A review of the comorbid conditions and cardiovascular risks with type 2 diabetes and the need for tighter glycemic control in these patients.
Tripp Logan, PharmD: Patients who present to us with diabetes have many other things other than just diabetes when they present. Not only do they have these other chronic conditions typically, but they’re at risk for many other things like cardiovascular disease and mental behavioral-health concerns. There are many, many things.
Cardiovascular disease is of utmost importance to us, and it’s something that we can influence at the pharmacy level in many ways. We had the ability to check a patient’s blood pressure and blood sugar, blood glucose, in the pharmacy—very helpful when we’re looking at these 2 things. And our approach is usually to take both of these conditions—diabetes and cardiovascular disease—together and use the multiple touch points that we have with patients and maximize those touch points by working to control not only blood pressure but the blood sugar as well, in those visits with us.
If a patient doesn’t have cardiovascular disease and they’ve got diabetes, they’re at high risk for cardiovascular disease. So as a pharmacy provider we need to look at that and consider that as we not only engage this patient based on their care plan but help modify and build their care plan down the road.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Patients with diabetes are at an increased cardiovascular risk. If you look at the different complications that a patient with diabetes can suffer from, we have what we call our microvascular complications that are neuropathy, retinopathy, nephropathy. And then we also have what we call our macrovascular complications. If you look at what patients with diabetes die from, 8 out of 10 patients are dying from cardiovascular causes. And so it is very important that we focus beyond glycemic metrics, and we’re not just looking at the patient’s blood sugars, and we’re not just looking at their A1Cs [glycated hemoglobin], but we’re managing the patient as a whole and not just their disease. Especially when we know that if we want to move the needle from a population health standpoint, that we’re going to have to start focusing on some of these cardiovascular preventive measures.
Common comorbid conditions that you’re likely to see in a patient who has type 2 diabetes include hypertension and high cholesterol, so dyslipidemia is a big one. More and more of patients are now presenting with being either overweight or obese. We also see patients having chronic kidney disease and obstructive sleep apnea. Depression is another comorbid condition. So we see a variety of them, and the point here is that again, you have to manage the whole patient and not just the condition. I can put you on the best medication for your type 2 diabetes, but if your depression isn’t well controlled and I don’t have you on the right therapy there, no matter what I do here is not going to make a difference.
And so to again address the chief complaint and looking at that patient and saying, well, what’s working, what’s not working. Let me first get you the help and get you to a mental health provider. Because if that side of the house is in a better spot, it’s going to make it that much easier for me to be able to control your diabetes. And we know those folks who are depressed are less likely to take their medication. So we see a lot of it. It’s hard to just say I’m going to manage this. We realize in the role of specialists that tends to happen. Just being at least aware or at least getting folks referred in to the right people makes a big difference.
If you look at the newer guidelines, the standard of care is being customized to the patient’s past medical history and their comorbid conditions. One example of that is the ADA [American Diabetes Association] guidelines as well as the ADA/EASD [European Association for the Study of Diabetes] consensus report that came out late last year. And you’ll see in both of them—in the ADA, for example—after 3 months of metformin therapy, as a clinician you should be asking yourself, Does my patient have established cardiovascular disease? And if they do, should we be using medications that have this positive cardiovascular data. Which you’re seeing with GLP-1 [glucagon-like peptide-1] agonists, you’re seeing that with the SGLT2 [sodium-glucose cotransporter 2] inhibitors.
Take that 1 step further, if you look at the ADA/EASD consensus report, they have an algorithm that basically gets you to ask yourself, Does my patient have established cardiovascular disease, or does my patient have heart failure or CKD [chronic kidney disease]? And depending on which path you go down, with the ASCVD [atherosclerotic cardiovascular disease] portion, it says first try a GLP. If that doesn’t work, then consider an SGLT2. And the heart failure side or the CKD side it says to start an SGLT2 inhibitor. Then if that’s not an option, or if there’s a contraindication to that, to consider a GLP-1 receptor agonist. And so a lot of it’s now in relationship with what their past medical history looks like as well as their comorbid conditions.
Tripp Logan, PharmD: Comorbidities are pretty unique to each patient. So for a patient who does not have cardiovascular disease but is reporting a high blood glucose, cardiovascular disease may be a secondary preventive approach that we take when the high blood sugar is what we target now.
We found in our practice that comorbidities are so unique among each patient that we need to take those patients uniquely and treat them accordingly. So when somebody presents with multiple chronic conditions and other comorbidities, we need to unpack those individually but then bundle them up with this patient as a whole. Because today in our health care system there’s a silo affect where, say, an endocrinologist treats their specialty, and then the orthopedist treats their specialty, and the pharmacy works with the prescription medications. But what we’re lacking is somebody to bundle this up and come up with an overall care plan for that patient based on all their comorbidities.
So I think that’s a really good place for pharmacy right now and where we try to spend most of our time. If the patient presents with comorbidities with diabetes, then we need to prioritize those comorbidities based upon that individual patient. So yes, all these comorbidities need to be addressed, but sometimes you can’t take a shotgun approach and address everything at once. So these need to be prioritized and the patient has to be brought into this conversation in order to determine how to prioritize. Even though I may think that cardiovascular disease is the most important piece of this and the most acute issue, if the patient is not willing to touch that right now, but they’re willing to look at blood glucose or vice versa, then we need to start where the patient is.
Having tighter glycemic control is definitely a goal for the patients who we see. We find this very challenging. Glycemic control in itself is typically our goal. And if we get to the point where patients are really responding to what we’re helping them achieve, then we push for tighter glycemic control.
We had several patients. Off the top of my mind I can think of several who have had hypoglycemic episodes and are very fearful of tighter glycemic control. So we try to frame that maybe with different language than tighter glycemic control. We’ll say, we’ll set your goal blood sugar levels a few points lower. We’ll try to explain to the patient, help them work through what scenarios may occur if they do have a hypoglycemic episode. But the literature definitely states that tighter glycemic control leads to better outcomes for patients, which is what we’re always driving for.
But if we’ve got a patient with a blood glucose that’s way out of control with a lot of comorbidities, we’re not immediately going for tighter glycemic control. We’re going to start unpacking every single problem that they have, starting with the highest risk and the low hanging fruit, working toward the glycemic control, and then our next step is tighter glycemic control.