Guideline Updates for the Front Line & Patient Counseling Tips to Improve Care

Transcription

1 Guideline Updates for the Front Line & Patient Counseling Tips to Improve Care Jorge Berrios, PharmD, MBA Clinical Director, Innovative Delivery Solutions Jaclyn Shine, PharmD, MBA Sr. Specialist, Outcomes MTM Clinical Services June 30, Learning Objectives Identify key clinical trials leading to new or updated treatment recommendations in various chronic disease state practice guidelines. Summarize new or updated treatment recommendations for various chronic diseases. Develop a patient specific pharmacologic treatment plan including appropriate drug selection and establishment of proper monitoring parameters and/or treatment goals. Communicate key patient counseling points including dosing/titration, adherence, potential adverse effects, drug, disease, or food interactions, monitoring, and appropriate follow up for drugs used to treat various chronic diseases. 2 1

2 Disclosure Jorge Berrios is an employee of Cardinal Health. The conflict of interest was resolved by peer review of the slide content. Jaclyn Shine is an employee of Cardinal Health. The conflict of interest was resolved by peer review of the slide content. 3 Agenda Hypertension Heart failure Hyperlipidemia Diabetes 4 2

3 Hypertension 5 Hypertension Definitions 2017 Key Takeaways Removed pre hypertension category Stage 1 now starts at SBP 130 mm Hg vs. 140 mm Hg with JNC 7 140/90 mm Hg now Stage 2 (was Stage 1 in JNC7) Diagnosis made using at least 2 readings on at least 2 occasions (out of office readings recommended) 6 Whelton PK et al. Hypertension 2017;71 3

4 BP Goals Condition BP Threshold, mm Hg BP Goal, mm Hg General Clinical CVD or 10 year ASCVD risk 10% 130/80 <130/80 No clinical CVD and 10 year ASCVD risk <10% 140/90 <130/80 Older persons ( 65 years; noninstitutionalized, ambulatory, community dwelling) 130 (SBP) <130 (SBP) Comorbidities Diabetes mellitus 130/80 <130/80 Chronic kidney disease 130/80 <130/80 Chronic kidney disease after renal transplant 130/80 <130/80 Heart Failure 130/80 <130/80 Stable ischemic heart disease 130/80 <130/80 Secondary stroke prevention 140/90 <130/80 Secondary stroke prevention (lacunar) 130/80 <130/80 Peripheral arterial disease 130/80 <130/80 7 Whelton PK et al. Hypertension 2017;71 SPRINT Trial 2015 Randomized trial comparing intensive versus standard BP control (N=9300) Patients: Age 50 years without DM or prior TIA/stroke Baseline SBP mm Hg with increased CVD risk Compared SBP goal <120 mm Hg (intensive) to <140 mm hg (standard) Primary outcome: Composite of MI, acute coronary syndrome, acute decompensated HF, death from CV causes 8 4

5 SPRINT Trial 2015 Results: Intensive control (SBP <120 mm Hg) reduced primary endpoint 1.65% per year vs. 2.19% per year (HR 0.75, 95% CI, ; p<0.001) Number needed to treat = 61 Benefits also occurred in patients older than 75 Higher rates of hypotension, syncope, electrolyte abnormalities, and acute kidney injury/failure in intensive arm Number needed to harm = 100 for hypotension 9 Initial BP Treatment & Follow up 10 5

6 Initial BP Treatment & Follow up 11 ACCORD Trial 2010 Action to Control Cardiovascular Risk in Diabetes Randomized trial comparing intensive with standard BP control in patients with type 2 DM (N=4700) Patients: With CVD or at least 2 additional CVD risk factors Mean baseline BP 139/76 mm Hg Compared SBP goal of <120 mm Hg to <140 mm Hg Primary outcome: Composite of nonfatal MI, nonfatal stroke, or death from CV causes Follow up: 4.7 years 12 6

7 ACCORD Trial 2010 Action to Control Cardiovascular Risk in Diabetes Results: Mean BP: mm Hg (intensive) vs mm Hg (standard) No difference in primary outcome 1.87% vs. 2.09% (HR 0.88; 95% CI, ) No difference in all cause mortality or CV death Intensive therapy associated with less stroke 0.32% vs. 0.53% (HR 0.59; 95% CI, ) More adverse events in intensive therapy group Hypotension, syncope, bradycardia, electrolyte abnormalities, angioedema, and renal failure 13 Hypertension and Diabetes Disagreement between hypertension guideline and ADA Hypertension: Goal <130/80 mm Hg ADA: Goal <140/90 mm Hg for most Lower goals (e.g., <130/80) may be appropriate for those at high risk for CVD without undue treatment burden All first line agents are useful and effective ACE I or ARB preferred in patients with albuminuria Two or more drugs often needed to achieve goal of <140/90 mm Hg 14 7

8 Hypertension in Patients with CKD 15 Hypertension in Patients with SIHD 16 8

9 Hypertension in Patients with Stroke 17 MTM: Hypertension Assess patient s current therapy: Is the patient s blood pressure at goal? Current recommended guidelines recommend goal of < 130/80 mmhg Does the patient monitor their blood pressure at home, at the pharmacy, etc.? If so, are there any trends that can be evaluated? Is the patient s antihypertensive medication appropriate? Any patient specifics that indicate one agent over the other? Contact the prescriber with any recommendations based on findings 18 9

10 MTM: Hypertension Review prescription fill history to monitor adherence: Are there any gaps in their refill history? Consult with the patient to identify barriers to adherence Offer solutions: Automatic refills 90 day fills Medication synchronization Compliance packaging Delivery Pill box Timing of medication administration 19 MTM: Hypertension Lifestyle Modifications: DASH Diet High in: Fruits, vegetables, whole grains, fish, poultry, beans, and nuts Low in: Sodium, sweets, added sugars, fats, and red meats Numerous resources available online to provide to patients Physical Activity: Goal: 150 minutes of moderate activity per week Tailor recommendations to patient s current lifestyle 20 10

11 Heart Failure 21 Classifications of Heart Failure 22 11

12 Classifications of Heart Failure 23 Treatment Algorithm for Stages C & D All HFrEF patients (without contraindications) 24 Yancy CW et al. Circulation 2017;136:e137 e61. 12

13 Treatment Algorithm for Stages C & D All HFrEF patients (without contraindications) Additional drug therapy for specific patients 25 Yancy CW et al. Circulation 2017;136:e137 e61. HFrEF Pharmacotherapy Aldosterone Antagonists Place in therapy: NYHA class II IV with LVEF 35% Stage II should have history of hospitalization or elevated BNP Post acute MI with LVEF 35% with HF symptoms or DM Benefits (added to ACE I and BB): Decreased mortality Decreased hospitalizations for HF Avoid if SCr >2.5, GFR <30 ml/min, or K + >5.0 meq/l Routine combined use of ACE I, ARB, and aldosterone antagonist potentially harmful due to risk of hyperkalemia Monitor K+ and SCr within 2 3 days and again at 7 days, then monthly x 3, then every 3 months Decrease dose or discontinue if K + >5.5 meq/l 26 Yancy CW et al. Circulation 2017;136:e137 e61. 13

14 HFrEF Pharmacotherapy Angiotensin Receptor Neprilysin Inhibitor (ARNI) Sacubitril/Valsartan Place in therapy: HFrEF NYHA class II or III who tolerate an ACE inhibitor or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality Benefits: Decreased composite end point of CV death or hospitalization for HF (20% RRR compared with enalapril monotherapy) Decreased all cause mortality (16% RRR) and CV death (20% RRR) compared with enalapril monotherapy Monitor for hypotension and hyperkalemia Start low dose and titrate as tolerated Neprilysin inhibition can cause angioedema Avoid concomitant ACE I within 36 hours Appears most common in African Americans 27 Yancy CW et al. Circulation 2017;136:e137 e61. HFrEF Pharmacotherapy Hydralazine/Isosorbide dinitrate Place in therapy: In addition to ACE I and BB for NYHA class III IV HFrEF in patients self described as African American Benefits: Decreased mortality (43% RRR vs. placebo) Improved exercise tolerance Monitoring: Headache, hypotension, drug induced lupus Discontinue if lupus like symptoms (e.g., fever, weight loss, musculoskeletal symptoms) 28 Yancy CW et al. Circulation 2017;136:e137 e61. 14

15 HFrEF Pharmacotherapy Ivabradine Place in therapy: NYHA functional classes II and III, stable, LVEF of 35% who are receiving GDTM, including a β blocker at maximum tolerated dose, and who are in NSR with a heart rate of 70 bpm at rest. Benefits: Reduced composite of CV death or hospitalization for HF (18% RRR SHIFT trial) Difference due to HF hospitalizations, not mortality Monitor for bradycardia, visual disturbances 29 Yancy CW et al. Circulation 2017;136:e137 e61. HFrEF Pharmacotherapy Digoxin Place in therapy: 2013 ACC/AHA guidelines recommend digoxin be considered in HFrEF to reduce hospitalizations but do not address when to add digoxin Benefits: Improved symptoms Improved exercise tolerance Decreased hospitalizations No effect on mortality Greater effects with low LVEF (<25%) or NYHA class III IV mg daily adequate for most patients Consider every other day in patients >70 years Serum concentration should be less than 1 ng/ml 30 Yancy CW et al. Circulation 2017;136:e137 e61. 15

16 HFpEF Pharmacotherapy 31 Yancy CW et al. Circulation 2017;136:e137 e61. MTM: Heart Failure Treatment Assess appropriate therapy Appropriate treatment for given HF stage? If taking a beta blocker, is it an evidence based beta blocker? Counseling pearls: Timing of diuretics Adherence Orthostatic hypotension 32 Yancy CW et al. Circulation 2017;136:e137 e61. 16

17 MTM: Heart Failure Treatment Symptoms of worsening heart failure: Shortness of breath Fatigue, weakness Swelling, edema Weight gain Pillow count Contact their physician if sudden weight gain occurs: > 2 lbs in one day OR > 5 lbs in 1 week 33 Yancy CW et al. Circulation 2017;136:e137 e61. MTM: Heart Failure Treatment Monitor salt intake Recommended vaccinations: Annual flu vaccine Pneumovax23 once 2 64 years old Prevnar13 once at 65 years old Pneumovax23 final dose 65 years old At least 1 year after Prevnar13 At least 5 years after Pneumovax23 34 Yancy CW et al. Circulation 2017;136:e137 e61. 17

18 Hyperlipidemia 35 ASCVD Risk Factors Age 45 yo (male) 55 yo (female) Family h/o premature CHD <55 yo (male relative) <65 yo (female relative) Current cigarette smoking Elevated BP ( 130/80 mm Hg) or on antihypertensive therapy Low HDL C <40 mg/dl (male) <50 mg/dl (female) Elevated LDL C 160 mg/dl 36 Jacobson TA et al. J Clin Lipidol 2014;8: Stone NJ et al. Circ 2014;129:S1 S45. 18

19 Pooled Cohort ASCVD Risk Equation Essentially replaces Framingham Risk Score Estimates risk of 10 year and lifetime risk of nonfatal MI or CHD death, or fatal or nonfatal stroke 10 year risk is used to initiate statin therapy Lifetime risk more appropriate for emphasizing lifestyle modifications Useful to assess ASCVD risk for primary prevention DO NOT USE in patients with established ASCVD or LDL C 190 mg/dl Does not include all races/ethnicities Accuracy unknown in non white and non African Americans 37 Goff DC et al. Circ 2014;129[suppl 2]:S49 S73. Stone NJ et al. Circ 2014;129:S1 S45. ACC ASCVD Risk Estimator Plus 38 Web version Mobile app Risk Estimator Plus 19

20 Lifestyle Modifications to Reduce ASCVD Risk Diet Fruits, vegetables, whole grains, low fat dairy, chicken, fish, legumes, vegetable oils, and nuts Limit intake of saturated and trans fats, red meat, sweets, and sugary beverages Physical activity Moderate vigorous aerobic exercise 3 4x per week for ~40 min per session Avoid cigarette smoking 39 Relevant Guideline Comparison 40 20

21 2013 ACC/AHA Cholesterol Guideline 41 ASCVD Statin Benefit Groups & Treatment 42 Stone NJ et al. Circ 2014;129:S1 S45. 21

22 Recommended Statin Dose Intensities Moderate intensity (LDL C reduction 30 to <50%) High intensity (LDL C reduction by 50%) Atorvastatin 10 mg, 20 mg Rosuvastatin 5 mg, 10 mg Simvastatin 20 mg, 40 mg Pravastatin 40 mg, 80 mg Lovastatin 40 mg Atorvastatin 40 mg, 80 mg Rosuvastatin 20 mg, 40 mg 43 Stone NJ et al. Circ 2014;129:S1 S45. Treatment Goals (NLA 2014) Risk Category Low Moderate High Very high Criteria 0 or 1 major risk factor Consider other risk modifiers 2 major risk factors Consider quantitative assessment Consider other risk modifiers 3 major risk factors Type 1 or 2 DM 0 or 1 major risk factors AND No signs of end organ damage CKD stage 3B or 4 LDL 190 mg/dl Quantitative risk assessment reaches highrisk threshold* Established ASCVD Type 1 or 2 DM 2 major risk factors OR Signs of end organ damage Non HDL Goal (mg/dl) LDL Goal (mg/dl) <130 <100 <100 <70 *Framingham 10 year risk score 10% or Pooled Cohort Equations Risk Score 15% or Framingham long term risk score 45% 44 Jacobson TA et al. J Clin Lipidol 2014;8:

23 Management of Elevated TGs (NLA 2014) TG >1000 mg/dl TG mg/dl TG mg/dl Non pharmacologic measures (e.g., physical activity/weight loss, alcohol, carbohydrate intake, improve glycemic control) 1 st line: TG lowering therapy* History of pancreatitis? 1 st line: Statin Consider statins in highrisk patients (e.g., clinical ASCVD and/or DM) Yes TG lowering therapy* No Statin May add TG lowering therapy if non HDL goal not achieved *TG-lowering therapies: Fibrates, Omega-3 fatty acids, nicotinic acid 45 Jacobson TA et al. J Clin Lipidol 2014;8: Statins First line for reducing atherogenic lipoproteins and ASCVD risk Inhibits HMG CoA reductase (enzyme that converts HMG CoA to mevalonate rate limiting step in production of cholesterol) Reduces coronary events, stroke, coronary revascularization, CV related and total mortality (primary & secondary prevention) LDL 24 60%, TG 7 10%, HDL 5 15% Monitor lipid profile 4 12 weeks after initiation; then every 3 12 months 46 23

24 Statin Associated Myopathy Risk Factors Higher intensity statins Older adults Frequent (or new) exercises Small body frame Chronic kidney disease Drug drug interactions Hypothyroidism Vitamin D deficiency Potentially helpful Decrease statin dose Temporarily hold statin Change to another statin Alternative dosing Unlikely helpful CoQ10 supplementation Routine CK monitoring 47 Jacobson TA et al. J Clin Lipidol 2014;8: Other Statin Related Adverse Events Elevated hepatic transaminases Usually transient, resolve with time Obtain LFTs before starting therapy Reasonable to repeat LFTs after statin initiation and dose increases Routine LFT monitoring no longer recommended Increased risk of new onset type 2 DM Dose dependent More likely in those with DM risk factors Not associated with hyperglycemia Benefits of statins outweigh risks 48 Jacobson TA et al. J Clin Lipidol 2014;8:

25 IMPROVE IT Trial Ezetimibe/Simvastatin vs. Placebo/Simvastatin Primary composite endpoint: CV death, MI, and hospital admission for unstable angina, revascularization, or stroke 18,144 patients 10 days post ACS Baseline characteristics Mean age = 64 years LDL C = 95 mg/dl 27% had DM LDL C at study end 53 mg/dl (ezetimibe) 69 mg/dl (placebo) 49 Jacobson TA et al. J Clin Lipidol 2014;8: IMPROVE IT Trial Ezetimibe/Simvastatin vs. Placebo/Simvastatin Composite: CV death, MI, and hospital admission for unstable angina, revascularization, or stroke 34.7% 2742 events P= % 2572 events Conclusion: Reduces coronary events, stroke, and CV mortality when added to statin therapy post MI; benefit unknown in stable CHD or primary prevention 50 Cannon C et al. N Engl J Med 2015;372:

26 FOURIER & ODYSSEY Evolocumab & Alirocumab Outcome Trials Original FDA approval based on ability to lower LDL C, not improvement in clinical outcomes CV outcomes trials for PCSK9 inhibitors FOURIER (evolocumab) Population: High risk but stable CHD (prior MI, prior stroke, or symptomatic PAD) Evolocumab reduced risk of major CV events (CV death, MI, or stroke) with no effect on all cause mortality ODYSSEY Population: Post ACS Alirocumab reduced risk of major CV events (CV death, nonfatal MI, ischemic stroke or UA requiring hospitalization) and all cause mortality 51 Sabatine MS et al. N Engl J Med 2017;376: ODYSSEY results presented at American College of Cardiology 2018, not yet published Role of Non Statin Therapy ***Adherent to lifestyle modifications & maximally tolerated statin with:*** Clinical ASCVD, ( ) comorbidities Clinical ASCVD (+) comorbidities and/or baseline LDL C 190 Baseline LDL C 190 ( ) ASCVD Diabetes b ( ) ASCVD <50% reduction in LDL C or LDL C >70 or non HDL >100 mg/dl <50% reduction in LDL C or LDL C >70 or non HDL >100 mg/dl <50% reduction in LDL C or LDL C >100 or non HDL >130 mg/dl <50% reduction in LDL C or LDL C >100 or non HDL >130 mg/dl 1 st : Ezetimibe 2 nd : PSCK9 inhibitor Ezetimibe OR PCKS9 inhibitor Ezetimibe a a Bile acid sequestrants may be used if intolerant to ezetimibe and TG <300 mg/dl b Role PCSK9 inhibitors not evaluated for primary prevention use in DM population 52 Lloyd Jones DM et al. J Am Coll Cardiol 2017;70:

27 Hyperlipidemia and Diabetes Pharmacotherapy Recommendations: 53 MTM: Hyperlipidemia Determine if the patient s statin treatment is appropriate Four statin benefit groups: Clinical ASCVD LDL 190 mg/dl Diabetes y 10 year ASCVD risk 7.5% Assess if non statin treatment is appropriate Best Practice: Use the AHA ASCVD Risk Calculator to calculate 10 year ASCVD risk 54 27

28 MTM: Statin Intolerance True intolerance or were side effects unrelated to statin? Addressing intolerance with the patient or prescriber: There is evidence of low, less than daily, statin doses providing benefit. Low dose of same or different statin Dose long half life statins intermittently i.e. rosuvastatin 2 3 times per week Use an alternative statin, i.e. pravastatin 55 MTM: Hyperlipidemia Monitoring Review the patient s most recent lab results Request labs from the patient s physician Ask patient to bring the results to the consultation Perform POC cholesterol screening at the pharmacy! May need to alert patient in advance Encourage appropriate lifestyle habits Diet & exercise Inform patients of healthy events occurring in your community! 56 28

29 Diabetes 57 Summary of Revisions: ADA Standards of Medical Care in Diabetes 2018 Diabetes Care 2018;41(Suppl. 1):S4 S6 SREV

30 Focus of the Diabetes Review To highlight the changes which will most impact pharmacists and their MTM practice. This is not an exhaustive list of the ADA 2018 changes. For a more detailed list of recommendations please visit the ADA website at: 1/S3 Will focus on the following changes in clinical practice: Prevention or delay of Type 2 diabetes Assessment of glycemic targets Pharmacologic treatment 59 Prevention or Delay of Type 2 Diabetes Pharmacologic Interventions for Prevention: Recommendations Metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially for those with BMI 35 kg/m 2, those aged <60 years, and women with prior GDM. A Long term use of metformin may be associated with biochemical vitamin B12 deficiency, and periodic measurement of vitamin B12 levels should be considered in metformin treated patients, especially in those with anemia or peripheral neuropathy. B Prevention or Delay of Type 2 Diabetes: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S51-S

31 Assessment of Glycemic Targets Patient and Healthcare Provider Education HbA1c does not provide information on daily glucose patterns Patients may experience periods of hyper and hypoglycemia throughout the day, despite HgA1c levels measuring within the target range Patients with similar HbA1c levels can have very different daily and nocturnal patterns of glucose excursions and rates of hypoglycemia Glycemic Targets: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S55-S64 61 Assessment of Glycemic Targets Flash Glucose Monitoring FreeStyle Libre Pro FreeStyle Personal now approved in the U.S. Touch screen reader scans the sensor Factory calibrated FDA approved for insulin dosing adjustments without need for fingerstick confirmation Glycemic Targets: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S55 S

32 Assessment of Glycemic Targets CGM: Recommendations 63 When used properly, CGM in conjunction with intensive insulin regimens is a useful tool to lower A1C in adults with type 1 diabetes who are not meeting glycemic targets. A CGM may be a useful tool in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes. C Given the variable adherence to CGM, assess individual readiness for continuing CGM use prior to prescribing. E When prescribing CGM, robust diabetes education, training, and support are required for optimal CGM implementation and ongoing use. E People who have been successfully using CGM should have continued access after they turn 65 years of age. E Assessment of Glycemic Targets 64 32

33 Assessment of Glycemic Targets Classification of Hypoglycemia Glycemic Targets: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S55-S64 65 Pharmacologic Therapy Food and Drug Administration (FDA) Guidance March 2008 FDA released a guidance for the industry All new anti diabetic therapies for type 2 diabetes (T2DM) should demonstrate that they are not associated with an unacceptable increase in major cardiovascular endpoints (MACE) Recommended studies: Trial duration at least 3 6 months to obtain enough events to provide long term data on CV risk Include endpoints such as CV mortality, myocardial infarctions (MI), stroke, hospitalization for acute coronary syndrome (ACS), urgent revascularization procedures, and other CV related endpoints Include high risk patients such as patients with advanced CVD, elderly, and patients with some degree of renal impairment Glycemic Targets: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S55-S

34 Pharmacologic Therapy FDA Guidance Continued Upper bound of the two sided 95% confidence interval for estimated CV risk ratio (medication vs control) >1.8 Approval denied. Risk identified. Conduct an additional singe large safety trial that can be alone or added to other trials to prove it is < Overall risk benefit analysis supports approval. Conduct a postmarketing trial to prove it is <1.3. Study should be adequately powered or can be added to other trials including the premarketing safety trial. <1.3 Overall risk benefit analysis supports approval. A postmarketing trial may not be necessary Glycemic Targets: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S55-S LEADER (Liraglutide) Results Liraglutide significantly reduced the risk of 3 point MACE (CV death, nonfatal MI, or nonfatal stroke) by 13%. It also significantly reduced the risk of the individual components of death from any cause, CV death, and nephropathy. Marso S, et al. N Engl J Med 2016; 375(4):

35 EMPA REG (Empagliflozin) Results Empagliflozin significantly reduced the risk of 3 point MACE (CV death, nonfatal MI, or nonfatal stroke) by 14%. It also significantly reduced the risk of the individual components of death from any cause, CV death, hospitalization for HF, and the composite of hospitalization for HF or death from CV causes excluding fatal stroke. Zinman B, et al. N Engl J Med 2015; 373(22): CANVAS (Canagliflozin) Results Canagliflozin significantly reduced the risk of 3 point MACE (CV death, nonfatal MI, or nonfatal stroke) by 14%. It also reduced the risk of hospitalization for HF and the composite of hospitalization for HF or death from CV causes excluding fatal stroke. No p values as it became exploratory outcomes. Neal B, et al. N Engl J Med 2017;377(7):

36 Pharmacologic Treatment Initial Antihyperglycemic Therapy in Adults with T2DM Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S73-S85 71 Pharmacologic Therapy Continued Antihyperglycemic Therapy in Adults with T2DM Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S73-S

37 Pharmacologic Therapy Intensification Combination Injectable Therapy in T2DM Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S73-S85 73 MTM: Diabetes Monitoring Ask the patient about their A1c goal Is it in line with guideline recommendations? Evaluate their most recent HbA1c Contact their physician to get their labs Ask the patient for any recent documentation/resources Assess the patient s BG readings Encourage the patient to bring their meter or log book! Ensure they understand what their readings mean Prevention or Delay of Type 2 Diabetes: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S51-S

38 MTM: Diabetes Treatment Following BG assessment, verify the patient s regimen is appropriate BG readings trending high? Possible dose increase or change in therapy may be appropriate Tip: Remember to check their adherence! BG readings trending low? Timing of dosing may need to be adjusted Possible dose decrease or change in therapy may be appropriate Assess insulin technique Drawing insulin Administering insulin 75 Prevention or Delay of Type 2 Diabetes: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S51 S54 MTM: Diabetes & Additional Treatment Hypertension: Blood pressure at goal? Blood Pressure Goal: < 140/90 mm Hg per ADA Guidelines < 130/80 mm Hg per AHA/ACC Guidelines Aspirin Therapy Recommended as secondary prevention for patients with diabetes and history of ASCVD ( mg/day) Consider as primary prevention for patients with diabetes and increased cardiovascular risk without an increased risk of bleeding ( mg/day) Majority of men and women >50 with at least one additional major risk factor (hypertension, dyslipidemia, smoking, albuminuria, family hx premature ASCVD) Prevention or Delay of Type 2 Diabetes: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S51-S

39 MTM: Diabetes & Additional Treatment Statin treatment: ADA chart by age ASCVD Risk Factors: LDL > 100 mg/dl Hypertension Smoking CKD Albuminuria Family history of premature ASCVD 77 MTM: Diabetes & Referrals of Care Referrals of Care: Biennial eye exam (no diabetic retinopathy) Annual eye exam (diabetic retinopathy) Annual foot exam Recommended vaccinations: Annual flu vaccine Pneumovax years old Prevnar13 once at 65 years old Pneumovax23 final dose 65 years old At least 1 year after Prevnar13 At least 5 years after Pneumovax23 Hepatitis B for unvaccinated adults < 60 years old, consider for unvaccinated adults Prevention or Delay of Type 2 Diabetes: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S51-S

40 Thank You 79 40