Type 2 Diabetes Mellitus and Cardiovascular Disease - Episode 3
What Is Prediabetes?
Troy Trygstad, PharmD, MBA, PhD: The term that comes to mind is 'metabolic syndrome.' Is metabolic syndrome still a contemporary term? And even if it’s not, what does it or did it mean to you? It was the first time, it seems to me, that we sort of admitted to ourselves that there’s a larger construct here than just the pathophysiology of cardiovascular disease or the pathophysiology of diabetes or the pathophysiology of hypercholesterolemia and so on and so forth. So, is that a contemporary term? Do we still use that term? And then, what does it mean to you in your daily lives? Tripp?
Tripp Logan, PharmD: From a retail pharmacy standpoint, if I’m dispensing a Phillips-head screw, and it goes with the Phillips-head screwdriver, and if I’m doing a standard—a nail to hammer—what we’re used to doing is dispensing a specific product. Well, that’s not the world we’re in right now, and there is a lot of overlap. In the community, pharmacists need to get out from behind the counter, to really engage patients about their total care and not just focus on adherence to PDC metrics or adherence to a particular medication. We really need to look at adherence to the plan. They could be 100% adherent to the medication or have claims cover 100% or, even worse, are not taking it. Maybe they’re not even on the right drug or the right dose? Maybe they never even filled the first one? So, there are so many complicated things that we should be addressing in the community space, to look at this patient holistically for every bit of indication that they get. So, if somebody gets a prescription for a medication for blood pressure, and they’ve got diabetes, and that blood pressure medication is never filled, most pharmacies really don’t do much with that. That’s something we need to be better about.
Troy Trygstad, PharmD, MBA, PhD: Well, it sounds to me like what you’re saying is, your lowest common denominator. For patients with these comorbidities and this particular topic, there is this idea that a patient goes to Dr. Patel’s practice, and they’re following the cardiovascular disease. The patient goes to Dr. Morales, and they’re following their diabetes. Community-based pharmacists need to get into a mind-set of 'I might have a patient walk in on day 1 with a diabetes medication, and they may not walk in until day 5 with a cardiovascular medication or for their refill for that.' You cannot separate those, and you can’t be thinking about prescription in and prescription out. It’s prescription in, patient care, and prescription out.
Tripp Logan, PharmD: Who is in charge of that patient’s care? Is it the specialist? Is it primary care? Is it the pharmacy? Is it the patient? Is it the health plan? Who has ownership of that patient? That’s hard. That is a hard system to navigate. Pharmacy likes to take ownership. There’s only so much pharmacy can do. Health plans like to take ownership, but everything isn’t available in a claim for reading. You can’t assess everything that’s going on with the patient based on paid claims. It’s so important to create this care team, where everybody is sharing information. I think this is just in its infancy right now. There’s not a lot of this going on, other than in Dhiren’s clinic and places like that. I’m very jealous of the interoperability of everybody there.
Troy Trygstad, PharmD, MBA, PhD: Javier, metabolic syndrome—Tripp is saying, 'Yes, I recognize it as a practitioner in a community, and we’re trying to counsel our staff to not be thinking about the prescription but be thinking about the patient and how that particular prescription relates to them when they’re in in concert with everything else and all the other prescriptions that are going on.' Do you find the scenario to be the same, as a primary care provider? I’m thinking to myself, 'Thank God for primary care providers, because we do have all of these specialists.' The statistic that always sticks out in my mind is that the average chronically ill Medicare recipient with multiple chronic illnesses sees 13 different prescribers in 1 year. He or she fills 50 unique medications in that 1 year, and they’re 100 times more likely to have a preventable hospitalization. So, this idea of metabolic syndrome being a condition, or a lifestyle—what is it?
Javier Morales, MD, FACP, FACE: In essence, I think that metabolic syndrome, and prediabetes are synonymous. They both lead down the same path. They’re both associated with an increased risk of developing diabetes. The difference is that with metabolic syndrome, the patient scratches their head: 'Well, the doctor says that I have metabolic syndrome.' But if you tell them, 'Hey, look, you have prediabetes,' it’s a whole new ball of wax. Patients themselves have come in contact with people who have had diabetes, who have suffered with both the microvascular and macrovascular complications of diabetes. It’s really a call to action. It’s a warning sign. I applaud the media for trying to bring it into the public opinion and public eye with commercials and so forth, because it’s going to be a major, major problem.
Troy Trygstad, PharmD, MBA, PhD: Yes. Dhiren, in some ways, I heard Dr. Morales say, 'Well, metabolic syndrome may be more of a verb that leads to the noun—which is ‘You’re prediabetic.’ ' If this metabolic syndrome is something that many of us can put ourselves at risk with, whether congenitally or through behavior, activities are happening over a long period of time. This pathophysiology is happening over a long period of time. They land with you. Are you catching them as prediabetic, or does it take that diagnosis of diabetes before you’re activated in your clinic?
Dhiren Patel, PharmD: We’re actually trying to do it even a step earlier than that, believe it or not. We’re looking at obesity. As you mentioned, this is all a trickle-down effect. Well, if you think about what’s underlying, for a majority of these conditions that we’re dealing with, it’s obesity, which doesn’t get the time and attention that it needs. It took the American Medical Association in 2013 to classify it as a chronic disease—to kind of make sure that those ICD-9 and ICD-10 codes were put in there. Now you’re seeing drugs that are on the market that are specifically indicated for chronic weight management and for obesity indications. Our thought process is that if we have these patients with these comorbid conditions, if I can treat the underlying condition with behavior therapy, lifestyle modification, and, potentially, a pharmacotherapy agent…because up until just recently, it was lifestyle. It was behavior therapy. If that didn’t work, then we had bariatric surgery, on the extreme, as with other chronic conditions. There was nothing in between to help that patient. So, in many situations, what we’re trying to do is take a further step back, because the reason for their hypertension is obesity or the reason for their high cholesterol is obesity. Maybe we could solve a couple of those problems by treating the underlying obesity…? So, we’re trying to start at a step earlier and not just look at diabetes.
Troy Trygstad, PharmD, MBA, PhD: Over time, we’ve at least had a national discussion, at least over the last decade—well, overdue and perhaps not amplified enough—with this idea of preventing downstream disease or downstream events. Really, we can’t rescue care our way, out of the humanistic and economic costs.
Tripp Logan, PharmD: That goes back to ownership. Who’s invested in that? Right now, we’re in a 12-month cycle. It’s a 12-month payer cycle. It’s a 12-month everything cycle. So, who owns that benefit 10 years down the road? Nobody is investing in that right now. We’re investing in incident to incident to incident. Unfortunately, I think that’s what’s gotten us in the situation that we’re in.
Dhiren Patel, PharmD: That’s why I always say that I practice in my little bubble. We take that holistic approach because that’s our patient forever.
Troy Trygstad, PharmD, MBA, PhD: It certainly is where you’re at.
Dhiren Patel, PharmD: Exactly. Here, it could be the next pharmacy benefit manager’s problem in 12 months, so do I really want to invest in the downstream? But, now you kind of see these mergers, and acquisitions happening. They’re going to have to change that mind-set pretty quickly because they now own the whole continuum. You’re seeing CVS, Aetna, and Express Scripts, and these mergers happening. Now they’re going to own that entire continuum, so that ownership is going to get more concentrated pretty quickly.