Activity Transcript

John Anderson, MD: Hello, I'm Dr John Anderson, and I practice Internal Medicine and Diabetes at the Frist Clinic in Nashville, Tennessee. Welcome to this program titled, "Comprehensive Cardiometabolic Disease Management: From Screening to Management & Monitoring." Today I will review strategies for comprehensive screening for and managing cardiometabolic diseases and also highlight the increasing importance of primary care's role in both identifying and managing these interrelated disease states.

Why is screening important? Well, those of us in the primary care world are on the front line of management of all of our patients. We've moved quite a bit from the acute care model of the 1950s, '60s, and '70s to the chronic disease model, so that most of us in primary care, while we are busy handling complaints that come in every time with a patient visit, 70% of what we do is managing chronic diseases. And therefore, if we're the ones on the front line of care, if we're the ones managing these chronic diseases, we're the ones to whom it falls to do the screening for our patients and to pick up these chronic diseases as early as possible.

We also know that statistics are somewhat alarming for chronic diseases in the US. Nearly 60% of adults in the US have a chronic disease, and 40% have multiple chronic diseases. Think about your practice. How many of your patients just have type 2 diabetes? I'm looking at my practice and the people I'm seeing today, and not many. These patients have type 2 diabetes, chronic kidney disease, diabetic retinopathy, neuropathy, obstructive sleep apnea, back complaints, and osteoarthritis. They may have nonalcoholic fatty liver disease. So, we have to be fairly adept at managing all of these. We know that [for] those patients with type 2 diabetes, chronic kidney disease, hypertension, and fatty liver disease, cardiovascular disease is still the leading cause of death for these individuals. Therefore, it's not just about glycemic management anymore. It's also about reducing risk for cardiovascular disease. We also know that patients with chronic kidney disease and diabetes have a much higher likelihood of dying of a cardiovascular death than they do of progressing to end-stage renal disease and dialysis. And current estimates are that if you screen the patients properly, if you're looking at your patients with type 2 diabetes, as many as a third of those patients will have some form of chronic kidney disease. Despite the improvements over the last 25 years with statins and RAS inhibition and antiplatelet agents, patients with diabetes are 2 to 4 times more likely to have or die of a cardiovascular event.

When we talk about screening, what do we need to do? Well, you need to know your patients. "Does this patient have hypertension? Does this patient have dyslipidemia? Is it a LDL cholesterol issue? Is it a high triglyceride? Is it both?" "What is this patient's BMI? Is obesity and overweight an issue? What are their lifestyles? Is this a person who leads an active lifestyle? Is this someone who sits at a computer terminal and is very sedentary? What are their smoking and alcohol habits like?" Again, assessing the importance of our aging population, "What's their frailty?" Because not all 75-year olds are alike. We have 75-year olds that play tennis. We have 75-year olds who are extremely frail and have difficulty with ambulation. And we also have to look at, "What are the modifiable vs non-modifiable risk factors?" The American Diabetes Association in its Standards of Care talks a lot about modifiable vs non-modifiable. You can't modify age, ethnicity, or family history, but you can modify things like weight, and alcohol habits, and smoking, and exercise, and diet. We always want to look at our patients when they come in for a visit, "What can we change? What can we help them improve upon that might help manage this chronic disease?"

We also need to listen to our patients. And when I say listen to our patients, that means give them time to tell us what they need. And one of the things I think it's been pointed out in motivational interviewing is give our patients permission to fail. One of the great things I hear is that adherence is a big issue when you've got multiple medications, but maybe ask your patient, "What's the most difficult thing about managing your diabetes? What's the most difficult thing about taking all these medications?" Give them permission to say that "Maybe I can't afford all of these and we need to find a less expensive alternative." Giving our patients permission to tell us their problems instead of just a cut and dry visit about what their HbA1c and blood pressure looks like.

The other thing that we talk to our patients a lot about is they should be prepared for their visit. If you've got somebody with type 2 diabetes, they need to bring their glucose finger sticks in. If they've got a CGM, I always want them to download the values before they come in. I want them to come in with their questions. I want them to come in with their concerns, but for as much as we ask our patients to do it, we in primary care need to be doing the exact same thing. Before you walk into that exam room to see that patient, "When was their last HbA1c? How long has it been since they've been here? Is it time to do a lipid profile, a UACR? Is it time to check an eGFR, a mammogram, PSA, colonoscopy screening, well woman exams?" But especially in the chronic disease category, "What lab [value] do we need to be looking at? What lab [value] was abnormal the last time they came in and what were our plans on doing something about it? Was a new medication or therapy added?" And in addition, let's go back and before we walk in that exam room, know what the issues were at the last visit, so we can refresh ourselves and be able to discuss that with the patient. Now, that sounds like a lot, but it's not. It's 30 to 45 seconds of quickly looking at all of that before you walk in. So both provider and patient should be prepared for the visit.

Let's talk about a couple of the most common things we see in these people with chronic disease, in particularly with type 2 diabetes, and that is chronic kidney disease. It's a whole new area now because we have 2 types of therapy to benefit our patients with type 2 diabetes and CKD, so we need to do a complete screening for chronic kidney disease, and that starts with a UACR, urine albumin-to-creatinine ratio, which is the spot urine choice of tests to do, in addition to the eGFR. We've always been good about getting CMP and BNPs and pretty much knowing our eGFR; studies show that over 90% of us in primary care practice are paying attention to that, but the UACR may precede a decrease in function that you may see evidence of albumin in the urine, which is an early indicator of kidney damage, long before you see a decrease in eGFR. And it's that time we want to be catching our patients early in their disease course. And one of the things that I think has become very popular to talk with our patients about is the KDIGO heat map, the Kidney Disease Improving Global Outcomes heat map that can help guide treatment and referral. And what you see here is on the Y axis is the eGFR going from normal or high grade and equal to 90, all the way down to kidney failure, less than 15 on the left. And then on the horizontal X axis, you can see the persistent albuminuria with the description arranged from less than 30 mg/g, which is considered normal, to moderately increased, 30 to 300 mg/g and severely increased. And what you can see here is that there are places where you have green is good to go, yellow is caution, orange is significant risk, and then the red is severe risk. You might have somebody with a mildly decreased eGFR between 45 and 59 and at 3A, but if they have over 300 mg/g of protein in the urine that they're spilling, they're at severe risk. And you might consider in that case, referring them to a nephrologist. So you see it's important, if we're really going to treat chronic kidney disease, that we understand how to screen for it early on. And that testing should start with the diagnosis of type 2 diabetes.

The other thing is heart failure. Again, most of our patients who have chronic ongoing heart failure are under the care of a cardiologist, but who's going to make that diagnosis early on? You have a female patient come in, perhaps she's overweight, she's a little short of breath, she's very sedentary, she's got a little swelling in her legs, it's really easy to dismiss that. "Well, she's out of shape. And of course, her legs are a little swollen. She's on amlodipine, or she's got some venous insufficiency," but it's really important when we get those opportunities to ask those questions that we pay attention. Because some studies will show that in primary care we're missing heart failure a lot and not picking it up as early as we could because it doesn't take a lot to listen to someone's lungs, ask questions, do a thorough interview, ask about orthopnea, swelling, shortness of breath, and to order a proBNP and/or an echocardiogram. And it is that kind of thing that will lead us to get them to the cardiologist and be able to engage in the standards of care for heart failure. The 2013 ACCF/AHA guidelines show the risk for heart failure. It's important to be screening these patients when they're still stage A, still stage B, before they progress to stage C and stage D and keep them out of the hospital and keep them from going into recurrent heart failure. In primary care, we're looking at lipid panels.

I haven't talked a lot about nonalcoholic fatty liver disease, but we have FibroScan that can be done. I know that our group of GI specialists, who’s part of our clinic, has this. You can get a FIB-4, which is a test that tells you about how much fibrosis this person may have in the liver. You can get a FIB-4 score based upon the patient's age, their ALT, AST, platelet count, and we need to be doing more of that. We are yet to have an FDA-approved product specifically to treat NAFLD, but there are some secondary outcomes in patients who have had significant weight loss with GLP-1 receptor agonists and other agents where this may prove beneficial in the near future.

So, you've made the diagnosis, you've done this screening. Should I treat, should I refer? Again, most of us can do most of this in our office without referring necessarily at early stages to specialists. For example, with type 2 diabetes, we know about all the therapies we have to offer. We can get help with diet and exercise. Nutritional specialists, use our CDCES experts.

Medical therapy for CKD and type 2 diabetes requires that you maximize RAS inhibition with either an ARB or ACE inhibitor. Use metformin if eGFR is greater or equal to 30, but now the 2 new pillars of therapy are SGLT2 inhibitors, which have been shown to be beneficial in decreasing the rate of progression of CKD in patients with type 2 diabetes and have cardiovascular benefits. We're also seeing the SGLT2 inhibitors are helping with patients with CKD who do not have type 2 diabetes in terms of progression of chronic kidney disease. The new nonsteroidal MRAs, mineralocorticoid receptor antagonists and specifically finerenone in the studies of FIDELIO-DKD and FIGARO-DKD, have shown to reduce cardiovascular events and prevent progression of their chronic kidney disease. So unlike 24 years ago, and all we had was RAS inhibition, we now have the ability to try to modify our patients' risk factors and improve their quality of life for many, many years. This slide looks at the KDIGO executive conclusions looking at practical guide to initiating SGLT2 inhibitors. The biggest side effect or potential is genital mycotic infections. They're generally well-tolerated. You can anticipate an acute drop in the eGFR, which is usually not a reason to stop the SGLT2 inhibitor because it's a prerenal effect.

With heart failure, we want to talk about weight, salt restriction, but the 4 pillars of therapy that we know about are RAS inhibition, and in particular an ARNI, which is a neprilysin inhibitor and an angiotensin receptor blocker combination. Beta blockers, particularly vasodilating beta blockers, a nonsteroidal MRA, and an SGLT2 inhibitor. When you see somebody with early onset of heart failure, particularly if there's a reduced ejection fraction, this is the way we need to be thinking, and of course, comanaging these patients with our cardiology colleagues.

There was a study done in Europe quite some time ago that showed if you took a good physical and history from a patient, and you did an EKG and you did an echocardiogram, in this large European cohort, it was obvious that about 30% of the time primary care was missing early heart failure. So again, it goes back to the importance of what we talked about earlier, which is screening these patients. And in managing hyperlipidemia, we have high intensity statins, we now have PCSK9 inhibitors, we have ezetimibe. And we also have new agents that are injectables for triglyceride-lowering and other omega-3 fatty acid prescription medications that lower triglycerides as well. And again, we need to know when to refer to our cardiology colleagues or refer to a lipid specialist if we're uncomfortable in writing some of these medications ourselves.

The other part of this, as a primary care provider, is "What role do I play?" Well, we are the ones at the center of these patients’ care. We have to be in communication with the endocrinologist, the nephrologist, the cardiologist, maybe the CDCES expert, the dietitian, the pharmacist, but we are at the center of it. About 34.2 million people in the United States have diabetes. That's about 1 person in every 10 people, but there's only about 8500 endocrinologists, half of whom don't do diabetes. The math doesn't work if everybody with diabetes had to see an endocrinologist. So we have to take upon the burden. And in some of our more challenging patients, that's what we need to do is be in concert with the endocrinologist. There's only about 9,000 nephrologists in the country, therefore they don't have the time nor the resources to see all the people with early CKD. So we need to know how to screen and treat it. And there's about 33,000 cardiologists, but many of them are highly specialized in what they do, whether they're interventionists, whether they're electrophysiology experts, whether they're heart failure experts. But if you look at the primary care world, that's family medicine, internal medicine, nurse practitioners and PAs, there's about 490,000 of us. It just makes sense that we become the experts in disease management and screening for these patients.

There's no question that in primary care we've got a lot to do. We're managing the whole patient. We're managing their acute care, but we're also managing their chronic care. And we have to be organized and good at doing it with this surge of new information, new therapies, new pillars of therapy for heart failure and CKD and management of type 2 diabetes, and hypertension and lipids. It sounds like a lot to do with every single patient, but we're seeing these patients with chronic disease several times a year. You don't have to accomplish everything with every visit, but you have to have a system in place for making sure you're hitting those highlights that you are responsible for, for this patient's overall care. We also know that in primary care, we're burdened with a lot of things we never thought we'd have to do, which is prior authorization for medications, multiple phone calls, nonmedical switching in January and February that have just come about at the beginning of the year, where all of a sudden medicines are no longer on their formulary. There's no question. It creates tremendous confusion and frustration in the primary care office, but it's still something we really need to do for our patients. I'm willing to spend the time in, my staff is willing to spend the time trying to get them covered as much as possible.

I hope this has been helpful to you. It's fun being a primary care provider and being on the front lines of these patients' lives, but it's also a daunting responsibility in being able to implement and incorporate new therapies as they come available. Thank you for participating in this activity. Please continue on to answer the questions that follow and complete the evaluation.

This transcript has not been copyedited.