COMMENTARY

Complex Type 2 Diabetes Patients: Who Should Lead the Team?

Jay H. Shubrook, DO; Mikhail Kosiborod, MD, FACC; Robert H. Eckel, MD

Disclosures

July 26, 2018

Editorial Collaboration

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Jay H. Shubrook, DO: Hello. I am Jay Shubrook, family physician and professor at Touro University California in Vallejo. We are at the 78th Scientific Sessions of the American Diabetes Association in Orlando, Florida. We are going to discuss the complexities of managing patients with type 2 diabetes and cardiovascular disease. Joining me for this discussion are two colleagues.

Mikhail N. Kosiborod, MD: I am Mikhail Kosiborod, professor of medicine and director of Cardiometabolic Research at Saint Luke's Mid America Heart Institute in Kansas City, Missouri.

Robert H. Eckel, MD: And I am Bob Eckel, professor of medicine in the Division of Endocrinology, Metabolism, and Diabetes, and the Division of Cardiology, at the University of Colorado Anschutz Medical Campus in Aurora. I am also privileged to have been the president of the American Heart Association (AHA) a decade ago.

Shubrook: Thank you both for being here. I saw a patient last week who had type 2 diabetes and a recent myocardial infarction (MI). This is becoming an increasingly common presentation and these patients need care from multiple different providers. One of the things I need to learn is how to manage these patients with the best care by involving all of our specialists. Any advice?

Kosiborod: The care of these patients is growing in complexity. We have made many advances in improving outcomes for patients with cardiovascular disease, but we know that the number of people with diabetes is rising and the number of people with prediabetes is rising even more rapidly. Unfortunately, this means that we will be seeing more and more diabetic patients having MIs.

People with diabetes already have established atherosclerotic cardiovascular disease and are among the highest-risk patients for having an MI.[1] The good news is that there are things we can do to reduce cardiovascular risk in this patient population.

We all need to provide a comprehensive strategy for risk reduction. We know several very clearly effective strategies that work in this patient population. Unfortunately, they are not always consistently applied. The number of patients that actually have good control of all of the key risk factors still remains relatively low. Clearly, a lot of work still needs to be done. I believe that is where the collaboration between the primary care provider (PCP) and the various specialists—cardiologist, endocrinologist, and, in many cases, nephrologist—will grow in importance.

The care of patients with diabetes and cardiovascular disease is really a team effort. We have stayed in our own silos for a long time, but now we must come together and make sure it is not each specialist running their own target organ system. Rather, we must be thinking of ways to improve all of the key outcomes for people with diabetes to make them live longer and feel better, which ultimately is what we all care about.

Eckel: Jay, here you are in primary care. You have a patient who has had an infarct and ultimately is being managed for type 2 diabetes. Where would you refer that patient next for help with decisions that relate to diabetes management? Would it be to the cardiologist, like Mikhail, whose cardiology practice is more focused on prevention, or to me as a metabolic physician?

Shubrook: That is a great question. Once someone has had a cardiovascular event, a specialist is usually involved during the event care. I would assume that there would be follow-up. I am equally concerned, since risk-factor modification is super important, about how we involve specialists to prevent primary events. Of course, every patient of mine with type 2 diabetes has substantial cardiovascular risk. But I don't believe that we have enough specialists to see every one of those patients. Do I wait for an event, and when the patient has that event, should I expect ongoing care from the specialist?

Eckel: No. I believe that as a PCP, as a family physician or an internist, you need to be involved in preventing that first event. There has to be a knowledge base that goes beyond simply knowing the HbA1c and the LDL. You need to be screening and being more aggressive in management up front. In type 2 diabetes, unless the patient is on insulin, you don't really require diabetes specialists to help you in that area. Certainly a patient who is insulin-requiring, either type 1 or type 2, should be seen by us and we will provide directions you can follow. Mikhail, what are your thoughts about where the PCP fits in?

Kosiborod: I agree. The overwhelming majority of patients that I and many of my colleagues see as cardiologists are not those who have not yet had an event and are referred so that we can come up with the preventive care plan. Most of the time, they see us because it is already a problem we have to deal with. It is in the realm of primary care to try to prevent those events. The question is, what is the best way to prevent an event and how do I identify the patients at highest risk? Frankly, those remain somewhat controversial issues.

We know that there are good prediction tools, but those prediction tools are not perfect. We are continually looking for ways to improve those prediction models and to come up with new imaging or biomarkers to identify high-risk patients. In fact, a study was just published that showed that NT-proBNP is a very strong predictor of developing heart failure in patients with diabetes.[2] This is yet another piece of evidence of how we potentially should not limit ourselves to this very rudimentary cutoff of primary or secondary prevention—someone who had an event; someone who did not. We will look at it on a risk continuum, trying to understand how we can tease out the risks and choose the patients who are more likely to develop MI, stroke, or heart failure, and try to intervene before those events occur. It is an evolving field and it is not easy to accomplish, but it is doable.

Shubrook: I would highlight that we still are not doing a great job on the primary risks. These additional tools are great, but let's not forget the things that we already know.

To get back to your question about who I would refer to, it largely depends on who I have around me. The resources are not universal. It may be that in some areas we have access to cardiology but not endocrinology. We have other areas where we have an endocrinology practice that may not have an available appointment for 6 months. I believe that is the biggest variable, depending upon where you are and what resources are available.

With these specialists, how do we maximize care of the patient? As we start to have diseases that overlap and treatments that overlap, how do we prevent duplication of services? How do we make sure we are doing the best together for the patient? Any insights?

Eckel: I believe that the primary care physician needs to be engaged in primary prevention: knowing issues that relate to metabolic-centered phenotypes, with blood pressure, lipids, glycemia, fasting plasma glucose, postprandial glucose metabolism, and HbA1c as a marker for those. Do your best to prevent those heart attacks with guidelines used to achieve goals. Once that patient transitions into more complicated care or has an infarct, you need one or both of us.

Kosiborod: For complex patients that already have established disease, you really need to try to create this team-based care. Essentially, have a team of specialists. In some cases, that could include cardiologists and endocrinologists. In some cases, there could be a nephrologist as well, if the patient has renal disease. Reach consensus about the best way to manage the patient.

Several programs around the country have successfully achieved that model. This is what Bob does in his practice every day. It works extremely well. As I said, the tide has started to turn toward making this the new standard of care. My hope is that it is only going to accelerate. It absolutely must accelerate if our goal is to improve important outcomes in people with type 2 diabetes—not just making their numbers look better, but making sure they live longer, feel better or, best of all, a combination of both.

Shubrook: Thank you both very much. And to our audience, I want to make sure you understand that the treatment of type 2 diabetes and cardiovascular disease is complicated, but you are not alone. It is important to know that you can optimize risk factors, but a team-based approach is necessary as we begin to recognize the complexity of cardiometabolic disease in patients with type 2 diabetes. Thank you.

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