Troy Trygstad, PharmD, MBA, PhD: Hello, and thank you for joining this Pharmacy Times® Peer Exchange® panel discussion on type 2 diabetes mellitus and cardiovascular disease. Among individuals with diabetes, cardiovascular disease is the leading cause of mortality. Pharmacists are on the front line, counseling type 2 diabetic patients about lifestyle modification, control of hypertension, antiplatelet therapy, and decreasing cholesterol to help reduce their cardiovascular risk.
This Peer Exchange® will explore the use of different classes of drugs that are used to help control glucose levels in addition to decreasing the risk of cardiovascular disease.
I am Dr. Troy Trygstad, and I am a vice president of Pharmacy and Provider Partnerships for Community Care of North Carolina, in Raleigh, North Carolina. I’m also the editor-in-chief of Pharmacy Times®.
Participating today on our distinguished panel are Dr. Tripp Logan, vice president of L&S and Medical Arts pharmacies, Charleston, Missouri, and partner of MedHere Today of Nashville, Tennessee; Dr. Javier Morales, associate professor of medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell University in Hempstead, New York, and vice president of the Advanced Internal Medicine Group in East Hills, New York; and, finally, Dr. Dhiren Patel, associate professor of pharmacy practice at MCPHS (Massachusetts College of Pharmacy and Health Services) University and clinical pharmacy specialist at the VA Boston Healthcare System in Boston, Massachusetts. Thanks so much for joining us. Let’s begin.
Dr. Morales, you’re an internal medicine physician, so you cover a lot of disease states across a lot of populations. Give us a sense of the impact of diabetes on an internal medicine clinic—the totality of it—and the proportion of effort that goes into treating this disease state.
Javier Morales, MD, FACP, FACE: It’s actually kind of interesting. As we’re starting to see an increase in obesity, not just in the United States but worldwide, we’re starting to see a lot more patients with insulin resistance, prediabetes, and diabetes. In fact, there are a lot of NHANES (National Health and Nutrition Examination Survey) data that have emerged, over the years, looking at the correlation of this weight gain and the development of insulin resistance. At this point in time, in my own personal practice on Long Island, New York, I would say that about 35% to 40% of my patients would be considered as prediabetic, on the basis of these guidelines that have emerged.
Troy Trygstad, PharmD, MBA, PhD: That’s dramatic. Thirty to 40%?
Javier Morales, MD, FACP, FACE: It is. It’s very dramatic because, for the most part, these patients will eventually develop full-blown diabetes if they don’t participate in any aggressive lifestyle intervention. So, it winds up being quite problematic. The other thing that’s also very important to recognize is that your life expectancy, if you have diabetes, is going to be significantly reduced. If you have diabetes, on average, you could discount about 6.7 years of your life. If you have diabetes and have had a myocardial infarction, we’re looking at about 11 years lost. And if you’ve had myocardial infarction and stroke, about 15.7 years of your life are lost. So, it is a very devastating illness with a significant public health impact.
Troy Trygstad, PharmD, MBA, PhD: The burden of illness is clearly large from a humanistic, but also an economic perspective. Dr. Patel, in your practice, you see a lot of patients with diabetes. What proportion of your practice, at the Veterans Administration or the VA clinic, might diabetes affect?
Dhiren Patel, PharmD: The population that I’m specifically dealing with, within the endocrine clinic, is obviously a big percentage of what we do. But if we even take a step back and look at the broader population, I think for those who are either prediabetic or diabetic, the CDC just recently issued their diabetes report card and said that there are 86 million people. And so, you just do the math and you know that 1 in 2, or 2 in 3, are pretty much walking around and would fit into these criteria for it. But that comment regarding the economic burden—it’s not just the direct cost of diabetes, it’s a lot of the indirect costs. When we look at microvascular complications—which is something that we’ve honed in on over the years because we’ve had some long-term trials that show that if you get patients to goal early and keep them there, you’re going to prevent retinopathy, neuropathy, and nephropathy—you can kind of see the costs adding up quickly with blindness and dialysis and what have you.
More often, in recent times, we have been focusing on and shifting to cardiovascular disease, which I think is not enough. If we actually look at those microvascular complications, a small majority of patients actually die from those things. If we look at those patients who have diabetes, and look at what they’re dying from, 8 out of 10 of them are dying from a cardiovascular cause or cardiovascular disease, and so it’s really important to not just focus on the microvascular complications, but also to focus on the macrovascular complications. Now, we know that if we can affect that, it’s going to affect the long-term cost, as well.
Troy Trygstad, PharmD, MBA, PhD: So, in many ways, what you’re saying is we have 2 silent killers that are really…
Dhiren Patel, PharmD: Converging.
Troy Trygstad, PharmD, MBA, PhD: In the same neighborhood?
Dhiren Patel, PharmD: Yes.
Troy Trygstad, PharmD, MBA, PhD: And so, we’ve got some scary numbers—with respect to the proportion of a primary care practice’s effort, the economics of it, and the reduction in life.
Tripp, you’re from a small town in Missouri. What’s the impact of diabetes on the community as a whole? What do you see as you’re walking down the street to your pharmacy and as folks are walking into the pharmacy? I think it’s important for the audience to step back and think about the totality, again, of this disease state and why it’s so important for us to figure it out, treat it, and come up with prevention programs.
Tripp Logan, PharmD: I’m in the Mississippi River Delta, so when I walk down the street, I see catfish, fried chicken, and sweet tea. Not only is this a notoriously poor area of the country, all the way up and down the Mississippi River, but there is a high incidence of diabetes. The incidence is so high that in our state, Missouri, the most current dollars that are going to diabetes prevention are first offered to my part of the country. And it’s not only just in the pharmacy or in the physician’s office or in the emergency room, it’s in the neighborhoods. There are so many people who have a grandmother and a mother and an aunt who have diabetes—well, they probably do, or they have prediabetes, and it’s somebody we need to be engaging with. How do we do that? What’s the benefit for the patient? How can a pharmacy be compensated to spend time with this patient? It’s everywhere, and I don’t think we’re unique. I think we’re a unique part of the country, but I don’t think it’s a unique problem.