Jeffery Davies, DO, MPH, FACOEP ACOEP Chicago, IL October Your DM patient is ready for discharge, now what?

Transcription

1 Jeffery Davies, DO, MPH, FACOEP ACOEP Chicago, IL October 2018 Your DM patient is ready for discharge, now what?

2 Financial Disclosures None

3 Objectives 1. Understand follow up patterns/capability of patients discharged from ED 2. Become familiar with newer types of diabetic medications, their use and side effects 3. Be able to formulate a good treatment plan for your diabetic discharged patients 4. Realize potential complications that can occur from use of newer diabetic medications

4 Question? What percentage of your patients that you see in the emergency room follow up with their primary care provider/clinic?

5 That was then Shlomo, Vinker et al. (2004) Primary care follow up of patients discharged from the emergency department: a retrospective study 359 ED visits and followed them Found that about 50% of primary care physicians had a discharge letter from the ED in the patient s file Follow up visit was only documented in 31% Neither discharge letter nor follow up visits was documented in 43% of the files

6 Question? How much does insurance affect ability to follow up and what time period do these patient s follow up?

7 This is now Shih-Chuan Chou et al. (April 2018). Annals of Emergency Medicine Volume 71, Issue 4, Pages men posed as discharged patients (secret shoppers) from the ED. Called 53 New Haven, CT practices to arrange follow up with local clinics using a script Each practice received 6 scripted calls from each caller during an 8 month period reflecting all possible scenarios based on 3 insurance types: Medicaid, state exchange and commercial insurance. Primary outcome was proportion of calls obtained an appointment in 7 days. Secondary outcomes included overall appointment rate and appointment wait time

8 Results 604 calls completed 7 day appointment rate was 30.7% Commercial- 35.7% (7 days), 77.8% (overall) Medicaid- 25.5% (7 days), 53.5 % (overall) State Exchange 30.9% (7 days), 73.4% (overall) Conclusion For patients without established primary care, obtaining timely follow-up after acute care in the ED is difficult, particularly for Medicaid beneficiaries

9 Diagnosis 2016 ADA Update- Refresher All adults begin testing at 45 y/o Obese patients with one more risk factors should be screening at any age No one test is preferred over other Random glucose > 200 mg/dl Fasting glucose greater than 126 gm/dl or greater after no caloric intake of at least 8 hours Two-hour oral glucose tolerance test (OGTT) of 75 gm with glucose greater than 200 mg/dl Studies have shown that compared to Fasting and A1C- OGGT diagnoses more people with DM A1C levels >6.5% or greater

10 ADA Updates Women and men 50 y/o and older who do not have risks of bleeding should take low lose ASA (Age reduced in women from 60 y/o to 50 y/o) ASA not recommended in people younger than 50 y/o that are low risk, clinical judgement for higher risk patients in this age group RCT of simvastatin vs simvastatin/ezetimibide- ADA now recommends combination for reduction in major adverse cardiovascular events for those that can tolerate only moderate-dose statin

11 Specialty Recommendations Do not recommend daily home finger glucose testing in patients with type 2 diabetes mellitus not using insulin- Society of General Internal Medicine Avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia- The Endocrine Society/American Association of Clinical Endocrinologists

12 Old School Oral Diabetic Medications Alpha-glucosidase inhibitors- Miglitol (Glyset), Acarbose (Precose)-Inhibit enzyme at intestinal brush border; slow absorption of carbohydrates Biguanides- Metformin (Glucophage)- Decrease hepatic glucose production; increase insulin sensitivity peripherally; and decrease intestinal absorption of carbohydrates Bile acid sequestrants- Bromocryptine Mesylate (Cycloset)- reduces LDL cholesterol and improves glycemic control D-phenylalinine Derivatives- Nateglinide (Starlix)- stimulates β-cells insulin production

13 Old School Oral Diabetic Medications Meglitinides- Repaglinide (Prandin) - Close potassium channels in β-cells; stimulate release of insulin from the pancreas Sodium-glucose cotransporter 2 inhibitors (SGLT2)- Lower renal threshold for glucose and reduce reabsorption of filtered glucose from tubular lumen; increase urinary glucose excretion Sulfonylureas- Glyburide (Diabteta/Micronase), Glipizide (Glucotrol), Glimepiride (Amaryl) - Bind to potassium channels in β-cells; stimulate release of insulin from the pancreas Thiazolidinediones- Rosiglitazone (Avandia), Pioglitizone (Actos)- Increase hepatic glucose uptake; decrease hepatic glucose production; increase insulin sensitivity in the muscle, adipose tissue

14 New School Oral Diabetic Medications Dipeptidyl-peptidase-4 inhibitors (DPP4)- Sitaglipin (Januvia), Saxaglipin (Onglyza), Linaglipin (Tradjenta), - Increase glucagonlike peptide-1; increase insulin secretion from β-cells and decrease glucagon secretion from α-cells in the pancreas Glucagon-like peptide-1 (GLP-1) receptor agonists- Increase insulin secretion from β- cells and decrease glucagon secretion from α-cells in the pancreas; suppress hepatic glucose production; delay gastric emptying

15 Injectables GLP-1 Receptor agonists- Exenatide (Byetta), Liraglutide (Victoza)- increase the level of incretin hormone, resulting in enhanced insulin secretion and reduced glucagon secretion in a glucose dependent manner. Amylin Mimetic- Primlintide (Symlin)- Mechanism unknown; decreased post prandial glucose, suppresses glucagon secretion, slows gastric emptying similar to GLP-1 agonists.

16 Trials- Just the facts UKPDS 33 - Multicenter RCT comparing sulfonylureas, insulin compared to diet alone intervention in 3,867 participants with newly diagnosed type 2 diabetes mellitus; mean age = 54 years Results- Treatment reduced the risk of microvascular end points by 25%; reduced mortality occurred with improved blood pressure and lipid control but not glycemic control Clinical Contributions: Blood pressure and lipid control significantly reduce cardiovascular mortality rates in patients with diabetes Tight blood glucose control reduces retinal microvascular complications but not other outcomes

17 Trials- Just the Facts UKPDS 34 - Randomized embedded trial comparing metformin vs. dietary intervention in 753 participants with newly diagnosed type 2 diabetes; BMI at randomization > 120% of ideal. Results- 36% reduction in all-cause mortality with metformin, and 42% reduction in diabetes-related death vs. conventional therapy Clinical Interventions Among overweight patients with T2DM, metformin reduces the rate of DM related complications and all cause mortality when compared to diet alone or any early-generation antiglycemic agents

18 Just the Facts Diabetes Prevention Program - Multicenter RCT comparing metformin, placebo, and intensive lifestyle intervention, which included 150 minutes of weekly exercise and a goal of 7% weight loss 3,234 participants at least 25 years of age with BMI 24 kg per m 2 ; fasting glucose level = 95 to 125 mg/dl; two-hour post glucose load = 140 to 199 mg/dl Results: Average weight loss: Placebo: 0.1 kg (0.2 lb) Metformin: 2.1 kg (4.6 lb) Lifestyle: 5.6 kg (12.3 lb) Clinical Contributions: Incidence of diabetes: 11 per 100 person-years for placebo; 7.8 per 100 person-years for metformin; and 4.8 per 100 person-years for lifestyle changes Number needed to treat to prevent one new case of diabetes in three years: Metformin: 13.9 Lifestyle: 6.9

19 Let s not get all too excited or should we? Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia Hyperglycemia frequently encountered, no optimal care prior to discharge. Importance of glucose reduction unknown Looked at 7 day adverse outcomes Cohort design looked at high volume urban ED with patient glucose 400 mg/dl or higher 422 patients with 566 ED encounters Mean arrival and discharge glucose was 491 mg/dl (SD 82 mg dl) and discharge glucose was 334 mg/dl (SD 101 mg/dl)

20 Hyperglycemia d/c effect results 7 day follow up period 62 (13%) and 36 (7%) patients had repeat ED visits for hyperglycemia and were hospitalized respectively 2 patients had DKA Conclusion: ED discharge glucose in patients with moderate to severe hyperglycemia was not associated with 7-day outcomes of repeat ED visit for hyperglycemia or hospitalization. Attaining a specific glucose goal before discharge in patients with hyperglycemia MAY be less important than traditionally thought

21 Baseball and Medicine Who are theses guys and what do they have in common? Mookie Betts- Boston Red Sox- AL Leading BA of.346 Christian Yelich- Milwaukee Brewers- NL Leading BA of.324 Don t expect to be able to practice medicine long if you bat.300 (30%)

22 Too Chef s ruin the soup

23 Category Ratings A = consistent, good-quality patient-oriented evidence B = inconsistent or limited-quality patientoriented evidence C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series

24 Where to start? Patient presents with BS of 400 mg/dl, not found to be in DKA or HHS. What do you do? (Am Fam Physician Guidelines) IV Fluids (0.9NS vs LR) Make sure to check potassium, phosphate Repeat BS and if less than 200 consider: Metformin first line (maximize dose if needed)- Cat A Patients with prediabetes or new-onset diabetes should undertake extensive lifestyle changes to slow the progression of type 2 diabetes- Cat A Patients with existing cardiovascular disease, two or more cardiovascular disease risk factors, or duration of diabetes of 10 years or more should have higher A1C goals because of a lack of benefit and the potential for increased risk of mortality compared with lower A1- C goals- Cat A Self-monitoring of blood glucose levels for patients taking noninsulin therapies does not significantly affect glycemic control- Cat B

25 Behavioral Therapy Lifestyle and nutrition counseling a plant-based diet (meaning eating mostly fruits and veggies) avoiding sugars and flours, especially those in processed food (prepared foods, foods in boxes) limiting animal products ANY increase in physical activity is desirable

26 How to manage and where to start Monotherapy- Metformin- highly effective, low hypoglycemic risk, neutral or little weight loss, GI upset and lactic acidosis, low cost Dual therapies Metformin + Sulfonylurea- highly effective, moderate hypoglycemic risk, weight gain, cheap (Recommend Glipizide or Glimepiride vs Glyburide) Metformin + TZD- highly effective, low hypoglycemic risk, weight gain, low cost Metformin + DPP 4 inhibitor- intermediate effectiveness, low hypoglycemia risk, weight neutral, rare adverse effects, high cost Metformin + SGLT2 inhibitor- intermediate effectiveness, low hypoglycemic risk, weight loss, adverse rxn- dehydration/genitourinary, high cost Metformin + insulin (basal)- highest effectiveness, high hypoglycemia risk, weight gain, adverse rxn- hyopglycemia, variable cost Triple therapies- Metformin + Sulfonyurea + (TZD or DPP-4 inhibitor or GLP-1 receptor agonist or insulin) Combination injectable therapy- Metformin+ basal insulin+ mealtime insulin+ GLP-1 agonist.

27 Euglycemic Diabetic Ketoacidosis (EDKA) Seen with some of the newer diabetic mediations SGLT-2 Inhibitors-Dapagliflozin, Empagliflozin, Ipragliflozin, Canagliflozin increase glucagon, decrease insulin, decrease acetly-coa carboxylase, increase carnitine palmitoyltransferase-1 Decreased insulin, increased lipolysis, increase FFAs, increased beta oxidation, increased ketone production DKA without hyperglycemia- increased AG, ketones Does also exist in patients who are not on SGLT-2 inhibitors Starvation, cirrhosis, exogenous insulin use, pancreatitis, depression Vomiting most common symptom More common in type 1 than type 2 DM Management the same as DKA

28 Summary Your patients don t follow up or often have a difficult time following up from discharge of the ED Appears to be generally safe to discharge patients with hyperglycemia, but still has some risks (13% return 7% admission) Metformin- only medication been show to reduce mortality and other complications- good starting place if new DM (start at 250 mg QD) Additional medication added as appropriate, however have not been shown to reduce the risk of diabetes related complication, cardiovascular mortality or all cause mortality Consider adding dual therapy such as sulfonylurea -glipizide 5 mg QD (2.5 elderly) or glimepride 1 mg QD preferred over glyburide)

29 Your diabetic patient is ready for d/c now what? Stop- clinical pause Why were they hyperglycemic- non compliance, advancing diabetes, infection etc Do they have euglycemic DKA? Normal BS with AG and ketones on SGLT-2 Inhibitors- (Dapagliflozin, Empagliflozin, Ipragliflozin, Canagliflozin) Gave IV fluids and re-assessed If not on any meds start: Metformin- 250 mg QD advance as tolerated If already on Metformin maximize dose Consider dual therapy- glipizide/glimepride If already on triple or combination injectable therapies consider maximizing doses, IM consult

30 References ADA Updates Standards of Medical Care for Patients with Diabetes Mellitus. American Family Physician Jan 1; 95 (1) Driver, Brian et al. Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia. Annals of Emergency Medicine December 2016 Volume 68, Issue 6, Pages e3 Management of Blood Glucose with Noninsulin Therapies in Type 2 Diabetes. American Family Physician Jul 1; 92(1): Shih-Chuan Chou et al. (April 2018). Annals of Emergency Medicine Volume 71, Issue 4, Pages Shlomo, Vinker et al. (2004). BMC Fam Pract 5: 16. Primary care follow up of patients discharged from the emergency department: a retrospective study Turner R, et al. "Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes". The Lancet (9131): UK Prospective Diabetes Study (UKPDS) Group.". The Lancet (9131): Diabetes management visited 9/21/18