PART 1 OF 3—Click "Full Text" to view commentary from presenters on diabetes topics
In July 2011, the inaugural MEDS (Metabolic and Endocrine Disease Summit) was held in Orlando, Florida. The meeting focused exclusively on diabetes, thyroid disorders, and other common endocrine-related conditions and was designed for PAs and NPs in primary care, with presentations by their counterparts in endocrinology.
In 2012, two MEDS events are planned: July 26-28 in Orlando and August 9-11 in San Diego. Save the dates and keep checking www.MEDSummit.qhc.com for more information. In the meantime, read on for a recap of some of the presentations from the first MEDS, in the faculty’s own words.
Scott Urquhart, PA-C, DFAAPA
It’s been an absolute honor to put this meeting together and to work with an amazing group of colleagues who are not only experts in their field but really wonderful clinicians with great clinical experience. And then to have the opportunity to work with Quadrant HealthCom—they really made it possible. You know, I’m a PA with an idea and a passion for education, but I can’t make it happen without the resources of that team. And then to work with the great editorial board and staff of Clinician Reviews, helping us to really start the spark of recognition for endocrinology and for this meeting. The meeting is clearly more than I ever expected it to be. All the hard work that went into it was absolutely worth it.
The feedback that I’m receiving … it really humbles you to see how happy and respectful people are of the time we’ve put into this meeting. So the reward is really giving back to the professions, to the patients, to the recipients of the best quality care. This meeting without a doubt has definitely met that goal and surpassed my own personal goals and expectations. I was expecting a good meeting, don’t get me wrong, but to really see it come together and have the attendance be nearly double what we expected for our inaugural meeting is amazing.
Joe Largay, PA-C, CDE
Type 1 Diabetes: Multidose Injections and Pump Therapy
In type 1 diabetes, it’s necessary to replace basal insulin and bolus insulin. Ultimately, that would entail two separate insulins with different PK profiles, which mostly mimics normal indigenous insulin secretions. That’s what we’re after. And with today’s analogue insulin, that’s fairly possible with intensive injections in about 80% to 90% of the population. Insulin pumps, while not for everybody, I consider to be the most flexible and individualized therapy for people with type 1 diabetes. We certainly know that insulin pumps have been shown to improve A1C and lower the incidence of hyperglycemia. Hyperglycemia is the biggest barrier for anybody with diabetes in achieving their targets. What we can do with insulin pumps is mainly lower the incidence of hyperglycemia as compared to the other treatment options.
Primary care clinicians usually do refer people for insulin pumps, and that’s probably the best option. But what we like people to understand is how they can review with their patients, when they get them back, how they’re actually being treated. So if providers could understand the basics of who are appropriate patients to refer and then how to follow them long term—so they can understand if anybody’s treatment needs to be changed—and if they can understand the basics such as carbohydrate counting that we teach the patients and insulin correction factors to help correct for any hyperglycemia, then that would probably go a long way to helping them understand their patients’ needs.
Lucia Novak, MSN, ANP-BC, BC-ADM
Overview of DM2 and Tackling Current Guidelines
Diabetes is such a challenging area. It seems that the better we become at addressing the pathophysiology of the disease and we come up with newer agents, there are a lot of risks associated with those agents and they haven’t been around very long so we don’t really know what the outcomes are for those agents.
The real reason we are addressing diabetes and controlling glucose is for the outcome. What is the outcome that we are looking for? Reducing microvascular complications and hopefully preventing macrovascular complications, which is cardiovascular disease, MI, stroke. We don’t have the data to support [the idea] that these newer agents will help us achieve those outcomes, and there are a lot of risks associated with them. That being said, we have many new agents that show a lot of promise as to how we can really address some of the underlying pathophysiology of diabetes.
My take-home message is that there are a lot of right answers, there are a lot of right ways to go about addressing the glycemic control, but there are certainly some wrong answers too, depending on the patient, his/her risk factors, and the risks associated with some of these medications. The important thing is to avoid clinical inertia. Try to work with your patients at every opportunity, to get them back on track. The cornerstone of diabetes management really is lifestyle–diet and exercise, which is a four-letter word for most. So we like to say “physical activity,” just get moving and move a lot. And then use the medications that have been proven to be helpful; use them to their fullest benefit and then look at what else is out there and weigh the risks and benefits with the patient sitting in your office.
Joe Largay, PA-C, CDE
Finger Stick vs Continuous Glucose Monitoring
Glucose monitoring is certainly important in helping to individualize therapy. Diabetes is such a behavioral disease. We have to help patients understand how their lifestyle affects their diabetes, and one of the best ways to do that is to identify the glycemic patterns and trends. You can do that in two ways: with finger-stick glucose monitoring, which we have patients do in various formats. For patients with type 2 diabetes, we use mainly methods such as paired readings—so you do a reading before you eat and a reading after you eat, to help the patient understand how that meal affects glucose. That’s one of the best ways for people with type 2 diabetes to do monitor their condition.
We also have continuous glucose monitoring, which is a much more advanced option. It is utilized more in type 1 diabetes; patients can purchase these units on their own and integrate that into their glucose monitoring to identify patterns and trends. These monitors don’t take the place of finger sticks, but they can be very beneficial in identifying these patterns so that they and their health care provider can make changes in their regiment to optimize A1C control and reduce hypoglycemia. So our goal again is to really empower the patient by looking at these patterns. Again, we try to coach them to make these changes, and that’s one of the most important facts about glucose monitoring in any shape or form: to get the patient to understand what it is they can do themselves to improve their condition.
Ellen Mandel, DMH, MPA, PA-C, CDE
Type 2 Diabetes Agents
I wanted to reinforce the notion that lifestyle issues are still very important. I think people don’t realize that there is clear data that shows that exercise or activity coupled with some weight loss—not even a significant amount of weight loss—can actually lower A1C by 1% to 2%, which is higher than most medications that you’re asking patients to take on a daily basis. So that was one of my focal points.
Another point, other than the specific details of how drugs work and what you can expect in terms of A1C reduction with certain medications, is that I wanted people to realize that they need to have a systematic approach to when they put patients on medication. When a practitioner fully understands what their purpose and goals are with their patient, that is translated to the patient subliminally—even the behavior and just the way the practitioner communicates with the patient. So they need to understand a couple of physiology points, such as certain medications really address what’s called the background or the fasting causes of hyperglycemia, as well as the postprandial effect. Medications are actually tailored to work that way, and providers need to be able to correlate high A1Cs with medication choices versus lower A1Cs with medication choices. Those were themes that I tried to drive home fairly consistently.