Patient Video

Dr. Gosmanov

01 Gosmanov Pt Video dr 2.18.14.pptx

Patient Case (webinar)

• New patient, recently relocated

• 55 year old male

• BMI = 31

• HbA1c = 11.2

• Other labs

– Kidney function? Is this an issue for the patient?

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Narrated by Dr. G in webinar format

Patient Case (webinar)

• Physical exam

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• Medications

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Narrated by Dr. G in webinar format

Patient Case (webinar)

• Medical history–

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• Social history–

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• Family history–

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Narrated by Dr. G in webinar format

Assessing the Patient: Stages of Change

(end of webinar section)

• Pre-contemplation (Avoidance/denial)

• Contemplation

• Preparation/Determination

• Action/Willpower

• Maintenance

Prochaska JO, et al. J Consult Clin Psychol. 1983;51(3):390-395.

Meeting the Patient Readiness to Change (Patient Video: 5’)

• First interaction with patient

• Assessment of readiness to change

• Why are you here?

Assessing the Patient: Stages of Change

(beginning of 2nd webinar section)

• Pre-contemplation (Avoidance/denial)

• Contemplation

• Preparation/Determination

• Action/Willpower

• Maintenance

Prochaska JO, et al. J Consult Clin Psychol. 1983;51(3):390-395.

What is this approach to this patient? (webinar)

• Review patient interaction • Current status

– Readiness to change – Clinical presentation– History

• Review of risk/benefit– Diabetes complications– CV risk

• Goals– ABCs– Weight

• Strategy

Type 2 Diabetes Risk Assessment

http://www.diabetes.org/are-you-at-risk/diabetes-risk-test/. Accessed February 2014.

Heart Attack Risk Assessment

http://cvdrisk.nhlbi.nih.gov/. Accessed February 2014.

Factor

Age years

Gender O Female O Male

Total cholesterol mg/dl

HDL cholesterol mg/dl

Smoker O No O Yes

Systolic BP mmHg

Current hypertension medication?

O No O Yes

10-Year Risk of Heart Attack

Stroke Risk Assessment1. Are you a female and over the age of 55, OR are you male and over the age of 45? YES NO

2. Do you have high blood pressure, or do you take medication for high blood pressure?

(Ideal Blood Pressure is 120/80) YES NO

Your Blood Pressure: _________________ Date Tested: _________________

3. Do you smoke or have a long history of smoking? YES NO

4. Do you have an irregular heartbeat? YES NO Don’t Know

5. Do you have high cholesterol, OR do you take medication for high cholesterol? YES NO Don’t Know

6. Cholesterol Levels (if known) HDL: ________ LDL:______ Total:_________

Date Tested: ______________

7. Has your mother, father, siblings, or children had a stroke or heart disease? YES NO

8. Do you exercise less than 3 times per week for 20-30 minutes at a time? YES NO

9. Do you eat a diet high in saturated and/or animal fat? YES NO

10. Are you diabetic? YES NO

11. Are you overweight by 20 pounds or more? YES NO

www.hopeheart.org. Accessed February 2014.

3 or more “YES” see your doctor

Treatment Goals: ABCs

• HbA1C

– < 7 % for many people

– Preprandial capillary plasma glucose 70–130 mg/dl

– Peak postprandial (1-2 hours) capillary plasma glucose < 180 mg/dl

• Blood pressure (mmHg)

– Systolic < 140 for most people

– Diastolic < 80 (< 90 per Joint National Committee-8 2014 guideline)

Inzucchi SE, et al. Diabetes Care. 2012;35(6):1364-1379. http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=114. Accessed Nov 2013.James PA, et al. JAMA. 2013 Dec 18. [Epub ahead of print]. http://jama.jamanetwork.com. Accessed Dec 2013.American Diabetes Association. Diabetes Care. 2014; 37:S14-S80.

• Cholesterol – Lipid Profile (mg/dl)

– LDL Cholesterol < 100

LDL < 70 with overt CVD

– HDL Cholesterol Men > 40, Women > 50

– Triglycerides < 150

Inzucchi SE, et al. Diabetes Care. 2012;35(6):1364-1379. http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=114. Accessed Nov 2013.James PA, et al. JAMA. 2013 Dec 18. [Epub ahead of print]. http://jama.jamanetwork.com. Accessed Dec 2013.American Diabetes Association. Diabetes Care. 2014; 37:S14-S80.

Treatment Goals: ABCs(cont.)

Diabetes Patients at Goal

Stark Casagrande S, et al. Diabetes Care. 2013;36(8):2271-2279. Ali MK, et al. N Engl J Med. 2013;368(17):1613-1624.

HbA1c 52%

LDL 56%

BP 51%

All 3 19%

Other Risk Factors(end webinar section)

• Smoking

• Sedentary lifestyle

Education Must Be Ongoing

Overview of Current Medical Condition (Patient Video—20’ for section?)

• Diabetes complications

– Consequences of continuing current path

• Diabetes comorbidities

• ABCs (current vs goal?)

– HbA1c

– BP

– Cholesterol

– BMI

Risk Assessment (Patient Video)

• Myocardial infarction

• Stroke

• Amputation

• Blindness

• Loss of limb

Action Plan(Patient Video, concluding initial visit)

• Review current patient condition

• Lifestyle changes, specific tools

• Medication changes

?3-Month Follow-Up Visit (Patient Video)

• HbA1c change

• Body weight change?

• BP, lipids, etc.

• Self-reported lifestyle changes/smoking cessation

• Medication adherence

• AEs

• Solicit patient feedback on treatment plan

Charting the Course (Patient Video)

• Reinforce positive accomplishments

• Review of risks in light of current values

• Areas for improvement

• Review of AEs

• Re-Assessing Goals

• Adjustments to medication?

• Set next visit

Case Summary (webinar)

• Initial state

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• Follow-up visit

– Improvements

– Challenges

• Next steps, likely course with this patient

What Happened at the Patient Visits? (webinar)

• Readiness to change• Initial visit

– Exam– Lab values– Goals vs current –

• 3 month visit–

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• Treatment plan for this patient

ReduceHyperglycemia

MetforminInsulin

ThiazolidinedionesInsulin

GLP-1 analoguesDPP-4 inhibitors

SGLT2 InhibitorsInsulin

-glucosidaseinhibitors

SulfonylureasGlitinides

GLP = glucagon-like peptide;DPP = didpeptidyl peptidase

Multiple Therapies for Type 2 Diabetes

Diabetes Drugs Impact Multiple Endpoints

Drug BWHyper-tension

Dys-lipidemia

Hypoglycemia Risk

-glucosidaseinhibitors

Neutral ImprovedNeutral/

ImprovedLow

DPP-4 inhibitors Loss/Neutral Neutral Improved Low

GLP-1 agonists Loss Improved Improved Low

Insulin Gain Neutral* Improved High

Meglitinides Gain Neutral Neutral Moderate

Metformin Loss/Neutral Neutral Improved Low

SGLT2 inhibitors Loss Improved ? Low

Sulfonylureas Gain Neutral Variable Moderate

TZD Gain Improved Improved Low

Basile JN. J Diabetes Complications. 2013;27(3):280-286.

*Hyperinsulinemia is associated with hypertension

Therapeutic Options (webinar)

• Initial visit

– How did therapy match patient?

– Successes

– limitations

• Follow-up visit

– How was therapy adjusted?

– Expected impact

– Challenges

What Do Patients Want to Know? (webinar)

• Benefits (long term avoidance of complications)

• Risks (short term adverse effects)– Weight gain

– Hypoglycemia

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• Other issues– Injection anxiety

– Adherence

– Self-image?

– Cost/insurance

– Impact of ACA on diabetes care

Key Messages (webinar)

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