myth 3: Diabetic patients are limited in their ability to exercise due to risk of complications Pearl: There are special considerations to be aware of for exercise & diabetic patients Be able to answer questions or direct patients to information resources about special exercise considerations so that they may exercise safely
Each patient has a personal concept of exercise: • What do you do for exercise? • How many minutes of exercise do you get every day?
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Exercise is Medicine • Patients recognize Blood pressure as an important vital sign of health • Start checking minutes of exercise per day on every office visit
Determine next steps in Exercise Counselling for this individual • Consider your medical assessment of the patient, current issues, chronic conditions, medications, other factors that limit or affect patient exercise and activity
Individual Exercise Prescription • Introduce the Idea of listening to your body, and getting familiar with working at a moderate intensity level of exercise • Look at BORG perceived exertion scale and describe examples of activities representing exertion levels for a less active person, and for a more active person
Answers to the Question: What do you do for exercise? • “I’m new to exercise” • “I am busy and active already with my daily routine” • “I exercise daily and know how to progress exercise intensity to get the optimal benefits”
Myth 2: A general exercise prescription of 150 minutes weekly will suit everyone
Help your patient recognize what it means to do at least 150 minutes of moderate exercise weekly
Describe Moderate Intensity Exercise • Work hard enough to get the maximal health benefit (After your exercise it is normal to feel somewhat tired, your muscles may feel fatigued, this should resolve after 30 – 60 minutes) • Do not work so hard that you feel uncomfortable for hours after your exercise. After your exercise you should not feel muscle aches or be unable to do your usual activities following a 30 to 60 minute rest.
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BORG Exertion Scale How Hard are You Working?
0 Nothing at all 0.5 Extremely Slight (just noticeable) 1 Very Slight 2 Slight 3 Moderate 4 Somewhat severe 5 Severe 6 7 Very Severe 8 9 Extremely Severe (almost maximal) 10 Maximal
How to Exercise: Basic Exercise Prescription to start with • Begin with a 5 minute warm up of walking, and / or moving arms and legs to warm up the muscles you will use during exercise.
How to Exercise: Frequency • Don’t leave off exercise for longer than 2 days or the benefits will be reduced
Refer to Physiotherapy for Complex Exercise Prescription • If patient has one or more Chronic Medical Conditions and / or previous injuries it is best to refer to physiotherapy for an assessment and exercise prescription
Starting/ Basic Exercise Prescription: self monitor exercise intensity • Exercise at a level of 4 to 6 on the Exertion scale • Exercise at least 3 times weekly • Gradually increase time activity to 20-60 minutes.
Progression of Exercise: Add short intervals of increased intensity • • • • •
Walk (or cycle) slowly for 4 minutes Walk briskly for 60 seconds Walk slowly for 4 minutes Walk briskly for 60 seconds Walk slowly for 4 minutes
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How to Exercise: cool down • Conclude with a cool down period of slower exercise / walking to return to a lower level of exercise exertion.
When to stop – warning signs • • • • • • •
Chest pain Nausea Dizziness or blurring of vision Excess fatigue Extreme shortness of breath Leg cramps Pain or pressure in the neck or jaw
Special Recommendations
Hypoglycemia • A serious problem that may occur for diabetics who exercise. • Monitor blood glucose before and for several hours after exercise, hypoglycemia may be delayed • Signs & Symptoms of Hypoglycemia: Feeling faint, drowsiness, hand tremors, sweating, dizziness, excessive hunger, fatigue, irritability, difficulty walking well.
When to slow down • Slow down if you feel you are exercising more than a 7 on the scale (very severe). • Slow down if you are breathing too hard to be able to talk. • Reduce your exercise time and or exertion level if you do not feel fully recovered 1 hour after exercise or if you experience prolonged muscle discomfort.
Myth 3: Diabetic patients are limited in their ability to exercise due to risk of complications Special Considerations for Patients with Diabetes: • Autonomic Neuropathy- during exercise may cause blunted BP response (chronotropic incompetence), silent ischemia may occur • Monitor perceived exertion in addition to HR and BP pre/post exercise
Special Recommendations
Peripheral Neuropathy • Inform patients of the importance of protecting and inspecting feet regularly to check for injuries. • Wear protective footwear when exercising both on land an in the water.
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Special Recommendations
Hyperglycemia
• A concern for individuals who are not in glycemic control • Symptoms are thirst, polyuria, weakness, fatigue, acetone breath • Test blood sugars often and refrain from vigorous exercise until blood sugars declining
Special Recommendations
Retinopathy • Exercises that produce high arterial pressures may increase risk of retinal detachment and vitreous hemorrhage. • Avoid heavy lifting / straining, avoid activities that dramatically increase Blood Pressure
3 Pearls to remember and use in your medical practice: 1. Have a discussion about the patient’s Minutes of Exercise per Day at every visit (a new vital sign to monitor and use to evaluate health). 2. Emphasize the importance of increasing intensity of exercise to add health benefit. 3. Advise on how to exercise safely regarding possible diabetes complications and special considerations for diabetics.
Thank you
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Diabetes and Nutrition
Abby Langer, RD May 27, 2015 Advancing the Health of Our Community by being Canada’s Best Community Teaching Health Centre
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Presenter Disclosure • Relationships with commercial interests: None
Pearl: There is No Such a Thing as a “Diabetes Diet” • Diabetes diet used to mean low sugar, low bread, sugar-free items • We now use The Plate Method for all people, regardless of blood sugar levels • Consistency with protein, CHO, and fat at all meals and snacks • No need to give a calorie level – focus on quality of food instead
Myth: Fruit is Bad • Recommendations for fruit are 2-3 servings a day • There is no difference between red and green apples, tropical and non-tropical fruit • No need to cut bananas or any medium/small fruit in half • Serving is ½ cup or 1 medium piece
Pearl: RD Intervention Should Happen Right at Diagnosis or ASAP • RDs are essential to help patients with management of DM • Referrals to RDs are sometimes only made when a problem with BG control arises • RDs should always be a part of the plan with new insulin starts for the CHO piece • Think proactively, not reactively
Myth: Test BG at the Same Time Each Day • Rotating the BG testing time – fasting, 2 hours pre and post meals – can give a better picture of what’s happening during the day • Aim for PC 5-10 mmol if A1C is <7% • Aim for PC 5-8 mmol if A1C is >7% • Goal? No more than 3mmol/L meal rise
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Pearl: Carbohydrates are Fine • Carbohydrates, especially resistant ones, may help stabilize BG • Portion size and consistency are most important – portion size has more impact than the actual food • Please do not put patients on a CHO-free diet, which can be problematic in terms of fat intake and sustainability
Myth: Sugar-Free Foods Are Fine to Eat • Sugar free doesn’t mean low carbohydrate, or that it’s a healthier choice • Eating more WHOLE foods instead of processed junk may help patients get more fiber and less additives • RDs teach patients how to make substitutions for some of their favourite foods without resorting to sugar-free junk
Pearl: ‘White Foods’ Aren’t Horrible (Mostly)
Pearl: Meal Timing is Extremely Important
• Most people counsel diabetics to stay away from ‘white foods’ like white rice, white pasta, and white bread • This can be confusing since:
• Emphasis should be placed on consistency • Limit space between meals and snacks to 4 hours • Emphasis on the importance of not skipping meals
– Many white foods are good for them – Many white foods aren’t much different from ‘brown foods’ such as ‘brown bread’
My Recommendations • 5-7 servings of non-starchy vegetables a day • Moderate-CHO diet - ~90-120g/day • Limit starches at meals to 1 cup • Limit fruits to 2-3 servings a day • Optimal meal timing
Quality of Life Matters • Important as healthcare professionals to realize that – Patient may be overwhelmed – People need to enjoy their food and their lives – Eating habits need to be sustainable – It takes time to change habits – The easiest way to change is little by little – Compassion and understanding go a long way
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Dr Paul Sullivan General Surgeon St Josephâ&#x20AC;&#x2122;s HC
Bariatric Surgery and procedures
St Joseph’s and the Ontario Bariatric Network
Bariatric Surgery and Diabetes
Metabolic Surgery and the future
Historical perspective:
Patients receiving operations to remove part/all of their stomach tended to lose weight after surgery RESTRICTIVE PROCEDURES
Patients receiving operations to remove part of their small intestine had improved patient fatty acid and cholesterol profile - MALABSORPTIVE PROCEDURES
Current practices involve either restrictive or restrictive/malabsorptive techniques
Less pain, quicker recovery, shorter hosp. stay, cosmesis Decreased wound complications, and hernias Decreased respiratory complications Mason 1971 Obsolete Purely restrictive
Technically demanding, specific training Requires special equipment, $$$
Forsell 1993
Gagne 2000
Private clinics
Patient preferred
Purely restrictive
Purely restrictive
Mason 1977
Scopinaro 1996
Laparoscopic 1993
Predominantly malabsorptive
Restrictive/malabsorptive
Selected Bariatric centres
“The Standard”
? metabolic procedure ?
Summary of results worldwide
Comorbidity Type II Diabetes Coronary artery dis. High Cholesterol Sleep apnea Hypertension Depression
% EWL roughly 70% at two years % BMI reduction 35% complication rate 10% mortality rate <.5%
Buchwald,H. Consensus statement 2005
Comorbidity outcomes following bariatric surgery:
Global prevalence of obesity approaches 10% Global incidence up 50% from 1995-2000 Least common in 3rd world – but rapidly rising Most health agencies now rank obesity above smoking as the leading cause of preventable deaths WHO Nutrition Data Banks 2001
%improved or resolved 80-90% 80-90% 96% 93% 88% 55% Albert, M. Clin. Fam. Prac. June 2002
Established 2009 by the Ministry of Health
5 Provincial Bariatric Centers of Excellence: Hamilton Toronto Ottawa London Guelph
Plan is to perform up to 3500 cases/year
Part of Ontario Bariatric Network 1 of 5 surgical sites in U of T bariatric collaborative 100% of pts to come from Sudbury RATC 2 Surgeons with advanced Laparoscopic training Plan to perform up to 250 cases this year
Early 2000 – marked improvement in Diabetic management with bariatric patients Was this because pts involved in multidisciplinary obesity management program? Several RCT’s comparing medical vs surgical programs for diabetic management
Mean Changes in Measures of Diabetes Control from Baseline to 3 Years.
STAMPEDE multicenter US trial Bariatric Surgery vs Intensive Medical Therapy for Diabetes management -3 yr results Prospective Randomized controlled trial 150 pts randomized to Intensive Medical or Surgery plus Intensive Medical arms
Medication Use at Baseline and at 3 Years.
We know it works, at least in the short term
How does it work?
These procedures induce a state of severe calorie restriction immediately post operatively prompting the weight loss
The rapid onset of T2DM improvement does not parallel the degree of weight loss
Not as simple as weight loss and decreased insulin resistance as the effects are noticed very shortly after surgery, before significant weight loss occurs
Multiple hypotheses put forward, actual mechanism still unclear
- upregulation of insulin response and sensitivity? - downregulation of insulin resistance?
The Malabsorptive procedures have an earlier and more profound effect on T2DM
foregut hypothesis
-incretins and ‘anti-incretins’ foregut or hindgut theory
exclusion of the duodenum and proximal jejunum from the transit of nutrients prevents the secretion of a putative signal that promotes insulin resistance and T2DM yet unidentified inhibitory product from the proximal bowel causes metabolic changes (antiincretin)
Rubino etal. Ann.Surg. 2014
Hundreds of gut hormones identified and studied
hindgut hypothesis diabetes control results from the expedited delivery of nutrients to the distal bowel produces a physiologic signal that improves glucose homeostasis Various neuropeptides: GLP-1, GIP, P-YY
Rubino etal. Ann.Surg. 2014
Grehlin effect Gut hormone primarily from fundus of stomach Serum levels increase before meals and decrease after meals Shown to have diabetogenic effects in humans, insulin suppression while increasing blood glucose
Rubino etal. Ann.Surg. 2014
SurgiCal Obesity Treatment Study (SCOTS) trial (UK/US)
Prospective, multicentre, 2000 pts, 10y follow up Weight, mortality, Diabetic results
Now accruing pts
Several centres in the US now have dedicated metabolic surgery programs in addition to bariatric programs Identical operations being performed, but for different indications - currently for refractory nonmorbidly obese diabetics
New operations being trialed
Not up and running in Canada . . . . . . . . . Yet
1983 - American Society of Bariatric Surgeons 2007 - name changed to American Society of Metabolic and Bariatric Surgeons Reflecting a contemporary view on surgery not only focusing on obesity, but other metabolic diseases - particularly T2DM
Living Well with Diabetes Clinical Case Presentation Dr. Donna Arab-O’Brien MD, FRCPc Service Chief, Division of Endocrinology St. Joseph’s Health Centre
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21/05/2015
FACULTY/PRESENTER DISCLOSURE • Faculty: Donna Arab-O’Brien • Relationships with commercial interests: - Advisory Board Participant: Novo Nordisk, Amgen, Sanofi, Merck
Clinical Case 48 yr old female referred to Diabetes Clinic –June 2007 Born South America- in Canada x 15 yrs Married with 2 children PMH: asthma, osteoarthritis, hypothyroidism, obesity Allergies: NKA Lifestyle: Non-smoker, no alcohol consumption, minimal physical activity Family history: Type 2 diabetes -mother, brother
Clinical Case-Cont’d Medications:
Glyburide 10 mg BID Actos 30 mg Levothyroxine 0.150 mg Ventolin
Physical Examination: Wt 108 kg, BP 132/80, Chest mild wheeze, no carotid bruits, acanthosis axillae/neck, no striae, no edema, pulses palpable, skin intact
MITIGATING POTENTIAL BIAS • Potential sources of bias identified in previous slide has been mitigated by lack of favouritism toward individual companies and products.
Clinical Case-Cont’d Diabetes History Gestational diabetes in second pregnancy at age 32 – diet managed Diagnosed Type 2 diabetes age 36-based on lab tests Diabetes education at TWH Diet “controlled” x ? Years Metformin –not tolerated-GI symptoms Progressively increasing weight -108 kg at presentation to clinic
Clinical Case-Cont’d Laboratory investigations: A1c 0.113, Creatinine 75, Egfr >60, LDL 2.89, urine ACR 15.3
What do we do now???
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Clinical Case-Discussion Points 1. 2. 3. 4.
Diet/Exercise/Compliance Medication compliance Achieving A1c target as quickly as possible Therapeutic options
Clinical Case-Discussion Points Diet/Exercise/Compliance : Role of the Primary Care Physician Role of the DEC-DM educators-Dietician/DM Nurse
Clinical Case-Discussion Points Medication Compliance: Identifying barriers to compliance Cost Tolerability Complexity/Convenience Role of Primary Care Physician Role of Pharmacist
Clinical Case – Discussion Points Choosing between therapeutic options Patient factors: degree of hyperglycemia Risk of hypoglycemia Weight considerations Co-morbidities-renal/cardiac Patient preferences/access
Clinical Case –Discussion Points Urgency to achieve A1c targets For each 1% drop in A1c: 21% decrease in any diabetes related complication 21% decrease in diabetes related death 14% drop in MI 37% decrease in microvascular complications
Clinical Case –Discussion Points Agent Issues:
Efficacy/Durability Weight effect Side effects Contraindications Cost/coverage
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Clinical case-Discussion Points Consideration for Bariatric Surgery For obese patients who have failed to achieve targets with optimization of lifestyle and medication who meet criteria bariatric surgery should be a consideration
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4 Annual Academic Achievement Day June 12, 2015 | 1200-1300
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