Troy Trygstad, PharmD, MBA, PhD: Dhiren, as I understand it, 8 out of 10 patients with diabetes will die of a cardiovascular complication. So, when we think about diabetes and treating it, we have to be thinking about how we think in terms of treating diabetes, with respect to what’s going on with their cardiovascular state, not late in the game but perhaps even early in the game. What’s your thought process, in your clinical practice, on combining these disease states in the way you go about treating your patients?
Dhiren Patel, PharmD: That’s a great question. One of the things that I currently tell the students, residents, and Fellows is that when you think about diabetes, you just think about blood sugars. It’s so much more, beyond that. We’re going to talk a little bit about what new information is coming out, but up until just recently, you could make an argument that says that if you really wanted to move that needle on those 8 out of 10 patients who are dying from cardiovascular disease, glycemic control is probably the least important thing that you could probably be doing for them. It’s making sure that they’re on aspirin therapy or an antiplatelet or a statin, with blood pressure control and smoking cessation. Those are all tied to cardiovascular disease. We now have cardiovascular data associated with specific drugs that are also starting to show an impact. But you could say that if you really wanted to move the needle from a population health standpoint, you should focus on those points, even more so than on blood sugar control. I’m not saying that you shouldn’t be looking at sugars, but if you take a step back and look at where we’ve kind of come from, don’t forget those big things.
Troy Trygstad, PharmD, MBA, PhD: That’s a great point. Javier, 10 or 20 years ago, you might think: disease state, how we treat that disease state, drug to go with it, column 1; disease state, how we treat that, column 2. And then, for the rare person who had 3—disease state, drug therapy, how to take, column 3. And you would sort of evaluate 1 and do, evaluate 2 and do, and evaluate 3 and do. In 2018, do you approach practice differently, with so many folks with comorbidities and diabetes—in particular, with many comorbidities beyond cardiovascular disease, such as behavioral health, and depression, and a whole host of other conditions? How has your practice changed, to be thinking about disease states together and therapy together and data together when you’re practicing? How has that changed over the last 10 or 20 years?
Javier Morales, MD, FACP, FACE: It probably has not changed very much. As the practicing internist, you’re always taking into consideration all of these different factors when it comes to the patient as a whole, but the limiting factor…
Troy Trygstad, PharmD, MBA, PhD: So, it goes with primary care? Is that what you’re saying?
Javier Morales, MD, FACP, FACE: It does. The limiting factor is the time factor, because it’s impossible to fix the world in a 10-minute visit. It really is. But just to elaborate on Dhiren’s point, which I think is really critical, when it comes to reducing cardiovascular risk, it’s not just about that hemoglobin A1C. I like to term it as the ABCs of diabetes: A, for hemoglobin A1C; B, for blood pressure; and C, for cholesterol or lipids. And if we really wanted to elaborate more, we could add that D in there—so the question is, what about D? What does D mean? It means diameter. How big are you? Even though we’re measuring body mass index, and we’re able to ascribe or label someone as having obesity based on body mass index, what correlates more with cardiovascular risk is waist circumference, so that’s where that D comes from. If you were to address the composite group, certainly your risk would be significantly lower. And, if you use the appropriate agents, it would be lower still.
The other factor is looking at the patient collaboratively, and at how all of the other ancillary services that are available to our patients will play a role in terms of adherence rates and success. That includes the use of the certified diabetes educator, emphasizing the need for exercise. And the pharmacy has a crucial impact on ensuring adherence to therapy with our patients, and furthering explanation over some of the concerns that patients may have, such as over adverse events that they may be experiencing or that might be anticipated with the use of certain agents.