Primary Care: An Ever Changing Landscape

Presented by:

Penny DeRaps, PhD, FNP-CMaine Nurse Practitioner Association

Fall Conference - November 14, 2015

Objectives

Review preventative care guidelines for primary care

Review new classes of DM medications Review new formulations of respiratory

medications

Colorectal (CDC and USPTF)

Colonoscopy every 10 years beginning at age 50 until age 75 and then continued or not based on shared decision making. More frequent screening based on results and scope; or

CT Colonography every 10 years (ACS approved, or

Flex sig every 5 years; or

Double contract BE every 5 years (ACS approved; or

FIT test yearly (or every 3years if used in conjunction with flex sig; or

Colorectal (CDC and USPTF) Continued

FOBT yearly (or every three years if used in conjunction with flex sig; or

Screening in high risk patients should begin at 40 or 10 years before 1st known diagnosed relative; or

Research is being done to evaluate other tests (stool DNA, FIT, CT scan) in use with adult populations starting at age 40

Breast Cancer Screening (USPTF)

Every 2 years mammo for women age 50-74

Earlier screening should be done in direct relation to known family risk or BRCA risk and decided with the patient

CBE every 3 years with prvider

**ACS says every year mammo after the age of 40, high risk patients should get an MRI or mammo annually

Cervical Cancer Screen

Age 21-30, pap smear every 3 years, HPV done only if abnormal results

Over 30 pap smear and HPV testing together or separate every 3 years; if abnormal repeat screening again in 1 year if low grade; colposcopy if more concerning abnormality

Yearly screening in presence of abnormals; If CIN2/3 and hysterectomy; see 3 annual negatives before discontinuing screening

Cervical Cancer Screencontinued

Over age 65, no recommended screening if adequate screening and normal results up to that point

ACS essentially similar except that if an abnormal results returns and HPV is positive and your are older that 25, colposcopy recommended

Prostate

No recommended screening unless patient expresses a clear preference for it

Inform patient of limited benefits of screening unless significant risk

Evaluate patient’s life expectancy in general

Lipid Disorders

Strong recommendation to screen men over the age of 35; screen men 20-35 if increased risk

Strong recommendation to screen women over 45; screen women 20-45 if increased risk

Lipid Disorders

Increased risk indicated by the following: Diabetes Personal history of CHD or non-coronary atherosclerosis (AAA, PAD,

coronary artery stenosis) Family history of CV disease before 50 in males, age 60 in females Tobacco use BMI greater than 30 Screen every 5 years for those not on statins, adjust per patient risk and

how close they are to abnormal

Screen every 5 years for those not on statins, adjust per patient risk and how close they are to abnormal

Diabetes

National guideline clearinghouse) In higher risj patients (determined by age, BMA, diet, physical activity, previous high FBG or gestational diabetes, family history) check ACI every 3 years; if very high risk, check annually.AIC is preferred but can do a GTT or FBS greater than 125 on two separate occasions, HgAIC>6.5=+

AACE - FBG>126, GTT>200 2hours after ingesting 75 gm oral glucose, hyperglycenia symptoms and random BS>200, AIC>6.5%

Diabetes Continued

If positive, need urine microalbumin yearly, dilated eye exam annually, annual lipid profiles if not on statins, foot exams yearly, bladder dysfunction screening, bowel dysfunction screening, HTN and ACVD

Screen AIC every 3 months after initiating therapy, have patient keep logs of BS in between until stable then decrease blood sugar checks. Can wean down to every 6 months AIC goal <110 FBS, <140 post prandial

Osteoporosis

Women age >65

Women age <65 with the following risk factors: Caucasian Low body weight Smoker Family History of osteoporosis

T2D Complex Metabolic Disease Characterized by Chronic

Hyperglycemia “Deadly Octete”

Liver: Hepatic glucose production Insulin resistance results in glucose over production as fating insulin

increases Pancrea Glucagon Secretion:

Increases glucagon secretion from alpha cells in pancreas

stimulates in hepatic glucose production Lipolysis in Adipose Tissue:

Insulin resistance in fat cells leads to lipolysis and the resulting elevated levels of free fatty acids stimulate hepatic glucose production, insulin resistance in muscle & liver and impair beta cell function

Glucose Reabsorption in Kidney The kidney reabsorbs more glucose and that exacerbates circulating

glucose

Pancreatic Insulin SecretionsProgressive decline in beta cell functions leads to insulin resistance

Glucose Uptake in Muscles Insulin resistance in muscles results in impaired glucose uptake excess glucose remains in blood

Incretion EffectGlucoregulatory effects of incretion hormones produced by gut are diminished

Neurotransmitter DysfunctionNeurotransmitter Dysfunction contributes to increase food intake obesity

T2D Complex Metabolic Disease Characterized by

Chronic Hyperglycemia “Deadly Octeth” Continued

Classes of Medication to Treat T2D

Insulin: Increases glucose disposal and hepatic glucose production

Sulfonylurea: Increases insulin secretion Both are associated with risk of hypoglycemia

Metformin: hepatic glucose production, intestional absorption of glucose and improves insulin sensitivity by increasing glucose uptake and utilization

First Choice Med for Most

TZD: Increases sensitivity to muscle, fat and liver thiazoladinedione. To insulin; reduces hepatic glucose production

Classes of Medication to Treat T2D

GLP – 1RA: Glucagon-like peptide-1 receptor agonistIncrease insulin secretion and decreased glucagon secretion; slow gastric emptying and decreased food intake

DPP-4i – Dipeptidyl Peptidose -4 inhibitor Prolongs the life of post prandial incretins resulting in increased insulin and decreased glucagon

SGLT-2i:

Reduces the amount of glucose reabsorbed by the kidneys

Drug in Each ClassInsulin, Sulfonylureas, Metformin

TZDs – Actos & Avandia GLP-I Tanzeum (albiglutide (1 wk)

Injectables below:

Trulicity (duloglutide (1 wk)

Byetta (examatide (BID)

Bydurea (examatide) ext-rel (1 wk)

Victoza (liraglutide) (daily)

DPP-4i

Nesina (alogliptin), Onglyza (saxasliptin), TrajeuTa (linaglyptin)

Januvia (sitagliptin

Combos & MetiformKazona; Jentadueto, Kiombiglyze XR & Jamumet & XR

Drugs in Each Class continued

SGLT-2i Farxiga (dapazliflozim)

Jardiance (empagliflozin)

Invokana (camagliflozin

Effects of Medications

Insulin: Fasting plasma glucose

PPG

hypoglycemia

weight

Sulfonylureas: Fasting plasma glucose

PPG

hypoglycemia

weight

Effects of Medications continued

Metformin: Fasting plasma glucose

PPG

Neutral hypoglycemia & weight

TZD Fasting plasma glucose

PPG

Neutral hypoglycemia

weight (? Of CHF)

Effects of Medication continued

GLP-1RA Fasting plasma glucose

PPG

Neutral hypoglycemia

Weight

DPP-4i Fasting plasma glucose

PPG

Neutral hypoglycemia & Weight

SGLT-2i Fasting plasma glucose

PPG

Neutral hypoglycemia

weight

COPD

The following COPD Pocket guide can be downloaded from the COPD website by going to:

COPD

COPD Pocket Consultant

2 Major Diseases Treated with Respiratory Medications - COPD - Asthma

Asthma: A chronic condition in which a person’s airway becomes inflamed, narrow and swollen, producing extra mucus which makes it difficult to breathe. This can trigger coughing, wheezing and shortness of breath. This can range from mild to life threatening. It can progress over time if under treated and can cause fibrosis

COPD: A common preventable and treatable disease characterized by persistent airflow limitations that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lungs to noxious particles and gases. Exacerbations and co-morbidities contribute to the overall severity in individual patients.

2 Major Diseases Treated with Respiratory Medications COPD - Asthma continued

COPD: Chronic air flow limitation is caused by

1. Small airways disease (obstructive bronchiolitis) and;

2. Parenchymal destruction (emphysema) measured by spirometry Gold (2014)

Global Initiative for chronic obstructive lung disease along the standard for diagnosis, management and prevention of COPD

Gold stages 1-4

Now some changes, but it remains that GOLD stage 2 have a steeper decline in FEV than those with more severe disease.

FEV1/FVC represents the proportion of a person’s vital capacity that they are able to expire in the first second of forced expiration

Medications

Asthma:

Advair (Albuteral)

Asmanex (Qvar)

Breo (Symbicort)

Dulera

Florent

Foradil

Pro-air –albuteral – proventil

Pulmicort

LABA:

Foradil

Serevert

Questions?

Thank you!!