The Sweet Spot

The cases above represent some of the most frequent lapses and missed opportunities in the cardiometabolic care of the diabetic patient:

Patient A: 

• Missing the point of landmark clinical trials
• • It’s about how you get to euglycemia
  • The failure of previous therapies employed to achieve intense glucose lowering is not a free pass to undertreat. An A1C of 7.5% is not desirable.
• Taking the easy way out by persisting with outdated, yet inexpensive (and therefore easier to prescribe) sulfonylurea drugs that have been relegated below several other proven therapies in just about every guideline. 
• • Yes, new branded medications can be expensive and may require labor intensive prior authorizations, but the patient needs to be informed.
  • Help is on the way with Federal initiative to make branded diabetes drugs cheaper
  • Farxiga (dapagliflozin) now has a generic
• It’s not always about the sugar anymore. 
• • Several clinical trials have now shown that glycemic control has little impact on major cardiovascular events.
• Thankfully, we now have many therapies that, independent of glycemic improvement, also improve cardiovascular endpoints

Patient B: 

• Lack of awareness of guideline recommendations
• Reliance on suboptimal metrics - in this case, LDL-C is less accurate and underestimates risk compared with nonHDL-C when TGs are elevated (see Atherogenic Triad article in Phenotypes)
• Failure to appreciate high lifetime risk and implementing early prevention - another example of undertreating cardiovascular risk in the female (diabetic) patient.

Patient C: 

• Applying outdated and more conservative guidelines to our highest risk patients - LDL-C needs to be much lower
• Failing to appropriately inform patients of potentially life saving therapies they may be eligible for
• • Even if some practitioners feel there is controversy with the REDUCE-IT Trial (see Something Smells Fishy - The Controversy with Fish Oil) , patients ought to be informed of icosapent ethyl (Vascepa) when they fit the indications for it. That’s part of shared decision making.

Patient D: 

• Passing the buck - assuming some other specialist will take care of it.
• We are in an interesting time in medicine, where multiple classes of diabetes medications now have separate indications for improving cardiovascular disease risk - independent of glycemic control. 
• “I don’t treat diabetes”
• • It’s not acceptable for a cardiologist to fail to treat the underlying cardiovascular risk in a high risk heart failure patient recently hospitalized, simply out of misplaced fear about a “diabetes” drug.

To put it bluntly, the diabetic patient is left behind due to a lack of cohesiveness across medical disciplines. The PCP, already burdened with everything else, is left holding the bag when the specialists (cardiologists, endocrinologists and nephrologists) assume that the other is going to act. So, nobody acts, and the diabetic patient is exposed to unnecessary “residual risk” when there are potentially effective treatments available. Far too often the patient is left in the dark and never finds out about these therapies. 

Instead of fostering mutual trust and building a multidisciplinary community that agrees to take advantage of every opportunity to attack this risk, at every encounter, the opposite often occurs. The cardiologist doesn’t want to step on the endocrinologist’s toes and vice versa. The PCP may yield to the specialist, assuming they had a reason not to act, rather than seeing it as a missed opportunity. 

This is why some are trying to create a “cardiometabolic” subspecialty in its own right. Someone needs to put it all together.

Read more in Deep Dive.