Stratification for Cardiometabolic Risk Reduction

Peter L. Salgo, MD: What proportion of patients with diabetes, all-comers, actually have an A1C greater than 7%, Rosemary?

Rosemarie Lajara, MD, FACE: Roughly speaking, it’s 50%. Our goal, meaning by the American Diabetes Association, is that 50% of patients do not have an A1C level higher than 7%.

Peter L. Salgo, MD: Now, that was all-comers?

Rosemarie Lajara, MD, FACE: Right.

Peter L. Salgo, MD: How many of these are newly diagnosed? And how many of that group (with an A1C greater than 7%) is already on therapy? One, 2, or 3 drugs.

Rosemarie Lajara, MD, FACE: I would say, probably, the vast majority who are not at goal are the ones who have had diabetes—a long duration of diabetes and several (multiple) agents. And we know that part of the problem is the lack of intensification, as needed. Even in this country, it takes several years to add agents and to intensify diabetes treatment. I would say, it varies significantly. Sometimes, I have a patient who’s newly diagnosed and the impact of receiving the diagnosis of having diabetes gets them involved with lifestyle interventions, medication, or whatever is needed to normalize blood sugar and is significant for them.

Peter L. Salgo, MD: You know, that’s counterintuitive to me. I would have thought that the majority of the patients with A1Cs greater than 7% would be newly diagnosed—new to the office, new to the disease. You’re telling me it’s not?

Rosemarie Lajara, MD, FACE: It varies, significantly. Sometimes people who tend to be on top of their health tend to be diagnosed at lower A1Cs because they transitioned to diabetes. Obviously, depending on access to healthcare, you may find a newly diagnosed patient with an A1C higher than 14%.

Peter L. Salgo, MD: That’s scary.

Rosemarie Lajara, MD, FACE: It is very scary.

Stephen A. Brunton, MD, FAAFP: And that’s part of the problem. When you come in with a high A1C like 10% or 12%, which is often what we’ll see, by starting them on 1 drug, you’re not going to get to goal. And, particularly, these people tend to be gluco-toxic. So, you really need to get the blood sugar down, under control, so the oral agents will work.

Peter L. Salgo, MD: But Dr Watson, over here, was after you to do this—more intensively, if you like. You were after one little control at a time. And you said, “Throw the meatball at them.”

Rosemarie Lajara, MD, FACE: Right.

Karol E. Watson, MD, PhD, FACC: I don’t think we’re seeing vastly different things.

Peter L. Salgo, MD: It sounds like that to me.

Karol E. Watson, MD, PhD, FACC: We’re not going to ignore it. I don’t think he disagrees with me that if his blood pressure is under control that you’re going to still start the statin and the ACE [angiotensin converting enzyme] inhibitor, right? But what he’s saying, and I totally agree with is, we’re not going to say, “I’d like to see a 10-pound weight loss by next week and I want you to start going to the gym 30 minutes a day.” We’re going to introduce all these things, gradually. I think the easier things are the medications. The harder things are getting them to change behaviors.

Peter L. Salgo, MD: But he did say that if an A1C is 14%, it’s not likely you’re going to get control with 1 drug.

Karol E. Watson, MD, PhD, FACC: I agree.

Peter L. Salgo, MD: So, why not start 2 de novo?

Stephen A. Brunton, MD, FAAFP: No, you would. But in the patient, we also need to see some success. If they have an A1C of 14% and you put them on metformin, and they come back 2 months later and they’re at 13%, that’s not success. So, I want them to actually know they’re making a difference. They’ll feel better. The thing is, they think that’s the way they should feel. Once their A1C gets under control, they will feel better, overall.

Christian T. Ruff, MD, MPH: I think people have to translate. The hemoglobin A1C of 14%, where you need to be very aggressive and use multiple agents up front, that’s sort of like showing up at the doctor’s office with a blood pressure of 200/110 mm Hg. That’s not a patient that you should start on a low dose of an antihypertensive and see them again in 6 months. You know that’s a big red flag. Those patients are toxic from their hypertension, toxic from their glucose, and they need aggressive management. Likely, multiple medications. And then once you control that to a reasonable level, I think then you could start to focus and fine-tune the rest of their risk factors.

Rosemarie Lajara, MD, FACE: Absolutely. And that’s what I meant when I said I don’t think we need to prioritize. Obviously, if that’s an individual who has an A1C of 14%, and he or she has a blood pressure of 200/100 mm Hg, guess what?

Peter L. Salgo, MD: How about, “Stay in the hospital with me.”

Rosemarie Lajara, MD, FACE: Right.

Karol E. Watson, MD, PhD, FACC: And exactly as you said, people don’t realize that they’re not quite feeling well. Their blood pressure is 160 all the time. Now, you get it under control and they’re like, “Wow, I thought I had migraines, and my headaches are gone.” Just like the glucose, they’re going to feel better and eventually that will translate into motivation to continue therapy.

Peter L. Salgo, MD: For the A1Cs over 7%, what are the common comorbidities that you see?

Rosemarie Lajara, MD, FACE: We’re talking about type 2 diabetes, so the usual comorbidities that accompany type 2 diabetes: 80% of our patients are overweight, with dyslipidemia, high blood pressure. Obviously, something that we can modify or the patients can modify. What is their smoking status? We could obviously start interventions to target all these comorbidities that add to their cardiovascular risk.

Stephen A. Brunton, MD, FAAFP: Part of the problem is that patients have multiple comorbidities and they’re on multiple medications. I think in one of the practices I work with, which is predominantly a Medicare HMO, those patients are on an average of 8 medicines—and they’re the healthy ones. So, you have a situation where patients either can’t remember, they can’t afford, or they’re basically overwhelmed by it. Working with all that, you are trying to manage all of this, but you recognize the patients in the middle of that.

Peter L. Salgo, MD: That’s again, patient-centric.

Stephen A. Brunton, MD, FAAFP: Right.

Rosemarie Lajara, MD, FACE: Yes.

Peter L. Salgo, MD: A human frailty, human physiology, human nature comes into play here.

Transcript edited for clarity.