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The Big 3

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

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The Big 3

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  1. The Big 3 UIM Resources

  2. 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

  3. Chronic diseases

  4. Quality Measures

  5. 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 lisinopriland 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”.

  6. Case studyWhat is this patient’s A1C goal? • <6% • <7% • <8% • <10%

  7. 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%.

  8. 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.

  9. 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.

  10. 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? • Walgreen’s • Walmart • Harris Teeter • CVS

  11. Free Oral Diabetes Med (metformin and XR, glipizide) • Harris-Teeter • Publix • Bi-Lo

  12. Case Study, cont.According to the 2013 ADA guidelines, how often should he be checking fingerstick glucoses at home? • Every morning fasting • 2-3 times per day rotating times • Only when symptomatic • Every evening before bed

  13. 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. ”

  14. What is this patient’s BP goal? • Systolic <120 • Systolic <140 • Diastolic <80 • Diastolic <90 • 1 and 3 • 2 and 3

  15. 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)

  16. Lifestyle Modification and Hypertension • What diet recommended by JNC-7 has been shown to effect reductions in blood pressure similar to single drug therapy? • Weight Watchers • Atkin’s diet • DASH diet • Southbeach diet • Jenny Craig

  17. 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

  18. JNC-7 Treatment • In general, what should be the first choice of medication class for most patients with Hypertension? • ACE-I • Beta blockers • Calcium channel blockers • Thiazide diuretics • Spironolactone

  19. 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.”

  20. Case StudyWhen would you bring the patient back to be seen? • 1 month • 3 months • 6 months • PRN

  21. JNC-7 • “Once antihypertensive drug therapy is initiated, most patients should return forfollow-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.”

  22. Adherence • In patients with chronic medical conditions, what percent is non-adherent after 1 year of treatment? • 10% • 20% • 30% • 50% • 70%

  23. 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.”

  24. 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? • <5% • 5-10% • 10-20% • 20-30% • 30-40% International Journal of Obesity (2011) 35, 1063–1070; published online 2 November 2010

  25. 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

  26. NHANES, cont. • What percentage of overweight patients had ever received a diagnosis of being “overweight” from a health care professional? • 10% • 20% • 30% • 50% • 90% International Journal of Obesity (2011) 35, 1063–1070; published online 2 November 2010

  27. 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

  28. 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? • 5% • 10% • 15% • 20% • 25%

  29. 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 associatedrisk factors.”

  30. 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

  31. 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

  32. 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)

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