An Evidence-Based Algorithm for Deprescribing Diabetes Medications
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
2019 MICNP Conference 3/23/2019
An Evidence-Based
Algorithm for
Deprescribing
Diabetes
Medications
Caroline Trapp, DNP, ANP-BC,
CDE, FAANP, DiplomateACLM
Director of Diabetes Education and Care
Physicians Committee for Responsible Medicine
Washington, DC
1
Disclosure of Financial Conflicts of
Interest for Caroline Trapp
• None
• Nada
• Zip
• Zero
• Not a bit
• Not an iota
• Not a hint
2
12019 MICNP Conference 3/23/2019
Objectives
1. Describe the risks of
antihyperglycemic
medication use in elderly
patients with type 2
diabetes.
2. Discuss appropriate use of
an algorithm to safety
deprescribe certain
medications.
3
NPs and Rxs – A reasonable effort to
prevent complications of T2DM
4
22019 MICNP Conference 3/23/2019
What 3 classes of medications for
T2DM can cause hypoglycemia?
• Insulin
• Sulfonylureas
• Meglitinides
5
Hypoglycemia
6
32019 MICNP Conference 3/23/2019
Severe Hypoglycemia - 20191
• Impaired cognition • Coma
and physical function • Falls
• Depression and • MVI or other injury
reduced quality of life • ER visits and
• Confusion, delirium hospitalizations
• Loss of • Major cardiovascular
consciousness events (within 3
• Seizure months – VADT)2
• Death
1. ADA Diabetes Care 2019;42(Suppl.1)S61-70
2. Davis SN et al. Diabetes Care 2018; doi:10.2337/dc18-1144
7
Repeated episodes of hypoglycemia:
• Hypoglycemia Unawareness
• Dementia
ADA Diabetes Care 2019;42(Suppl.1)S61-70
8
42019 MICNP Conference 3/23/2019
• Serious hypoglycemia: a national public
health issue.1-2
• Defined as requiring third-party
assistance.3
• Any reading2019 MICNP Conference 3/23/2019
Tight control – the holy grail of diabetes management
11
Factors to consider with A1c target
• Age
• Life expectancy
• Comorbid conditions
• Duration of diabetes
• Risk of hypoglycemia
• Motivation and adherence
• Quality of life
• Patient satisfaction
12
62019 MICNP Conference 3/23/2019
Approach to the Management
of Hyperglycemia
more A1C less
Patient/Disease Features 7%
stringent stringent
Risks associated with hypoglycemia
& other drug adverse effects low high
Disease Duration
newly diagnosed long-standing
Life expectancy
long short
Important comorbidities
absent Few/mild severe
Established vascular complications
absent Few/mild severe
Patient attitude & expected treatment
efforts highly motivated, adherent, less motivated, nonadherent,
excellent self-care capabilities poor self-care capabilities
Resources & support system
readily available limited
American Diabetes Association Standards of Medical Care in Diabetes.
Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
13
Choosing Wisely
Avoid using all Among non-older
medications other than adults, …using
metformin to achieve medications to achieve
A1c2019 MICNP Conference 3/23/2019
New Guidelines!
March 6, 2018, American College of Physicians
15
Qaseem et al. Ann Intern Med.2018;168:569-576.
16
82019 MICNP Conference 3/23/2019
American College of Physicians
• Five large-scale international trials.
• Problems with major guidelines.
• Evidence does not support using medications to
aggressively lower A1c for most patients.
• Greater use of lifestyle interventions – A1c
reduction with lifestyle is SAFE! And Effective!
– #1: Discuss benefits and harms, individualize care.
– #2: A1c range of 7-8% for most patients.
– #3: No target A1c for frail elderly: treat symptoms
only.
17
Not without controversy…
18
92019 MICNP Conference 3/23/2019
There is agreement re: need to
use less in older adults.
How?
19
Deprescribing.org
20
102019 MICNP Conference 3/23/2019
21
22
112019 MICNP Conference 3/23/2019
Besides hypoglycemia, are
there other reasons to
deprescribe?
23
Polypharmacy
29.4% of elderly patients have been
prescribed 6 or more concurrent drugs.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546482/
24
122019 MICNP Conference 3/23/2019
COST
Over the past 11 years, insulin
prices have increased 197%.
Herman et al.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4886177
http://care.diabetesjournals.org/content/42/Supplement_1/S90
25
The Miracle of Insulin
26
132019 MICNP Conference 3/23/2019
Unforseen Risks of Specific Medications
Consider:
Troglitizone – Off the market
2000
Insulin inhalation – Off the
market 2007
Exenatide and sitagliptin –
concerns re: pancreatitis
Rosiglitazone – FDA restricted
access due to cardiovascular
risks May 2011
Pioglitazone – FDA linked to
bladder cancer June 2011
Cartoon by permission of Dan Piraro, creator of
Bizarro, Bizarro.com
27
Opportunity Costs vs. Gains
Costs:
• John Abrahamson, MD: “A prescription is
a missed opportunity to empower the
patient to change lifestyle.”
Gains:
• Lifestyle changes get at the underlying
problem(s).
28
142019 MICNP Conference 3/23/2019
Meet Debbie, RN
A1c 6.6%
2013
29
Circulation. 2017;135:180-195. DOI:
10.1161/CIRCULATIONaha.116.022622.
30
152019 MICNP Conference 3/23/2019
“Glycemic control [with medication] had no
effect on mortality or clinically relevant
complications.”
Makam & Nguyen. Circulation. 2017;135:180-195.
DOI: 10.1161/CIRCULATIONaha.116.022622
31
32
162019 MICNP Conference 3/23/2019
The reported benefits of tight control (UKPDS)
Retinopathy 29% ↓ per 0.9% A1c drop
Neuropathy 19% ↓ ‘’ ‘’
Nephropathy 33% ↓ ‘’ ‘’
Nonfatal MI 15% ↓ per 1% A1c drop
Makam, AN & Nguyen OK. Circulation.2017;135:180-195.
DOI:10:1161/CIRCULATIONAHA.116.022622
33
What outcomes were studied?
Outcomes Risk Reduction
Retinopathy 29% ↓ per 0.9% A1c drop
Neuropathy 19% ↓ ‘’ ‘’
Nephropathy 33% ↓ ‘’ ‘’
Nonfatal MI 15% ↓ per 1% A1c drop
Reported Outcomes: Surrogate, not Meaningful
• Progression of retinopathy on exam, vs. loss of vision
• Loss of reflexes or sensation, vs. symptomatic neuropathy or
amputation
• Microalbuminuria vs. kidney failure requiring dialysis
• Non-fatal MI vs. stroke or death from CV disease
Circulation.2017;135:180-195. DOI:10:1161/CIRCULATIONAHA.116.022622
34
172019 MICNP Conference 3/23/2019
Can you spot the surrogate marker?
35
36
182019 MICNP Conference 3/23/2019
% drop, compared to what?
Outcomes Relative Risk
Reduction
Retinopathy 29% ↓ per 0.9% A1c drop
Neuropathy 19% ↓ ‘’ ‘’
Nephropathy 33% ↓ ‘’ ‘’
Nonfatal MI 15% ↓ per 1% A1c drop
Circulation.2017;135:180-195. DOI:10:1161/CIRCULATIONAHA.116.022622
37
ADVANCE Study:
Benefit of intensive control
NEPHROPATHY
20% relative risk reduction;
1.1% absolute risk 1 in 100 people
reduction in 5 years did not
• 4.1% (intensive develop
control) nephropathy
• 5.2% (standard
treatment)
38
192019 MICNP Conference 3/23/2019
Figure 6. Conceptual model for classifying hemoglobin A1c
distribution among US adults with diabetes, NHANES, 2011-2012
Makam & Nguyem. Circulation. 2017;135:180-195.
DOI: 10.1161/CIRCULATIONaha.116.022622.
39
Lending a Hand to Patient with Type 2 Diabetes: A
Simple Way to Communicate Treatment Goals
Erlich DR, Slawson DC, Shaughnessy AF. Am Fam Phys 2014;89(4):257-258
40
202019 MICNP Conference 3/23/2019
How do we best advise patients when:
• Guidelines for clinical targets are not in
agreement.
• We are exhorted to aggressively use
medications to fix “uncontrolled” diabetes.
• Quality measures look at intermediate
measures (e.g. A1c); prevention of
hypoglycemia or other adverse outcome(s)
are usually not measured.
41
Evidence-based medicine framework for clinical decision making. a Estimated on the basis of
age, comorbidities, and functional status. b Includes an individual’s lifestyle, social support,
financial circumstances, and workload capacity.
Anil N. Makam, and Oanh K. Nguyen Circulation.
2017;135:180-195
Copyright © American Heart Association, Inc. All rights reserved.
42
212019 MICNP Conference 3/23/2019
STEPS Mnemonic
1. How safe is the drug for various patient
populations?
2. Is the drug well tolerated or do its adverse
effects cause patients to stop taking it?
3. Has the drug been shown to be effective
for various patient populations?
4. How will the price of the drug affect
adherence?
5. Will addition of this drug be simple or
difficult for various patient populations?
43
Management of Hyperglycemia in T2DM
ADA, 2018
44
222019 MICNP Conference 3/23/2019
2019
Glucose-lowering medication in type 2 diabetes: overall approach.
American Diabetes Association Diabetes Care 2019;42:S90-S102
©2019 by American Diabetes Association
45
How not to choose
46
232019 MICNP Conference 3/23/2019
47
48
242019 MICNP Conference 3/23/2019
Medication Sample Closet and Refrigerator
If all you have is a hammer,
everything looks like a nail.
49
50
252019 MICNP Conference 3/23/2019
K.I.S.S.*
Keep It Simple, Sister!
51
Safest Intervention?
Lifestyle
Medications
52
262019 MICNP Conference 3/23/2019
Treat the Cause
Deprescribing medications, while
prescribing evidence-based lifestyle
intervention(s), may lead to prevention
or remission of type 2 diabetes.
53
Plant-Based Dietary Pattern
• Whole grains
• Vegetables
• Beans, Peas, Lentils
• Fruit
• Water (not cow’s milk)
• Small amounts of nuts and seeds
• Vitamin B12
The Power Plate – Physicians
Committee for Responsible
Medicine
54
272019 MICNP Conference 3/23/2019
Debbie, RN, 2017
55
A plant-based dietary pattern is recommended by:
• American Association of Clinical
Endocrinologists (2018)
• American Diabetes Association (2010-2019)
• Canadian Diabetes Association
• Canada Food Guide (2019)
• Dietary guidelines of Sweden, Brazil, Germany,
Qatar, the Netherlands, Denmark, Finland,
Iceland, Norway & Sweden
• USDA Dietary Guidelines Advisory Committee
(2015)
• American Institute for Cancer Research (2009)
56
282019 MICNP Conference 3/23/2019
Acceptability
A Plant-Based Diet has been found to be highly
acceptable in diverse populations with various
disease states.
Trapp C, Barnard ND, et al. A plant-based diet for type 2 diabetes: scientific
support and practical strategies. Diabetes Educ. 2010;36:33-48.
57
Plant-Based Dietary Pattern: Significant Benefits
Beyond Diabetes*
• Acne
• Appendicitis • Hypertension
• Arthritis • Irritable Bowel Disease
• Atherosclerosis (CMS, • Multiple Sclerosis
2014) • Osteoporosis
• Cancer (WHO, 2015) • Renal Insufficiency/CKD
• Constipation • Stroke
• Erectile Dysfunction • Weight Control
• High Cholesterol
*More information: NutritionMD.org and NutritionFacts.org
58
292019 MICNP Conference 3/23/2019
https://www-ncbi-nlm-nih-gov.proxy.lib.umich.edu/pubmed/29659968
59
Easy. Delicious! Affordable.
60
302019 MICNP Conference 3/23/2019
“Cross Titrate*”
Up-prescribe Plants De-prescribe Meds
1. Assess interest. 1. Identify medications that
2. Assess diet (typical can become too strong with
meals, likes and diet change.
dislikes, etc.) 2. Identify medications that
3. Basic instruction (plan patient would most like to
some meals) discontinue.
4. Resources (Pt and 3. Discuss known benefits
Family) and risks, establish
priorities, and document
5. Referrals discussion.
4. Determine targets for BP,
lipids, A1c/glucose.
* Term from Michelle McMaken, MD 5. Schedule follow ups.
61
Special Considerations
• Hypoglycemia: Patients on insulin or sulphonylureas
• Hypotension
• Anticoagulants (warfarin)
• Add Vitamin B12 (recommended with plant-based
diet, and/or over the age of 50, and/or metformin)
62
312019 MICNP Conference 3/23/2019
What to do with those de-prescribed drugs?
Do Not Flush!!!
Find a local program: search “drug disposal/takeback.”
Last resort: mix with wet cat litter or used coffee
grounds and put in sealed container in trash.
63
Summary – Type 2 Diabetes
• Prevention of hypoglycemia is a greater priority than tight control,
especially in elderly patients.
• Patients on SFUs, meglitinides or insulin should be regularly
assessed for reduction or discontinuation (see deprescribing.org).
Hypoglycemia s&s, prev. and tx should be regularly reviewed.
• Medication might be reserved for patients who are symptomatic and
unwilling or unable to make lifestyle changes.
• A plant-based dietary pattern over any medication offers benefits
beyond glycemic control and is a safe, affordable and an acceptable
option that may be offered to all patients.
• Nurse practitioners should resist calls to intensify treatment, in favor
of patient-centered care and shared decision making.
64
322019 MICNP Conference 3/23/2019
Resources
65
66
332019 MICNP Conference 3/23/2019
21-Day Vegan Kickstart (Free!)
21DayKickstart.org
App Website
67
https://nutritionguide.pcrm.org
68
342019 MICNP Conference 3/23/2019
Coding/Billing
• E & M Codes (99212-99215)
(document: “>50% of time spent on
counseling & education”)
• ICD-10 Codes
– Type 2 Diabetes (e.g.E11.65 w/hyperglycemia)
Plus Z codes (help to explain the time spent)
– Dietary counseling and surveillance Z71.3
– Inappropriate diet and eating habits Z72.4
– Long Term Insulin Use Z79.4
69
PreventionOfDisease.org
Sat. May 18 – Mon. May 20, 2019
70
352019 MICNP Conference 3/23/2019
July 25-27, 2019
71
Be a joyful NP!
72
362019 MICNP Conference 3/23/2019
Cartoon used with permission of Dan Piraro
73
37You can also read
