High-risk diabetes patients would benefit from getting team-based care from multiple physicians in an approach that would optimize their treatment for cardiac and metabolic issues, experts said.
In the U.S., only 15% of all diabetes care is provided by endocrinologists, who often defer to cardiologists for cardiovascular protection. With the arrival of SGLT-2 inhibitors as a potential medication for heart failure prevention and treatment in these patients, it is especially important to get all care providers on board for the implementation of these drugs, noted Jennifer Green, MD, of Duke Clinical Research Institute in Durham, North Carolina.
“I think that the team approach is going to be very important for the high-risk type 2 diabetes patients,” she told MedPage Today. “It would be easy for cardiologists or endocrinologists to defer to the other specialist to take action. I do think institutions need to establish care pathways to make sure that these beneficial drugs are incorporated into the care of these high-risk patients.”
Primary care will be important as well, she added. “We need to think about ways to close the loop and involve all care providers.”
“I would encourage endocrinology, cardiology, and primary care groups to work together to ensure that their patients aren’t falling through the cracks,” Green continued. “We’ll all need to work together to think through issues related to access, adjustments of other medications, and other therapies like diuretics in order to safely introduce new medications that patients should be taking as a component of their care.”
There may be room for Cardiometabolic Medicine to be a new subspecialty of Internal Medicine so that diabetes patients can be optimally treated for cardiac and metabolic issues, said Robert Eckel, MD, of the University of Colorado Hospital in Aurora. Until that is established, he said, “a team approach is needed.”
To boost interdisciplinary care for diabetes would entail several structural changes at each institution.
The Stanford Experience
Marina Basina, MD, of Stanford University Medical Center in California, noted that Stanford has several such changes in place, and its diabetes care program received American Diabetes Association certification in 2017.
The program is focused on standardizing education and documentation and encouraging interdisciplinary referral processes to optimize patient care. By streamlining education and treatment for patients with diabetes across the specialties, it makes it easier to refer providers to communicate with the diabetes education and treatment team, Basina told MedPage Today.
“Protocols for initiation and adjustments of diabetes medications were developed with collaborative efforts of clinical pharmacists, diabetes nurse educators, primary care physician champions, and endocrinologists to allow clinical pharmacists to follow the patients more closely between clinic visits either over the phone or in person,” she explained. “This helps diabetes patients monitor their progress, prevent hypoglycemia, and recognize complications and medication side effects early on.”
Importantly, a protocol for use of SGLT-2 inhibitors and GLP-1 medications in patients who are either at risk for or have a personal history of cardiovascular disease was developed by a collaboration between cardiology and endocrinology leaders. This has been successfully implemented in various cardiology subspecialty clinics.
SGLT-2 inhibition is notable, as the EMPA-REG trial was the first to show that this diabetes therapy does result in less heart failure hospitalization and cardiac mortality. A higher risk of amputation is observed with these drugs, however.
Stanford also holds monthly “Zoom” conferences in which clinical pharmacists present challenging cases for discussion with endocrinologists and diabetologists. “These case discussions are beneficial for the pharmacists to gain more experience and for the patients, since they do not have to wait for an appointment with a specialist and can get their treatments modified sooner to improve the outcomes,” she said.
In addition, regular group meetings bring clinicians and researchers together to work on further improvement of diabetes treatment. The meetings provide participants with updates on research efforts and strengthen collaborations, Basina continued. “Diabetes is a complex condition affecting multiple organ systems and requires a multidisciplinary approach in order to achieve glycemic goal and prevent long-term complications.”
“I strongly believe that other institutions can adopt some, if not all, of our initiatives and develop their own or adapt our protocols. In a current busy medical world, it is impossible to provide comprehensive diabetes care without using interdisciplinary approaches to the care of the patients,” she emphasized, suggesting that smaller hospitals and physician groups reach out to their local academic institutions to see if some of the protocols are available and if collaboration can be established.