Diabetes is Primary Conference - Special Edition 6/28/2013

Summary

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Podcast Episode Summary

Diabetes Core Update – "Diabetes is Primary Conference – Special Edition" (6/28/2013)

Main Theme:
This special edition, recorded live at the 2013 American Diabetes Association Scientific Sessions, distills essential take-home practice points from conference lecturers. The episode addresses crucial updates in diabetes management for primary care, focusing on new blood pressure recommendations, strategies for insulin intensification, and diabetic foot care and amputation prevention.

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Key Discussion Points & Insights

1. Update: New Blood Pressure Recommendations

Speaker: Dr. Reinhardt (Medical Director, Johnson Memorial Diabetes Care Center; ADA Professional Standards Committee)
Timestamps: 01:38 – 03:34

• Main Change:

  • The systolic blood pressure target has been raised from <130 mmHg to <140 mmHg, while the diastolic goal remains <80 mmHg.
  • “Instead of less than 130, the new goal was less than 140. And so our new target for blood pressure 2013 is less than 140 over less than 80.” (Dr. Reinhardt, 01:48)

• Rationale:

  • The change is rooted in an evidence-based review, which showed no improved outcomes (e.g., stroke, heart disease, kidney failure) from stricter (<130) control, but greater treatment burden and side effects from more aggressive medical therapy.
  • “As we looked at the data… the people’s outcomes… are essentially the same as trying to push less than 130… but didn’t have a better outcome. So, less than 140 seems to be our new target.” (Dr. Reinhardt, 02:11)

• Practical Tip – Medication Timing:

  • Patients on multiple antihypertensives achieve better control if one medication is taken at night.
  • “There is a trial…it actually showed that when you take one of your antihypertensives at night…you get better overall blood pressure control.” (Dr. Reinhardt, 03:08)

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2. Clinical Approach: Intensifying Insulin Therapy

Speaker: Dr. Eric Johnson (Assistant Medical Director, University of North Dakota; Altrudiabetes Center)
Timestamps: 03:36 – 09:06

• Simple Next Step for Basal-Only Insulin:

  • Many PCPs are comfortable with basal insulin initiation; intensification is approachable and impactful:
    • “The good second step… is to do what we call a 90-10 program…start with a single injection of a rapid acting bolus insulin with the biggest meal of the day.” (Dr. Johnson, 04:20)
    • For example, reduce basal dose by 10% and use that 10% as rapid-acting insulin with the largest meal.

• Managing Oral Agents When Advancing Insulin:

  • Discontinue TZDs (due to weight gain/edema concerns with intensive insulin) and sulfonylureas (since they target postprandial sugars, now better addressed by bolus insulin).
    • “We often stop TZDs…as they are more likely to have weight gain issues with intensive insulin… we stop the sulfonylureas.” (Dr. Johnson, 06:11)

• Moving to Multiple Daily Injections Without Carb Counting:

  • Employ a non-carb-counting method inspired by Dr. Bergenstahl:
    • Basal insulin is titrated for fasting glucose; then, split insulin 50/50 between basal and bolus.
    • Bolus doses are based on meal size (large, medium, small), not carb counting.
    • “That works pretty well and doesn’t require them to carb count.” (Dr. Johnson, 07:34)

• Practical Impact:

  • Simpler regimens can be more accessible to primary care clinicians and patients, overcoming carb-counting barriers.
    • “Carb counting is very intimidating for most primary care physicians…This approach sounds wonderful and implementable.” (Dr. Skolnik, 08:24)

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3. Diabetic Foot Care & Amputation Prevention

Speaker: Dr. David Armstrong (Professor of Surgery, University of Arizona; Director, Southern Arizona Limb Salvage Alliance)
Timestamps: 09:06 – 17:19

• Disease Burden:

  • Chronic diseases, not infections, now account for the majority of global death:
    • “For the first time in human history, more people died from non-infectious diseases…than from all of the plagues in the world combined.” (Dr. Armstrong, 09:45)
  • Diabetic foot complications are common, complex, costly, and a leading cause of hospitalization.

• Core Concept – “The Gift of Pain”:

  • “People with diabetes lose the gift of pain.” (Dr. Armstrong, citing Prof. Paul Brand, 11:00)
  • This leads to unnoticed foot trauma, ulceration, infection, and high amputation risk (amputation every 20 seconds worldwide).

• Assessment Framework (“3 Questions”):

  1. Loss of Protective Sensation (neuropathy test: monofilament, touch)
     • If absent in any site, risk is elevated.
  2. Peripheral Artery Disease (pulse exam; ABI if pulses indistinct)
     • Absent pulses prompt further vascular evaluation.
  3. History of Prior Complications (ulcers, amputation, Charcot foot)
     • Any history puts patient at highest risk.
  • “…if they can’t feel one or more of those sites, that is diagnostic…they will be at higher risk for development of a wound.” (Dr. Armstrong, 12:20)
  • “Has the person had previous problems…that automatically puts them at the highest risk stratum.” (Dr. Armstrong, 13:30)

• Risk-Based Action Plan:

  • Low risk: No neuropathy or PAD – annual specialist review, daily self-checks.

  • Medium risk: Neuropathy but no PAD – review 2–3x/year, footwear education, possible orthotics.

  • High risk: PAD ± neuropathy – more frequent checks, vascular consults, possibly every few months.

  • Very high risk: Prior complications – "36 times greater risk," review every 1–2 months, in-depth specialist follow-up.

  • “Even in the most high-risk patients, every one to two months to the foot doctor…possibly also for follow-up with a vascular specialist.” (Dr. Armstrong, 16:34)

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Notable Quotes

• Dr. Reinhardt [02:11]:
  “As we looked at the data and really delved deep…there’s really no great evidence to be less than 130…People had more treatment burden from being on more drugs, more side effects, but didn’t have a better outcome.”
• Dr. Johnson [04:20]:
  “A good second step to advance a program is to do what we call a 90-10 program…starting with a single injection of a rapid acting bolus insulin with the biggest meal of the day.”
• Dr. Armstrong [11:00]:
  “People with diabetes lose the gift of pain.” (quoting Prof. Paul Brand)
• Dr. Armstrong [09:45]:
  “For the first time in human history, more people died from non-infectious diseases, Neil, than from all of the plagues in the world combined.”

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Timestamps for Important Segments

• 01:38: Dr. Reinhardt on new blood pressure targets and rationale
• 03:08: Nighttime dosing of blood pressure medications
• 04:20: Dr. Johnson's practical 90-10 insulin intensification strategy
• 06:11: Adjusting oral agents when intensifying insulin
• 07:34: “Non-carb counting” basal-bolus insulin regimen
• 09:45: Dr. Armstrong on the impact of chronic disease
• 11:00: “The gift of pain” and its implications for diabetic foot care
• 12:20: Three-step assessment for diabetic foot risk
• 13:30: Prior ulcer/amputation as a high-risk marker
• 14:59: Practical risk stratification and follow-up intervals

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Memorable Moments

• The practical and empathic framing of neuropathy as "losing the gift of pain."
• Concrete, actionable protocols for both insulin intensification and foot risk assessment.
• Evidence-based endorsement of relaxing previously strict blood pressure targets to lessen treatment burden.

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This episode arms primary care clinicians with succinct, evidence-based updates and actionable frameworks for improving diabetes care, emphasizing risk-based management and the importance of simple, implementable steps in busy practice environments.

Transcript

[A]

Hello, I'm Dr. Neal Skolnick and this special edition of Diabetes Core Update is being recorded live at the 2013American Diabetes Association Scientific Sessions meeting during the Diabetes is primary portion of the meeting, which was a day long conference devoted to the educational needs of primary care physicians. What we've done today is ask each of the lecturers from this conference to talk for a short period of time about what they feel are some of the most important learning points to take from their talks. For further and detailed information about their talks, please just go to www.professional.diabetes.org primary and you can download and watch full webcasts of the meeting. And now for our first speaker. We're here with Dr. Reinhardt today who is medical director of the Mountain State's Health alliance of Johnson Memorial Diabetes Care center in Abingdon, Virginia. Dr. Rinehart is also on the professional Standards committee for the American Diabetes association and just gave a wonderful talk on the new blood pressure recommendations issued in the Standards of care. Welcome, Dr. Rinehart.

[B]

Thank you for having me.

[A]

Would you like to go over some of the changes in the recommendations for blood pressure that you just reviewed for the group? Yes.

[B]

There's really one main change and that's for systolic blood pressure. We actually raised the target. Instead of less than 130, the new goal was less than 140. And so our new target for blood pressure 2013 is less than 140 over less than 80.

[A]

That's fantastic. Review a little bit. Why the change? That's a landmark change.

[B]

It is. It's a big change. And what we've done over the last few years with Professional Practice Committee and the Standards of Care is we really want to be evidence based. We want to give guidelines that are based on the evidence. And as much as we'd like to say our old guideline was always evidence based, maybe it wasn't because as we looked at the data and really delved deep into it, there's really no great evidence to be less than 130, less than 140. The people's outcomes in terms of stroke, heart disease, kidney failure, they're essentially the same as trying to push less than 130 and actually less than 130. When some of the studies, people had more treatment burden from being on more drugs, more side effects from the drugs, but didn't have a better outcome. So less than 140 seems to be our new target.

[A]

That's an important new recommendation. The other thing that I noticed in your talk you mentioned about taking at least one of your blood pressure medicines at night. Can you tell us a little bit about that?

[B]

Yes, and I would love to see. I remember the name of the trial, but you and I know you see all these trials that get the names mixed up. But there is a trial, it was randomized, controlled clinical trial, and it actually showed that when you take one of your antihypertensives at night, if you're on more than one, that you get better overall blood pressure control. And so the recommendation is to try to take one of your blood pressure medicines at night.

[A]

Fantastic. Those are some helpful take home points. Thank you.

[C]

Thank you very much.

[A]

Our next speaker today is Dr. Eric Johnson, who is Assistant Medical Director, Altrudiabetes Center, University of North Dakota School of Medicine and Health Sciences in Grand Forks, North Dakota. Welcome, Dr. Johnson.

[C]

Yeah, thanks, Neil. Great to be here.

[A]

That was just a wonderful talk on what to do when basal insulin is not sufficient and intensifying insulin management. And you really went over a wonderful algorithm, both a simple approach for initial approach and then more advanced approach. Could you start with telling our listeners about the simple approach about what to do when basal insulin is not sufficient?

[C]

Sure, Neil. Our experience is a lot of primary care practices are very comfortable initiating basal insulin at this time. Now that these products have been on the market for a while, we think that these same offices and practices can really do this next additional step. It's not very complicated and it will kind of resonate with some of the things they do with basal insulin initiation. A good second step to advance a program is to do what we call a 9010 program. You'll see this published in a variety of diabetes periodicals. But basically you have a patient on a basal insulin who is probably meeting their fasting blood sugar goals, but not their A1C goals. And that would be suggestive of a patient who has postprandial glucose elevation. Basal insulin is not going to address postprandial blood sugars very well. So we suggest starting with a single injection of a rapid acting bolus insulin with the biggest meal of the day. For most people, that's going to be their evening meal. So if we have a patient who say, is on 60 units of Glargine or Denimur and we're going to add this mealtime dose, we would subtract 10% from the basal dose and then we take that 10% and convert that to rapid acting bolus insulin with the biggest meal of the day. So in this instance, there's 60 units of their basal would be reduced to 54 and they would get 6 units of a rapid acting with a big meal. And that does address a substantial portion of the out of range postprandial blood Sugars in a 24 hour period.

[A]

That's really helpful. And then can you mention, you also talked about when you go to that more intensive regimen, what do we do with our oral hypoglycemics when we start.

[C]

Intensifying insulin with more than one insulin product? Product, we often stop certain oral agents. It's our practice to stop TZDs, typically in people who are going to do intensive insulin as they are more likely to have weight gain issues with intensive insulin or problems with edema as well. When we go to multiple daily injections or even just this two injection program, we stop the sulfony area. The savanna area's original job was to address postprandial blood sugars. And if it was doing its job, we wouldn't need to be doing this bolus insulin.

[A]

That makes a lot of sense. And then for patients whose A1Cs are not sufficiently controlled on the 2 injection program, what then?

[C]

We often move to what we call a non carb counting approach. This was proposed by Dr. Bergenstahl at the International Diabetes center in Minneapolis about five years ago in a paper in Diabetes Care. And you're going to go to bolus insulin that will be taken with meals along with the basal insulin. The basal insulin is presumed to be titrated to have appropriate fasting blood sugars. And you want to have about a 50, 50 split between your total daily basal dose and your total daily bolus dose. So let's say we have a patient on 50 units of a basal insulin and we're going to do three injections with meals. We often will reduce that basal insulin by as much as 50%. So in this instance we would go from 50 down to 25. Then we take that 25 that we split off and we're going to give that with meals in a non carb counting fashion. And what we do is we have patients estimate their meal size, large size, medium size and small small size. Then we kind of cut up that remaining 25 units of bolus insulin, depending on meal size. So maybe a big meal will be 13 to 15 units, maybe a medium sized meal will be more like seven or eight, and a small meal will be more like three or four. And that works pretty well and doesn't require them to carb count.

[A]

That's fantastic because I think carb counting is very intimidating for most primary care physicians. And Takes a lot of long learning to get there. I think that this approach sounds wonderful and implementable and something that really we can take home and use to help our patients.

[C]

Yeah, I think so, Neil. I think it's really a nice smooth continuum that flows together logically. The person has been somewhat successful using their basal insulin. We had the second thing with their biggest meal of the day, they come in pens. So it's not really a difficult instruction. And then at some point we're just going to say to them, let's take this rapid acting with all of your meals. But we have this simple approach based on meal size.

[A]

Fantastic. Thanks so much for joining us. We're pleased to have the next speaker for this morning, David Armstrong, who is a professor of surgery and director of the Southern Arizona Limb Salvage Alliance, University of Arizona College of Medicine in Tucson, Arizona with us. He just gave a talk on diabetic foot care and prevention of amputations. Welcome, David.

[D]

Thanks a lot.

[C]

Pleasure to be here.

[A]

Well, it's a pleasure to talk to you. You opened your talk with some compelling information from the BMJ from 2009. Can you tell us about that?

[D]

Sure. So, you know, I guess in 2009 we were all mired in a worldwide kind of economic funk and no one was really thinking about the future of our race or where we're going and whatnot. But the point of things is, for the first time in human history, more people died from non infectious diseases, Neil, than from all of the plagues in the world combined.

[A]

That's amazing.

[D]

And so that's going to change pretty much everything about how we care for our patients, be us, be we primary care physicians, nurses, specialists. And I think we're moving from an era of disease or from plagues to an era of decay. And we're managing these non communicable diseases and we're going to be dealing with managing chronicity and replacement parts and it's going to dictate everything about what we do.

[A]

You know, it's interesting, when you talked about the era of decay, you used a quote that really struck me about the situation that patients with diabetic foot problems have. What was that quote?

[D]

So? Well, the point being is that, you know, these diabetic foot problems are really, they're common, they're complicated and they're costly. It's amongst the most common reasons that people will show up in the hospital. But the reason all this happens is because people with diabetes lose the gift of pain. And that's a quote from one of my mentors Professor Paul Brand. But when people lose that gift, and we don't think of it as a gift very often, but it leads us to behave differently and we will wear a hole in our foot and our skin just as we might wear a hole in a shoe or a sock. And that hole is called an ulcer. About half the time it gets infected. Once it gets infected, about 30%, 20 to 30% of them are going to lead to an amputation of some kind. That's why there's an amputation, Neil, every 20 seconds around the world. The good news, though, I will tell you, is that amongst all the bad, the good news is that this is all preventable.

[A]

And that's the important piece that I want to focus on now. You gave advice about how to assess accurately and quickly for diabetic foot issues over that for our listeners.

[D]

So here. So let's just go through that really rapidly on the podcast and hopefully really accurately. So, three, let's ask three questions. The first question is, has that person lost the gift of pain? Does this person have what we call loss of protective sensation or enough neuropathy not to be able to feel when there's a problem? That can be done through a variety of means, through either a 10 gram monofilament wire, through what's called a simple touch test, where you can just lightly touch the ends of the toes. Now with a similar amount of force, asking the patient, Ms. Jones, close your eyes and tell me where I'm touching you. And you can kind of mix it up a little bit. If they can't feel one or more of those sites, that is diagnostic, quite accurate for what we call loss of protective sensation. They will be at higher risk for development of a wound. That's the first barrier to pass. The second is, do they have peripheral artery disease? That can be done by assessing a standard pulse exam, by looking for a dorsalis pedis or posterior tibial pulse. If you can't feel one or more of those, then this might compel you to do either an ankle brachial index or it might compel you to seek further consultation from your colleagues in vascular surgery and podiatric surgery. That's the second question. Is there loss? Excuse me, is there peripheral artery disease? The third question is a real simple question, but it often goes unasked, and that is, has the person had previous problems? Is there previous history of complications? If they have previously had a wound, and if they obviously previously had a partial foot amputation or anything like this, and then that automatically puts them at the highest Risk stratum. But if you have these three things, then you can put them into a really evidence based kind of framework for triage and you can put them into kind of a low, medium and high risk framework.

[A]

That's great. And that framework leads to an action plan.

[D]

So one can have. If someone has no loss of protective sensation and no vascular disease, that person only needs maybe to be referred out for annual review by a foot doctor. And that person is at quite low risk for developing a complication. But they can go out for annual review and they can have some diabetic foot education, maybe just for them to knock their socks off and look at.

[C]

Their feet every day.

[D]

Just like they comb their hair, they brush their teeth. But quite low risk. The next stratum would be relatively low risk. And that is someone that has loss of protective sensation but no vascular disease. That person is at higher risk than the person that has not lost protective sensation. And this person may need to come back a couple of times a year. They may need to be in athletic shoes if they don't have a deformity. If they do have a deformity, they may need to be in more robust protective shoes. Doesn't mean ugly grandma shoes, it just means shoes that might help to protect their feet. And they may be coming back anywhere from two to three times a year. As I said, the next category is someone that has peripheral artery disease. That person is at higher risk than the person with just neuropathy. This person needs to be seen a bit more often. Everything else that we talked about needs to be done to them. They may be coming back again maybe a few times a year to the foot specialist. They certainly need a vascular surgery, a vascular specialist consultation for assessment, even if it's just for watchful waiting, just to get on the radar screen. The final stratum is the person that's had a history of a complication, like an ulcer, an amputation or something we call charcotropathy, which happens in a lot of patients, which we don't have time to discuss, but we can, if you like, another time. And that high risk patient is at 36 times greater risk of developing a complication than someone lowest risk. That person needs to come back several times a year. Even in the most high risk patients, every one to two months to the foot doctor to have his or her feet checked and shoes checked and possibly also for follow up with a vascular specialist. If they've had previous vascular complications, they need to get scanned for a graft that they've had.

[A]

Fantastic. So that's really helpful. You've gone over with us how to assess accurately and quickly for issues in patients with diabetes with regard to foot care and then a clinical clear guidance about what to do after that assessment. Thanks so much.

[C]

It's a pleasure.

[A]

So that concludes part one of our three part special series recorded live at the American Diabetes Association Scientific sessions during the Diabetes Primary meeting. Please tune in for parts two and three where we'll cover diabetes in the older adult, the kidney in diabetes, distinguishing between type 1 and type 2 diabetes, new therapies in diabetes and blood glucose pattern management. Also, if you care to see these lectures in full detail, just check out the webinar that will be on the American diabetes website at www.professional.diabetes.org primary where they will be putting up the full slide deck and lectures for this whole Diabetes is Primary series. Again, that's professional.diabetes.org primary. Thank you for listening.

[D]

Sam.