Dr. Athena Philis-Tsimikas discusses the current standards of care for diabetes treatment.
Back to Symposium Page »
Good morning, everybody. It's my pleasure to be here this morning for our 2020 updates and diabetes management being brought to you from scripts with your diabetes institute. I'm Dr Athena, Phyllis Sinica's I'm the corporate vice president here and very happy to have my co directors with me today of this conference. Dr Samantha Harris and more a row backer. Thank you for that team to help put this on. We have a great agenda for you this morning and we're excited to present it to you. With that, I'm going to just do a few brief course updates. Uh, so you're aware of how the day will flow and then we'll start with the program first. The conference agenda and the course materials can be found on the scripts, Health, CMI, Conference app and on the Livestream event page. The APP is available free of charge for all participants and will be continuously updated during the day and after the course. Today's program is also being recorded and will be available toe access approximately one month after the event. Some live stream details. All the participants will be muted today during the lecture to avoid any background noise for best streaming results, Be sure to close all other Web pages and APS on your computer that may slow down your Internet connection. Be sure to close any VPN or office connections that may slow down your Internet speed. You may submit questions using the Ask a question button on the live feed, and they will be shared with the faculty. If the live video feed freezes, refresh your browser and hit play to resume the video. Okay. Ah, little announcement about our exhibit hall. We are going to have a scavenger hunt. Don't forget to visit the virtual exhibits during the break time. We're very grateful to our sponsors who have helped us put this program on. Download the scavenger hunt chest slit checklist posted at the bottom of the main event page to find each of the images hidden in the various booths. Once you find all those images, email your completion list. Two scripts at med dot e d u. At scripts health dot org's for a chance to win various prizes. Winners will be announced on Friday, November 20th. For our noon symposium, we will have an additional non CMI event supported by Abbott diabetes care from noon to 12 45 it's open toe. Also, no need to pre register again for that one. Networking with colleagues, Use the network with colleagues. Chat board toe. Let us know your name, where you are from your role and connect with other attendees that are here today. You can also find contact information for all attendees, faculty and exhibitors in the mobile conference APP CMI certification. To receive your CMI, you must complete the online course evaluation and be sure to claim your credits. Instructions for taking the course evaluation will be emailed to you early next week. Upon completion of the survey, you will be redirected to your CMI certificate, which you will need to print and keep for your records. The survey will be available for four weeks after the conference faculty evaluation. Please take a moment at the end of the conference to raid our faculty. The link will be in the APP and on the livestream page. It is separate from the main course evaluation. Yeah, and finally supporting companies that have helped us put this on. We'd like to extend an incredibly special thank you to those that are supporting us today. We really wouldn't be ableto put on such a high quality educational program without their support. So thank you, of course, all of you for attending. And we hope to see you next year in San Diego. With that, I believe my announcements for the day are over. But we are going to begin with the first talk of the day so that the first talk is my opening on. Just what? What's the most current standards of care for? 2020 And we usually because we do this conference, usually the beginning of the year. The standards come out every January a little bit later, so you'll be catching up with those now. And it could be that within the next two months will actually have the next standards. We'll see how those change up compared to this year, but there were a few changes this year and and we'd like Thio bring up to date on those before we begin with our keynote speaker. These are my disclosures. Yeah, and we've already done the welcome, but I wanted to show you what these welcomes looked like many times at the beginning of the year when the pandemic. Uh, Kobe Pandemic hit us. And a lot of times this is what we were scrambling for when we were working from home. What I wanted Thio bring to you, though at this point near the end of the year, we are now about 78 months into this pandemic. I really wanted to celebrate all of you and everybody that has really been on the front lines of this pandemic, whether in our hospitals, in our ambulatory care clinics, in so many other environments, Um, really kudos to all of you that have done an amazing, amazing job. So with that, let's begin. We have a full day in our agenda. I'm not going to review each of these, but we will have introductions for each of our speakers as we begin. It's an exciting day. And what are just some of those practical challenges that all of you face in diabetes? It's a complex treatment regimen I seem to control that continues to progress and not not necessarily do well over time. If you're not actively managing it, we have to manage food and weight gain inflexible regimens and stress. Sometimes there's some clinical inertia around and managing hypoglycemia. All of those things are important in the management of diabetes. So to try and help you overcome those, some of our goals of this conference are to provide insights into diabetes from a weight management technology and position provider perspective to share experiences with management of diabetes, distress, diabetes and pregnancy, including some case examples and appreciating the complexities of diabetes in terms of medical management decision making and finally to have an engaging, interactive exchange of ideas and discussions. So what's been happening in the maps of diabetes is here in the United States, and you may remember, in past years these have usually been maps that go from yellow to orange to red. The CDC changed these up a little bit this year, and they're now greens, purples and yellows. So as you go from light blue to dark purple, it means increasing obesity as you go towards yellow. It's increasing diabetes, and as you go towards dark green, it's increasing both obesity and diabetes. So 2000 and four here sort of middle of the road light green, but you can see 2000 and 10 darker purple, darker green and the most recent map that they put out is 2016 and lots of purple and dark green, indicating both obesity and diabetes. This is not surprising. This is something we've all seen before, but the trends definitely continue. The costs are high, with one and four health care dollars in the U. S going for some sort of diabetes care. The estimated cost in 2017 was 327 billion and costing nearly $17,000 per year to take care of someone with diabetes, which is 2.3 times higher than someone without diabetes. So what are the standards of cartel is around a few different things, and I'm going to start with the classifications and the diagnosis of diabetes and how those air defined by the American Diabetes Association. We've always had the classic type one and Type two, which aren't necessarily always that classical because we've seen Type one occur not only in Children but in adults type two Also, maybe not that classical occurring in adults, but also we're finding now in in older Children and adolescents and young adults where it's occurring, there's a lotta, or sometimes known as 1.5 diabetes, 1.5. This is, um, a slowly developing, autoimmune type of type. One usually do have to have Gadd antibodies that are positive for this diagnosis, but it has much slower onset in terms of its diabetes course than type typical Type one diabetes and then maturity onset diabetes of the young. This is a mono genic form of diabetes occurring and usually many members of a family at a very young age under the age of 25 years old. So we've seen those for a while here with the standards of care. Um, in addition to that, they have a special categorization of diabetes in pregnancy. There's again the more classic gestational diabetes that all of us know. But they've also termed for women with type two diabetes going into pregnancy, pre gestational type two and those with type one pre gestational type one. And you'll be hearing more about management of diabetes in pregnancy from Roman near one of the last speakers of the day. But stick around for that because he's gonna be giving us some new insights around this. This staging criteria for Type one came out probably a couple of years ago, now with the A d A standards, but I wanted to remind you of it, because it's important related to some of the offerings we have for people that are recognized in earlier stages. So for type one, for relatives of people with Type one diabetes, you can now get antibodies early on. And we've been doing that here in the United States through a program an N. I. H sponsored program called Trialing Net. And if someone were to go to Google trial met, you could find where you could get blood test locally near you. You don't have to go to a center any longer if that relative has positive antibodies. But his pre symptomatic not yet developing glucose abnormalities they would be categorized in Stage one if you begin to have some disguise senior Stage two and then overt onset of diabetes Stage three. So this is important because if we recognize someone is in Stage one, there are now studies that can be offered to them that might delay or maybe at some point prevent the onset of type one. And what I wanted to share with you is a study that did that was presented um, at the A d A. Not this past year, but the year before, with an agent called to please um AB, which is an anti CD three monoclonal antibody, which declared delays the decline of beta cell function. As you can see here, it attaches this, um, anti CD three antibody attaches to the effect of T cell and can block the beta cell destruction. It had been shown that it could reduce, ah, the delay, the onset in patients recently diagnosed with type one. But in this follow up study out of the trial net, it showed that with a 14 day outpatient course, it is an infusion that you could actually delay the onset of type one diabetes by twice Asl Aung. So instead of within two months where someone would be developing Type one diabetes, it was delayed out to 48 months. So this is really a remarkable uh uh finding, And it didn't happen in all patients with type one. It was really a subset, but it offers hope that there might be a way to slow down that progression. So that's the benefit of identifying these patients early. Okay, One other thing I think I may have shown this in past years, but I also think this one is an important and this Came was published in The Lancet came out of Scandinavian data, which showed, If you take that traditional classification of diabetes, which I just showed you type one lot and type two Onley. About 78% of the population has insulin deficient diabetes, which is seen here in the gray in the blue, and the rest are categorized in this type two diabetes. Whereas if you take the data set that the Scandinavian group used and take six variables, get antibodies age diagnosis B, M I, H B one C and different measures of insulin resistant coma. You can actually now get a number five different types of categorizations and the light blues. There really are the ones that are insulin deficient or complete lack of insulin. The next category are those that fall into more of an obesity insulin resistance type of category, and then the final 40% are mild age related. So this begins to become important because now you might look at the grouping that insulin deficient and think about adding insulin insulin to that category much sooner then you might otherwise, and it's about 25% of the population, whereas in the previous graph you see it's only around 78% that might fall into this. Make you think about that. So I thought this was interesting and something for us to keep in mind. I believe we will be doing more of this as we go forward in the management of diabetes. Okay, diagnostic screening. Just a quick update on this. No one screening is preferred over another between fasting glucose, ugtt and hemoglobin, a one C, and sometimes it's really best to do both of fasting glucose and an HB A one C to capture all those that might have diabetes test all adults beginning at 45 regardless of weight. But if someone is high risk, even if they're asymptomatic, if they're overweight or obese and have more risk factors, you might want to check them sooner. And the A. D. A. Does have a screening paper test that you can give to them, and this could be used to help bears and other things to try and identify people earlier that are at risk. Okay, where are the recommendations and targets for this past year. In terms of weight, at least 5% weight loss should be prescribed for those that are overweight and obese and who are ready to achieve that weight loss. The B M I should be calculated and documented at least yearly. I think this changed. It used to be in every visit, and then this is another big one. Diets that provides some caloric restriction, but different protein carbon fat content are equally effective in achieving weight loss. So ask the patient what they prefer and then allow that to guide you in what kind of recommendations to make. Um, Samantha Harris will be speaking a little bit more about weight loss later on in the day, and we'll touch on some of these topics. But so many of our patients are coming in and asking us about carb restricted diets, keto diets, all these other things. And the recommendation really has changed to allow the patient Thio to choose what type of diet they might want beyond. Physical activity remains pretty much the same. 150 minutes per week, no more than two consecutive days without exercise. Resistance training is okay two times a week. Onda limit that sedentary time psychosocial care was added in 2017. Incredibly important, it's hard to imagine how you can help someone get through with their care of diabetes if they have psycho social issues. If they're experiencing diabetes distress. A recommendation is to add this screening scale for your patients with diabetes. It's just a two questions screen. If positive, you could go on and do the full 17 question survey. And later on the day again, we thought this was important, and we've asked Carla Espinosa to discuss this a little bit further, so you'll be hearing more about that later. A swell. The target for glucose remains. Uh, the general target recommendation is less than 7% pre meals. You can see 80 to 1 30 post meal less than 1 80. And that individualization of targets remains is well, if you're younger, healthier, you could go down to 6 6.5%. If you're a little bit older, with many co morbidity is, you could go 7.5 percent to 8%. But I want to add a caveat here, and I know there are a number of people in the audience that work in clinics where there might be financial restrictions. Other things. If you have a young patient that doesn't have access to test strips and you're putting them on insulin, are you going toe? Have a target of this person of 66 a half percent? And the answer is no. That's not the right situation for that again, a no older person that might be on medications that don't cause any hypoglycemia. Are you going to keep them at 8%? And the answer again is no. You might wanna have that person down at 7% where they're feeling better. So these all have to be taken with a little bit of thought behind them on the targets. But these are the general recommendations at this time. Okay, Where we going with pharmacologic approaches? There were a few things specifically for Type one diabetes that I wanted to mention. Most people with type one should be treated with multiple daily injections. We know that, but just to emphasize it could be Pran deal on basal insulin or a continuous subcutaneous insulin infusion and insulin pump, which nowadays is becoming very sophisticated with all sorts of other connected devices. And you will be hearing more about these types of technologies from David on Who is going to be here later this morning? Um, the other thing, they said very specifically is, if possible, use rapid acting insulin analog. So we know again in some of these financially constrained environments, human insulin regular is definitely a less expensive choice. But in this situation, type one diabetes. If you can prescribe and allow the patient to get rapid acting, this is really a situation where it can make a difference in how they manage their diabetes. And then finally, for type one, um, they have suggested that there should be training to match Randall insulin doses to their carbohydrate intake, their pre meal glucose and their anticipated physical activity. So all the education around this, the time to take to educate patients is important because it could make a difference on once again. There are more and more APS, um, different types of technology that can help people do this. You still have to learn how to count your carbohydrates, but once you do that, there's connected pens. There's APS where you can put this information in. And then it does a lot of the calculations for you. How much insulin is left on board? How much should your next dose be if there is insulin left on board? So So those are some of the specific recommendations for type one diabetes and pharmacology. How about type two? This is the most recent guideline algorithm that has been put out Very complex. Looking at it really is not that complex. When you break it down into three categories of heart disease, those that want to minimize hypoglycemia, you wanna minimize weight gain and minimize, um, cost effect. And Lauren Vincent will be going over these a little bit further to look at the details of this. I just wanted to emphasize something else about this, this guideline for many, many years, and it still has on it. If you see on here in the middle and all these little gray boxes, you progress your therapy. If a one C is above the target, you have set and there has been a lot of discussion around. Ah, if someone is at a target, let's say 6.5% or 6.8% and they have heart disease and their unmet foreman, but not on one of the agents that has been shown to reduce cardiovascular events in the future. And they have a history of cardiovascular disease. Does that mean we don't put them on that agent? So this is a very glucose centric driven guideline. I'm wondering if some of that might change in the future, especially based on this enormous amount of evidence that we now have coming in from different trials showing that there's improvement in cardiovascular disease and heart failure in renal disease. All these other things that might benefit the patients, So this has also had met Foreman for a very long time is the first line agent, and some of those factors may play a role in how these guidelines are made for the future. So we'll have to wait and see what the next ones show. But just keep that in mind. Injectable therapies. This guideline has been cleaned up quite a bit and simplified. It does look, it looks complicated, but this is better. I think again from this, the one thing I wanted to point out right at the very top before starting Basil insulin. If someone is not on a GLP one, they have added in here considered GLP one receptor Agnes in most patients prior to insulin. So just think about it. If that patient looks like they're not doing well in terms of control, if they haven't been yet placed on the GLP one and they are, it's not Contra indicated. Consider that from there on, then the basal insulin and the Pran deal. Insulin recommendations have remained very similar to previous years, just a little bit on hypoglycemia in the past few years. They did change the classifications to a Level one, which becomes an alert value between 54 70 if they're below 50. For this becomes a more critical value. Really needs immediate attention on Ben. Level three remains the severe event that may need help from someone else in order to treat it. What's new in this 80 A 2020 international glue Coogan as a treatment or glue Coogan solution for subcutaneous injection. Both are improvements over what we've had before, where you had to mix up everything in order to give the glue gone. For someone that required treatment, uh, and couldn't eat so This is a really nice edition cardiovascular disease and risk management to finish up. Let's see, um, blood pressure recommendations. These have continuously changed over the years. A little bit higher, a little bit lower. They have remained essentially the same for this year. The goal, systolic and diastolic, is less than 1 40/90 used lifestyle recommendations for a blood pressure above 1 20/80 and pharmacologic therapy for blood pressure above 1 40/90. But you can individualize, especially if someone's 1 30/80. Should you treat them or not? And what was added this year? Thea Marican College of Cardiology has a risk calculator, and they have added in here that you can use that calculator. And if it looks like they're higher risk, you might want to drop their blood pressure a little bit lower than 1 40/90 or 1 30/80 Additional lifestyle recommendations remain the same weight loss, dash diet, moderate alcohol intake and increased physical activity. They have added this guideline for medications. The medications still remain very similar to what we've seen in previous years. ACE inhibitors, a RBS calcium channel, blockers, diuretics and some of the first line agents. We will hear more from Kimberly Harper. Ornithologist who will be here is part of the panel. And still, I'm sure, bring us up to date on some of the latest studies with the SPLC two inhibitors and other agents that really have had a nice effect in preventing the progression of renal disease and then, after a sclerotic cardiovascular disease, dis lymphedema, static Staten Indications the first step evaluate age and risk factors. The risk factors are shown here, and in this update, they have again added the allow us to use the A. C C risk calculator and this, uh, this was not done in previous years. So once again, they're beginning to adopt a little bit of what's going on in some of the other societies and recommendations. They've also said Mediterranean style diets. This has been added a swell reduction of saturated fat and trans fat and increased the dietary omega three fatty acids, viscous fiber plants, Dannell sterols and in take their, uh, this chart is from a previous here, but I liked one thing that they did on this. It really emphasize who should get a staten, and it's really almost everybody. If you're under 40 years old and have no risk factors, that's the only person that maybe doesn't get a Staten. That would be someone. For example, type one diabetes, very lean and young. Um, almost everybody else is going to get a Staten recommendation. And what has been added is when you use that risk calculator if you run in the higher risk categories you might want to add. Is that a mob or PCSK nine inhibitors? If you can't get your LDL down by greater than 50% and the other thing that has been added is to consider Aiko's upend ethel for cardiovascular risk? So these were from those, right? Both of those recommendations were from the Reduce it and the Improve IT Studies that had gone on and reported benefit for both of that. Um, I'd and my Costa penned Ethel. All right, so okay, summarizing our standards of care for our patients. How do we do that? And we have this page. It's in our basics of diabetes handbook. It really outlines for the patient many of these standards that are expected Um, what's nice about this is they could take this to their physician. They can say, What's my target for my A. One c my blood pressure, my cholesterol. They can write it down. They can track it and see how they're doing. And if they're meeting what those targets are, it also puts a little reminder in here your eye exam, foot exam, flu shot, pneumonia vaccine and the other vaccines. Have you had those done? And have you had your urinary albumin checked as well? So with that, it's been a quick summary. But we know that diabetes rates and costs continue to skyrocket nationally and internationally. Consider when you're looking at your patients. Some of the newer classifications for diabetes diagnosis to more accurately define and treat the type of diabetes they have focus on screening to identify those at high risk. If we can catch them early, we might be able to do something better about them and maybe look for diabetes to stress. If it's around. Lifestyle changes include dietary choices, physical activity and which are important in diabetes care, and then finally individualized your targets. Whether it's for glucose, a one C blood pressure and lipid lowering indications all important in taking care of these complex patients with diabetes. So with that, I want to thank you for being here for starting off our our meeting with us. And cheers to you. The new year is definitely gonna be a better one than this year. And this one has certainly not been bad, although absolutely challenging, I would say.
