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Type 2 diabetes is associated with a two- to four-fold increase in the risk of CVD. Pharmacists can monitor and manage the risk factors.
Type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) are intertwined. T2DM is a major risk factor for CVD, and CVD is the most common cause of death among people with T2DM. Type 2 diabetes is associated with a two- to four-fold increase in the risk of CVD.1 Pharmacists and other healthcare professionals seeking to reduce this complication must closely monitor and aggressively manage CVD risk factors in people with diabetes.
To this end, the American Diabetes Association (ADA) and the American Heart Association (AHA) have issued an update on the prevention of cardiovascular disease in adults with T2DM. The update, presented in a scientific statement, was published in both Diabetes Care and Circulation.1
The update covers the same areas of treatment that ADA and AHA addressed in a joint statement in 1999 that focused on prevention of cardiovascular disease in diabetes mellitus.2 In 2007, the two organizations issued a combined set of recommendations that focused on the primary prevention of CVD in diabetes mellitus.3
Since then, several clinical trials have produced results that have changed the clinical practice of cardiovascular risk management for people with diabetes. In addition, the screening and diagnosis of diabetes have changed, with the addition in 2010 of HbA1c levels as a diagnostic criterion.
Diabetes is being called a continuing epidemic in the United States. The number of adults diagnosed with diabetes in the United States nearly quadrupled between 1980 and 2012. According to the Centers for Disease Control and Prevention, if this trend continues, by 2050 as many as one-third of American adults will have diabetes. Diabetes is not spread evenly through the population, however. Half of all Hispanic men and women and half of non-Hispanic black women can expect to develop diabetes sometime during their lives.4
There is a little good news in diabetes trends. People with diabetes are living longer. Preventive care for adults with diabetes and for the risk factors that cause complications has improved significantly. Mortality rates from heart attack, stroke, amputations of the legs and feet, and end-stage renal disease, as well as deaths due to a hyperglycemic crisis, have all declined in adults with diabetes between 1990 and 2010.1 But this silver lining is still clouded by the large numbers of patients with diabetes who incur these complications, especially in the case of CVD.
Craig WilliamsThe scientific statement is a synthesis and summary of recent findings from key clinical trials in diabetes and cardiovascular disease. It does not contain any information that is new, “but there is a whole lot of information in it, so there will be something in it that is new to almost everyone, unless they’re a real expert in the field,” said Craig D. Williams, PharmD, FNLA, BCPS, clinical professor at Oregon State University/Oregon Health & Science University College of Pharmacy in Portland.
Caroline Fox “People are seeing it in one spot for the first time,” said Caroline Fox, MD, MPH, senior investigator in the Laboratory for Metabolic and Population Health at the National Heart, Lung, and Blood Institute. Fox served as lead author on the scientific statement. “We pooled a lot of diabetes recommendations from other places.” The entire field of diabetes care is moving fast, she added. “Pharmacists need to be aware that there is a lot of information, and that things are changing quickly.”
Robert EckelThe update was intended as the latest version of the Adult Treatment Panel Cholesterol Guidelines (ATP) first issued in the 1980s, said Robert Eckel, MD, professor of medicine at the University of Colorado, Anschutz Medical Campus, in Aurora. Eckel, a past president of the American Heart Association, is a co-author of the update. The National Heart, Lung, and Blood Institute no longer creates guidelines and the responsibility passed to AHA, ADA, and the American College of Cardiologists, Eckel said.
Pharmacists need to be aware of newer findings in diabetes and cardiovascular disease, especially concerning the use of cholesterol-lowering drugs, Eckel said. The pharmacist can reinforce and educate patients about the prescriptions they are being given.
One change revealed in the update concerns HbA1c levels, which are no longer seen as hard and fast numbers for one and all. “We have moved away from stringent A1c targets. It is more of a personalized approach,” Fox said.
This change has come about because, although the link between hyperglycemia and the risk of cardiovascular disease is strong, clinical trials have found only limited evidence that intensive glycemic control reduces this risk.
Tracey TaveiraOther goals also need to be tailored to the individual, said Tracey Taveira, PharmD, CDOE, professor at the University of Rhode Island College of Pharmacy in Kingston and an adjunct professor at Brown University School of Medicine in Providence. The targets for hypertension, hyperlipidemia, and glycemic control are laid out in the update, but the update also prioritizes these problems, she said.
“We can’t achieve everything for every patient, due to competing demands,” Taveira said. There are four modifiable risk factors for cardiovascular disease: glucose levels, cholesterol levels, blood pressure, and tobacco cessation, she noted. What takes priority may be different for different people. “Which one is going to get you the most return for your money?” she asked.
For example, controlling lipid levels and blood pressure may be more important for an older patient than controlling their blood glucose levels, she said.
Another issue in caring for patients with diabetes is hypoglycemia, which the statement notes is a risk factor for cardiovascular disease. “We’ve homed in on tight glycemic control, and there is a consequence to that,” Taveira said. According to the update, studies have shown that rates of severe hypoglycemia are more likely with intensive glycemic control.1 However, there are more and safer medication choices that protect patients from hypoglycemia but which still help them achieve glycemic control, she added.
A balance needs to be achieved for each diabetes patient. “If we are not careful, we start focusing on one part,” said Jerry Meece, RPh, CDE, FAADE, director of clinical services at Plaza Pharmacy and Wellness Center in Gainesville, Texas. “If we concentrate on glucose and ignore blood pressure we lose patients. If we concentrate on blood pressure and ignore glucose we lose patients,” he said.
When dealing with medication therapy management, the best way to reduce cardiovascular risk is through managing lipid levels, Williams said. Reducing blood pressure and controlling glycemic levels come after that, he added. Another area of pharmacologic management to consider would be adding aspirin or antiplatelet medications to a patient’s drug regimen.
Any patient who is over age 40 should be on a moderate dose of a statin, Eckel noted, even if he or she has no history of cardiovascular disease. If a patient has known cardiovascular or peripheral disease, that patient should be on an intensive dose of statins, he said.
A pharmacist can speak with a patient about lipid-lowering drugs, Eckel added. “The pharmacist can ask, ‘Have you talked to your physician about being on a statin?’ That is a good way to go about it.”
Ideally, all medication interventions would be secondary to lifestyle management for those with diabetes, Williams said.
A medication for some aspect of diabetes needs to be supplemented with nutritional guidance and suggestions for becoming more physically active, Meece said. “This is a three-legged stool: nutrition, activity, and medication. If any of those things are not in place, the stool falls over.”
The ADA/AHA update refers to lifestyle management as a cornerstone of care. Evidence from clinical trials has shown that intensive lifestyle interventions, which include weight reduction through reduced caloric intake and increased physical activity, can help people with T2DM lose weight, increase their fitness, and lower their A1c.
Pharmacists can help patients with diabetes make the lifestyle changes that can minimize their risk of cardiovascular disease, said Meece. He works at a hybrid pharmacy/wellness center that offers classes along with one-on-one counseling for patients with diabetes.
“Controlling diabetes is as much sociological as it is medical,” Meece said. This includes learning about the patient’s lifestyle to find out what approach would work best. The pharmacist can help patients understand that they can make changes and achieve their health goals. “We have to make the right thing to do the easier thing to do,” he said.
Many parts of a patient’s lifestyle have an impact on what can be achieved, Williams said. If a patient has arthritis or does not live where walking is safe, the healthcare team needs to come up with another way for that person to become more active. If patients are on a limited income, emphasizing the need to eat more fresh vegetables might not work if they cannot afford fresh produce or have no access to stores that sell it, he noted. “As long as the patient understands what is wanted, we have to work with what is feasible or possible to achieve.”
You do what you can, said Williams. “For some patients, you can work miracles, and for some, you are pounding your head against the wall.”
One of the first things Meece does to empower diabetic patients is to have them obtain a copy of their lab results to bring in when they come for a consultation. “This isn’t for us, but for them,” he said; patients need to become “co-producers” of their own care. Patients should understand what the lab numbers mean, what the lab numbers should be, and what they can do about it.
Many patients in his diabetes education classes start out not knowing what an A1c is and how it differs from blood glucose readings, said Meece. “We help them understand what they need to do to improve their outcomes in their own lives,” he said.
The pharmacist’s role is important because pharmacists see people with diabetes more often than their physicians do, said Meece. “We are not going to get diabetes under control with patients seeing their doctor four times a year.”
Taveira agreed. People generally see their pharmacist more often than anyone else on their healthcare team, which means that pharmacists can introduce and reinforce messages about diabetes. “Traditionally, we have community pharmacists, and we have underestimated that relationship and how they are so well positioned,” she said. Pharmacists can provide patients with skills in self-management and in comprehensive medication management, she added.
Many pharmacies are becoming health centers that offer classes for diabetes patients, but even a small pharmacy can get these health messages across. Fitting that message in when the diabetic patient picks up a prescription takes only a few minutes, said Williams, but the pharmacist needs to know how to deliver that message in that time in a way that empowers the patient. Teaching these communication techniques is an area that pharmacy schools are starting to emphasize, added Meece.
1. Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence: A scientific statement from the American Heart Association and the American Diabetes Association. DOI: 10.2337/dci15-0012.
2. Diabetes mellitus: a major risk factor for cardiovascular disease. A joint editorial statement by the American Diabetes Association; the National Heart, Lung, and Blood Institute; the Juvenile Diabetes Foundation International; the National Institute of Diabetes and Digestive and Kidney Diseases; and the American Heart Association. Circulation 1999;100:1132–1133.
3. Buse JB, Ginsberg HN, Bakris GL, et al.; American Heart Association; American Diabetes Association. Primary prevention of cardiovascular diseases in people with diabetes mellitus: A scientific statement from the American Heart Association and the American Diabetes Association. Circulation 2007;115:114–126.
4. Centers for Disease Control and Prevention. Diabetes Report Card 2014. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2015. http://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2014.pdf. Accessed on Sept. 3, 2015.
Valerie DeBenedette is a medical news writer in Putnam County, N.Y.