Learning and Earning with Gateway Professional Education CME/CEU Webinar Series. Diabetes Update July 6, :00pm 1:00pm

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1 Learning and Earning with Gateway Professional Education CME/CEU Webinar Series Diabetes Update July 6, :00pm 1:00pm Jennifer Pennock Holst, MD Endocrinology, Diabetes & Metabolism AHN Center for Diabetes Stacey Bethea Senior Clinical Quality Management Analyst Quality Improvement, Gateway Health

2 Shout Out! Washington Health System Washington, PA CTC: Carol Rhodes To arrange for a group viewing and lunch at your practice for a future webinar, please contact your Gateway Clinical Transformation Consultant (CTC). 2

3 Today s Presenters: Jennifer P. Holst, MD Medical Director, AHN Diabetes Support Initiative for Primary Care Stacey Bethea Senior Clinical Quality Management Analyst Quality Improvement Gateway Health 3

4 Outline Management of Pre-diabetes Glycemic Control in Diabetes Review older and newer classes of drugs Review diabetes treatment guidelines Review statin and hypertension guidelines Things we are not discussing today: Smoking cessation Aspirin Management of obesity

5

6 Intervention for Pre-diabetes N Engl J Med 2002; 346: February 7, 2002DOI: /NEJMoa012512

7 Diabetes Prevention Program CDC and YMCA rolling out nationwide 1 year program, education, support, coaching

8

9

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11 Number of Classes of Antihyperglycemic Agents History of Antihyperglycemic Agents SGLT-2 inhibitor Bromocriptine-QR Bile acid sequestrant DPP-4 inhibitor 8 Amylin GLP-1 RA Intermediate-acting insulin Phenformin Sulphonylurea Glinide Thiazolidinedione Human insulin Metformin Basal insulin analog α-glucosidase-i Rapid-acting insulin analog Soluble insulin Page 11 UGDP, DCCT and UKPDS studies. Year

12 Mechanism of action Page 12

13 Oral Antihyperglycemic Agents for Type 2 Diabetes Class Secretagogue Agents Sulfonylureas Glinides Biguanide α-glucosidase inhibitor Bile Acid Sequestrant Thiazoladenedione (TZD) DPPIV inhibitors SGLT-2 Inhibitors Metformin Acarbose, miglitol Cholesevelam Pioglitazone, rosiglitazone Sitagliptin, Saxagliptin, vildagliptin linagliptin, alogliptin Dapagliflozin, canagliflozin, empagliflozin Page 13

14 Injectable Antihyperglycemic Agents for Type 2 Diabetes Class GLP-1 analogs Agent Exenatide Liraglutide Abiglutide Delagludite Amylin analogs Pramlintide Insulin basal/bolus/pumps

15 Metformin Major effect is to decrease hepatic glucose output Increases insulin mediated glucose utilization Lowers A1C by about 1.5% FDA revised its labelling of metformin previously contraindicated women 1.4 mg/dl and men 1.5 mg/dl new labeling contraindicated egfr <30 ml/min initiation not recommended egfr ml/min if egfr falls below 45 ml/min, revisit risk/benefit

16 Insulin secretagogues Sulfonylureas Long acting Taken once or twice a day Main effect is on fasting glucoses The basal insulin of pills Meglitinides Short acting Taken with meals Main effect is on postprandial glucoses The bolus insulin of pills

17 Sulfonylureas Most widely used drug in treatment of type 2 diabetes Mechanism Inhibition of ATP-dependent K channel in pancreatic beta cells Leads to calcium influx and insulin secretion Lowers A1C by about 1-2% Hypoglycemia is the most common side effect Highest risk of hypoglycemia is with glyburide Higher risk in those with renal insufficiency, undernourished

18 Thiazalodenediones Mechanism Increase insulin sensitiviity in adipose, muscle, liver Activate PPARs to regulate gene expression A1C lowering % decrease Side effects Weight gain Edema Fracture Contraindications Heart failure Low bone mass

19 DPPIV inhibitors and GLP-1 Analogs Incretin effect

20 * * * * Incretin Effect * * * Page 20

21 Page 21 GLP-1 secreted upon the ingestion of food

22 DPPIV inhibitors Sitagliptin, Saxagliptin, vildagliptin, linagliptin, alogliptin DPPIV is the enzyme that breaks down incretin hormones A1C reductions % Side effects No hypoglycemia No weight gain, or weight loss increase in URI, UTI frequency Hypersensitivity reaction Possibly increased pancreatitis frequency Page 22

23 GLP-1 analogs Mechanism Acts on GLP-1 receptor A1C lowering % Side effects Hypoglycemia Nausea Possibly pancreatitis Possibly renal failure Contraindications GFR less than 30 gastroparesis

24 Page 24

25 Page 25

26 SGLT-2 inhibitors

27 Do any diabetes treatments reduce risk of cardiovascular events?

28 Metformin may reduce cardiac risk From the UKPDS study A subset analysis was done looking at 342 obese patients with type 2 diabetes treated with metformin versus 951 obese patients with type 2 diabetes treated with a sulfonylurea or insulin. The metformin group had less all-cause mortality and stroke. UKPDS 24, Lancet, vol 352, p ,1998

29 Pioglitazone may reduce risk of MI PROactive study Prospective, randomized, controlled trial 5238 patients with type 2 diabetes and evidence of macrovascular disease. Pioglitazone versus placebo in addition to other glucose lowering drugs. The pioglitazone group had lower A1C (0.5%) lower BP (3mm), lower TG(13%), higher HDL (9%), and higher LDL (2.3%) Dormandy, PROactive study, Lancet, vol 366, pp

30 Proactive study continued Dormandy, PROactive study, Lancet, vol 366, pp

31 EMPA-REG OUTCOME Trial design Placebo (n=2333) Screening (n=11531) Randomized and treated (n=7020) Empagliflozin 10 mg (n=2345) Empagliflozin 25 mg (n=2342) Study medication was given in addition to standard of care. Key inclusion criteria: Adults with type 2 diabetes and CV disease (heart attack, stroke, etc.) HbA1c 7 10%; egfr 30 ml/min/1.73m 2 (MDRD) 1 outcome = 3-point MACE (CV death, non-fatal MI, nonfatal stroke) CV, cardiovascular; BMI, body mass index; egfr, estimated glomerular filtration rate; MDRD, Modification of Diet in Renal Disease. Zinman B et al. N Engl J Med 2015 [Epub ahead of print]. 31

32 Empagliflozin Reduces Cardiovasculr Death Zinman B et al. N Engl J Med 2015, published on-line, , DOI: /NEJMoa

33 Patients with an event (%) LEADER trial: Primary Outcome First occurrence of CV death, nonfatal myocardial infarction, or nonfatal stroke in the time-toevent analysis in patients with type 2 diabetes and high CV risk Hazard ratio, 0.87 (95% CI, ) P<0.001 for noninferiority P=0.01 for superiority 10 5 Placebo Liraglutide Months since randomisation Liraglutide Effect and Action in Diabetes: Evaluation of cardiovascular outcome Results (LEADER) trial Page 33 Adapted from: Marso SP et al., NEJM 2016

34 Primary Risk Factors for CVD: Treatment Goals Hyperglycemia FPG / preprandial glucose PPG A1C mg/dl <180 mg/dl <7%, or lowest possible without unacceptable hypoglycemia Hypertension Blood pressure <140/80 mmhg, or further lowering if tolerated by patients Dyslipidemia LDL HDL Triglycerides <100 mg/dl, patients with diabetes <70 mg/dl, very high risk patients with diabetes and CVD >40 mg/dl, men; >50 mg/dl, women <150 mg/dl A1C = glycated hemoglobin; CVD = cardiovascular disease; FPG = fasting plasma glucose; HDL = high density lipoprotein; LDL = low density lipoprotein; PPG = postprandial plasma glucose. AACE Algorithm 2016 American Diabetes Association, Diabetes Care 2016;39 (Suppl 1).

35 Things to remember Refer to lifestyle intervention for your patients with prediabetes Remember lifestyle intervention for patients with diabetes Start with metformin, and add other agents if needed

36 Diabetes HEDIS Measure and Initiatives

37 Statistics 1 Diabetes is one of the most common, costly, and preventable of all health problems The $386 million in medical spend for this diabetic population accounted for 28.1% of the total medical spend for all Gateway members during the same time period As of May 31, 2017, Gateway Health Plan had 37,999 current members identified as having diabetes Gateway Health s diabetic members account for 43,442 ED visits

38 Who are Gateway s diabetic members: An analysis of the population revealed that 61% of the diabetic population are females and 60% are classified as Caucasian Just under 55% of the diabetic population were in Medicare, while just over 45 % of the population were in Medicaid plans. 38

39 Comorbidities in Gateway s Diabetic Population: Hypertension is the most prevalent comorbidity in the diabetic population with 77.9% of the population having hypertension Lipid disorder and depression were the second and third most prevalent at 65.6% and 45.2%, respectively Acute cerebrovascular disease had the highest readmission rate at 43.6% 39

40 2017 GPE Diabetes PROGRAM COMPONENTS $20 Eye Exam $20 Nephropathy Tx $20 HbA1c < 9 1 One incentive payment per member per year 2 One incentive payment per member per quarter 3 Additional $5 for electronic submission 40

41 Current Diabetes Initiatives Inovalon Member Outreach Diabetes Report Card/Care Plan Diabetes & Cardiac Workgroup Eliza 2017 Preventive Health program comprised of IVR/ /SMS Includes CM transfer for barrier/sdoh assistance Eliza 2017 Gap Closure Program comprised of one IVR call with transfer to Eliza live agent for appointment scheduling Diabetes Transformation Project w/ahn & HM HEC: High HbA1c AA Campaign HEC: Analysis of High HbA1c Campaign 41

42 Current Diabetes Initiatives Member Newsletter: Diabetes Care Provider Newsletters: highlighting diabetes care, current initiatives, and incentives Saint Vincent Partnership: Gap Closure Collaboration American Heart Association Collaboration- Annual Power of Laughter Health Workshop AHN Diabetes & Endocrine Centers Collaboration Gateway & Medical Society Collaboration Provider Tip Sheet: Diabetes HEDIS Measure and Qualifications of Care Screening Days Diabetes Gap Closure Blitz Call Campaign Goodness Reward by Gateway- member outreach and incentive program 42

43 Access slides by navigating to: Provider>Provider Resources> Educational Tools>What s New (CME credit only for enrolled participants in live webinar) 43

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