Beyond Blood Sugar - Team Up For Health: Integrating diabetes and kidney care Jan 21, 2025

Added: 2026-05-13

[00:00:28]e e hello and good morning welcome to the first webinar of our Beyond blood sugar improving kidney and lipid care in diabetes webinar series these are hosted by the office of lifelong learning and the physician learning program at the University of Alberta of note on March the 4th we will have a third webinar that will focus on your diabetic dilemas so as we go through this presentation and in future think about real life cases that you're dealing with and submit them to us and we will incorporate those into our March 4th presentation my name is Donna Mana I'm a professor emeritus a family physician a network director of the Northern Alberta Primary Care research Network the director of quality improvement in the department of family medicine as well as a director in the physician learning program and the lifelong learning program The Physician learning program and the office of lifelong long learning are committed to providing reliable updates and resources for clinicians Health Care professions and everyone committed to providing the best care for our patients I'd like to start off with a land acknowledgement the University of Alberta its buildings labs and research stations are primarily located on the territory of the cre Blackfoot matey Deni iqua and obij lands that are now known as parts of treaties 67 and 8 as well as the homeland of the mate the University of Alberta respects the sovereignty lands histories language knowledge systems and cultures of all First Nations matey and Inuit Nations for some housekeeping I would like to provide some information please use the chat feature if you have a question about technical difficulties or L3 programs and services if you have a question for the speakers please use the Q&A feature of the webinar review what has already been submitted and don't repeat the exact same question just up vote questions that you'd like answered we cannot guarantee the panelist will be able to resp respond to all of your questions but we'll try a recording of the webinar will be sent by email to all of those that have registered participants can claim CME credits and complete a personal development activity using the my lifelong learning plan tool and for information visit the QR code on your screens this activity has not been formally reviewed by the College of family physicians or the royal royal College however it is eligible for non-certified credit and Main Pro Plus uh credits may be earned by completing a linking to learning exercise so today we're very pleased to welcome our speakers uh Dr Darren Lao and me I'm Donna Mana I introduced myself earlier and we'll be providing an update on teams for health integrating diabetes and kidney care now we are very fortunate to hear from Dr Lao he is an assistant professor a general internist and diabetologist as well as a clinical epidemiologist at the University of Alberta and the K Clinic Darren is also an acting medical director in the physician learning program and the L3 apart from his research on outcomes of medical therapy in adults and diabetes he enjoys sharing the newest and greatest things in diabetes with anyone who will give him the time of date Darren has uh focused his research on very meaningful things that impact us as clinicians in our practice both of us have no conflicts of interest to declare other we are conflicted in that we want to improve Diabetic Care and hence this work thank you so much for your time and Welcome to our PLP webinar thank you so much for that wonderful introduction Donna again I'm Darren Lao it's a pleasure to meet you all virtually in this forum and I'm very excited about this talk in this series of talks not least because again our talk on March 4th is a bring your own case talk byoc and I'm looking forward to seeing what you our um audience and Community providers provide in terms of interesting or tricky cases that um that you'd like us to comment on so I'm really looking forward to that particular format uh but okay today we're talking about Kidney Care and diabetes and boy have there been a lot of developments in the last couple of years and Natasia I'll take the next slide now uh okay so the objectives of today first we're going to identify neuro agents with cardiorenal benefits and specifically that would be sglt2 Inhibitors that's almost old news now uh what's newer to talk about is ferone and then most recently stide uh we're going to sketch the evidence for the renal benefits of these agents we're going to apply these agents to our own patients and then we're going to contemplate how we might ensure that all of the patients in our practice benefit equally from these agents and in these respects Donna has lots of interesting tools for you Natasia I'll take the next slide so I thought I'd open with a case this is based on a real patient of mine uh but I see patients like this quite typically in my referral practice at the K Edmonton clinic this is MF he is a 72-year-old male he's an indigenous former law enforcement officer his past medical history consists of diabetes dyslipidemia chronic kidney disease and satica in terms of his diabetes his A1C is 7.8% LDL is 1.47 blood pressure is 140 over 79 his kattin is 123 making his egfr 48 his urine album into cortin ratio is 150 milligrams per Millar just a word on the units there these are of course our Canadian units but the American units are milligrams per gram and um you know American units differ from a factor of 10 in case you're reading the primary literature and you're wondering how the American units map on to our Canadian guidelines just be aware that there may be a factor of 10 difference there the medications that MF is on consists of what you see there torvest stattin candesartan insulin glorene insulin gline so rapid acting insulin five units three times a day metformin and clytin when you ask the patient what his concerns are he volunteers many people from my community have gone on dialysis and so that's something he's seen and is Keen to avoid so we pull up the online calculator and there's one calculator that's getting a lot of traction right now and that's the kidney failure risk equation kfre this was developed using administrative data sets in Manitoba by neologist nap tangry and colleagues at the kfre produces a five-year estimate of the risk that someone requires renal replacement therapy or suffers kidney failure and for Mr MF that 5-e risk turned out to be about 6% so just just over one in 12 chance then the next 5 years he needs renal replacement therapy driven largely by his urin alment I'll take the next slide so I thought I'd pause for a moment and see if any of you all have any thoughts about the case you can throw up some comments in the chat despite donst Specific Instructions to save questions for QA or you could raise your hand and say a couple of words so what do you think what should we do what are your thoughts on Mr MF no takers yet is it too early I'll give it a couple more seconds to see if there any takers I think we have one person with the hand up oh oh yes um I'm oh okay here let's see I'm trying to find the at hande list on my screen right yeah go ahead you should be unmuted and able to speak yeah I don't know if they can hear me oh we hear you perfectly okay excellent so thanks a lot for inviting us to this presentation and uh just to avoid delays I'm going to going to be specific on the topic uh because of what I see so uh is blood pressure to start with I'm starting from up there it needs more more care uh it's it's not on target looking at his systolic uh diabetics would want that uh if I life possible under 130 the diastolic is fine so that is one so we might have to look at his medications see if we can get that better number two is his uh his weight is definitely you know overweight and that is something that we should address uh going down looking at his A1C is A1C at least based on everything else I mean if it wasn't for everything else maybe yes would accept it but with his issues uh his uh kidney function is definitely deteriorating and one way of improving that apart from improving his blood pressure is addressing his A1C so look at his medications try to improve that and the hope is that yes if we can improve his his blood pressure improve his uh uh A1C we might arrest at least delay deterioration of his egfr and The Improv is A1C sorry the US and as you've already indicated the agents that you've highlighted and all of them all of them can be used in this situation so I think I think I'll end it there for now so I allow my colleagues to make comments thank you Dr MCA I I really appreciate a very systematic approach to this patient that's that's fantastic um I agree with all of that and a couple of things I want to bring out from your comments the UAC R you mentioned is something that is potentially actionable and that is true because many of the kidney protective agents we have you might be waiting to see the impact on egfr decline you might never know if it's made a difference in egfr decline because obviously you don't have a counterfactual world where you have the same patient where you didn't give them the special agent but one thing you can see right away often with starting a new kidney protective agent is that the uacr improves and that's something you can bring to your patients and say hey your kidneys are less leaky than they were before and that's good for the future right so that's really cool uh Cheryl car Carl says consider use of an agent Beyond glycemic control offering renal benefit yes we're going to see where the guidelines position medications with renal benefit versus glycemic control and it's it's a Brave New World out there where it's it's kind of we have the luxury glycemic control is hard but we have the luxury of options that address end organ function now and you know after we get these agents on sometimes glycemic control isn't an issue anymore add sglt2 inhibitor for renal protection that was from gulam Mustafa oh absolutely absolutely absolutely okay this is great I love where everyone's at Let's uh let's flip the next slide so what I want to point out is that ACE inhibitors and arbs have been the foundation of our kidney risk protection and diabetes for 20 plus years now uh based on seminal trials in the early 2000s late 1990s but despite ACE inhibitor and ARB therapy there exists a high degree of residual risk present so despite maximally tolerated Ace and ARB and we see this in the current generation of Trials as well at two years in high-risk individuals with severe aluria the risk of you know a doubling of their serum creatinin sustained or or needing renal replacement therapy or renal death is up to 15% again despite maximally tolerated a and inhib an ARB therapy H we have another comment from K on Wright we want his LDL less than 1.0 that is uh interesting interesting the usual targets I think for primary prevention are 2.0 1.8 LDL in secondary prevention I haven't heard about the 1.0 Target but that is uh if you know something that I don't you know let's uh let's bring that back let's come back to that okay next slide I want to point out that this residual Al risk is cardiorenal so as egfr worsens as alurri worsens what people end up dying from is not kidney failure it's cardiovascular events so worsening kidney function albanuri are both independent predictors of cardiovascular risk and what we're really doing here when we're addressing CKD is we're addressing future cardiorenal risk next slide so that brings us to the New Kids on the Block and the wonderful thing about all three of these these class of medications is that they not only offer renal risk reduction but they offer cardiovascular protection as well and since most individuals with chronic kidney disease end up having cardiovascular disease as a big source of morbidity mortality that's that's what's really made these agents important to us H so first let's talk about sglt2 Inhibitors I'll take the next slide I don't want to belabor the point I I you probably have heard about this in many other talks you probably use a lot more of this in practice as a general internist we were almost late to the party we started seeing these in our hospitalized patients before we started using them but I I think I think the family dogs have been very quick to pick up uh pick up sglt2 Inhibitors uh I just want to remind folks about the seminal Credence trial published in 2019 this was a kidney outcome trial enrolled high-risk patients with severe alua so Ur an albumin to creatinin ratio greater than about 30 in our units and it made its primary endpoint that three-point nephrologic outcomes endpoint which consists of um 50% loss of egfr sustained uh or renal death or initiation of renal replacement therapy and they found that the number needed to treat was 25 individuals with Canoga in 100 milligrams over 2.6 years to prevent one case of that adverse kidney outcome which is clinically significant and by our prevention standards 25 people to prevent a big important thing is is quite a steal I'll take the next Slide the mechanism of benefit is thought to be reduced intraglomerular pressure now remember in diabetic kidney disease the pathophysiology is thought to be you know at first you get hyperfiltration the kidney function looks better than it actually is and that's because of high pressures in the glomerulus but over a long period of time that pressure damages the filter you get aluria and then kidney function eventually Falls at a continuous rate and so one of the mechanisms by which sglt2 Inhibitors and ferone for that matter is thought to work is by reducing intraglomerular pressure what that tends to mean is that on paper when you start an sglt2 inhibitor you do see a dip a reduction in egfr upfront on average that's about four points uh it's uncommon to see more than a 30% reduction but interestingly enough a 10% reduction was fairly common observed in about 30 to 40% of individuals and in the Dappa HF trial which looked at heart failure in dppa gphin individuals on dppa gphin who had a 10% or more dip in egfr actually had better outcomes compared to those who did not so again possibly reflecting that this is the group of patients in whom there was a successful reduction in intraglomerular pressures and Improvement in long-term hemodynamics so our guidelines currently recommend that sglt2 Inhibitors uh okay I should rephrase this you're going to see new guidelines soon at diabetes Canada has updated its kidney guidelines those are going to be published very soon okay and I can tell you right now I saw the preview of these guidelines at the diabetes candidate meeting just in the fall here and what we're going to see is a recommendation that sglt2 Inhibitors be prescribed in adults with egfr 20 to 45 okay forget about aluria egfr 20 to 45 so that's how low the egfr threshold is now for starting an sglt2 inhibitor or egfr 4 to 90 if the aluria is at least is high enough so 20 is the uh is the typical cut off and that's based on the most recent kidney trial and that would be empa kidney okay H so yes sglt2 inhibitors for chronic kidney disease and diabetes that's that's a big yes uh with that egfr lower limit being pushed down progressively okay I'll take the next slide uh I think we've talked about this already the point is that yes upfront if you if you choose to monitor up front yeah you're going to see a bit of an egfr dip and most kidney doctors are willing to accept a 20 to 30% egfr dip because what we see in the trials is that despite that dip long-term egfr is preserved and it it only takes about 18 weeks before that's evident and this was again from empa kidney okay I'll take the next Slide the next class of Agents I want to talk about is non-steroidal mineralocorticoid receptor antagonist NSM and right now we only have one licensed agent in this class and that would be ferone uh the trade name is Kenia it is marketed by Bayer I'll take the next slide I guess it's bar if you you know speak German anyways mineral corticoid receptors are implicated in multiple pathologic Pathways responsible for heart and kidney disease this is known fact um and the thinking here is that blocking these receptors might fix a lot of these Pathways and definitely has a big role to play and heart failure with reduced ejection fraction where ainon and spiral actone have proven mortality benefit right but the case is different for chronic kidney disease in diabetes I'll take the next slide people have looked into traditional steroidal M for chronic kidney disease and diabetes and the conclusion is there might be benefit the evidence is inconsistent the benefit doesn't appear to be huge there definitely is a big risk of hyper cmia in the chronic kidney disease um population uh being on one of these agents doubled that risk with a numbered need to harm of 41 and then because they're steroidal of course you also get gynecomastia and sexual side effects so the risk benefit profile purely for the indication of chronic disease is not typically thought to be worth it for steroidal mineral corticoid receptor antagonist that be SP spolon or plone unless there are other compelling indications so heart fail reduced ejection fraction definitely but blood pressure control it is a it is a pretty good uh third or fourth line agent um you know but requires monitoring that brings us to the next class of masas the non-steroidal versions I'll take the next slide H so this is a distinct pharmacologic class of mineralocorticoid receptor antagonist that does not hit glucocorticoid or Androgen receptors so it's a much more specific molecule and as a result of this there is far less hyperemia it's still an issue still an issue uh but there's much less of it than with spal octone or plone and without any CNS penetration and no sexual side effect so no gynecomastia h no sexual side effects okay I'll take the next slide now ferone has been tested in the Fidelio kidney trial so this is a true kidney trial uh which enrolled high-risk individuals with severe aluria but also enrolled a group of individuals with moderate aluria so urine ALB into kenin ratio uh of a moderate extent I think um uh greater than um three uh or thereabouts uh who had reduced kidney function so egfr less than 60 so a slightly broader group of inviduals than was observed in Credence and this was ferone versus placebo they randomized over 5,000 individuals and followed them for 2.6 years uh average age of 65 uh with a mean egfr to begin with of 44 I'll take the next slide and what they found was on the primary kidney outcome again that kidney composite outcome a decided benefit with the number needed to treat of 29 so 29 individuals treated with ferone and you would prevent one instance of uh sustained loss of egfr of 50% readal replacement therapy or renal death now hyperemia was an issue that occurred in about 12% of individuals versus 5 % of placebo treated adults uh but hyperemia leading to discontinuation only occurred in 2.3% of individuals and there was no real difference in acute kidney injury so overall the safety profile was reasonable although monitoring uh is of course required to catch these cases of hyperemia I'll take the next slide uh similar to sglt2 Inhibitors we do see a upfront dip in egfr but long term we see preservation of EG TFR I'll take the next slide now there was a parallel figuro trial which was a cardiovascular outcomes trial of ferone uh with that enrolled slightly different individuals and when you pulled the two analyses together H you get two trials that collectively represent a decent swath of individuals with at least moderate Alura so uacr greater than three and you have evidence of both cardiovascular and kidney benefit and in the pool trial population over 3 years the numbers needed to treat were 46 to avoid a major cardiovascular outcome and 60 to avoid an important renal outcome so demonstrating cardiorenal benefit I'll take the next slide uh so the guidelines have will incorporate the Canadian guidelines will incorporate ferone the kidney guidelines already include ferone in them H this is ferone it comes in 20 and 10 milligram flavors I don't want to get too far into the weeds of dosing and adjusting the dose of ferone so you can refer to the P product monograph for details or talk to your local pharmacist or farmaceutical representative I suppose uh but I will point out that the initial dosing depends on their initial egfr you can start at 10 or 20 milligrams uh monitoring is recommended of potassium and creatinin in four weeks time and that was what was done in the trials and that was proven to be safe in the trials some of us are used to monitoring a little bit sooner than that but that's clinician discretion and depending on the serum potassium there are guidelines about what to do with the ferone dose there after okay I'll take the next slide and that brings me now to gluc glucagon like peptide one receptor agonists particularly stide a trade named as OIC for diabetes and marketed by noo Nordisk next slide so of course glp1 receptor agon we know them as very impactful medications that provide glycemic control and weight loss without increasing the risk of hypoglycemia the side effect profile is variable from Patient to Patient but mostly consists of gut side effects although the other side effects uh have attracted a lot of popular attention now those are a little bit beyond the scope of this talk but I I do welcome questions about your experiences using any or all of these agents and again we do have a bring your own case uh webinar on March 4th where we can address specific cases that you found challenging because of unusual or severe side effects uh the interesting thing about glp1 receptor agonists is that they have demonstrated cardiovascular benefits in high-risk individuals that's really important to us and it's long been known that these agents reduce ALB manua in fact if you include aluria as part of your kidney composite then these then there's already lots of evidence that these agents improve kidney outcomes but albanuri of course is a surrogate outcome and the kidney doctors have always cared more about the hard clinical endpoints and again those are held to consist of sustained loss of egfr Ral replacement therapy or Ral death right H so for a long time we've known that these agents can reduce aluria but we didn't have conclusive evidence that they could reduce clinically meaningful kidney outcomes until actually just this last summer when the flow trial was published I'll take the next slide so the flow trial was a trial of stide versus placebo and this was ltid so in the OIC flavor of smti dosed up to 1.0 mgram subcutaneous weekly so the usual diabetes related dosing uh this trial included adults with diabetes and high-risk CKD defined by egfr 25 to 75 with urinal abum aarin ratio greater than 30 so severe aluria by our standards or greater than 10 if the egfr was less than 50 and the primary outcome again was that composite kidney outcome average age here was 67 so these aren't quote unquote spring chickens uh BMI 32 average egfr at start was 47 and they followed up about 3 3500 individuals over 4.5 years so quite an undertaking this trial I'll take the next slide and they hit their outcomes their primary kidney outcome showed benefit with a number needed treat of 22 22 individuals could be treated with smati at this dose to prevent one important kidney outcome which Again by our standards of prevention is pretty good but more importantly they also met their cardiovascular in outcome again indicating that renal risk is really cardiorenal risk H so the mace the major adverse cardiovascular event number needed to treat was 41 and the all cause mortality number need to treat was 33 that that Hazard ratio was also statistically significant in terms of safety of course with smde everyone's interest in ropy risk and eye disorders were a little bit more common in the smti treated arm but diabetic retinopathy events specifically were not different in this particular trial Adverse Events with this continuation were roughly similar although of course individuals in smti treated arm had far more GI side effects and those were primarily what led to discontinuation uh one and 10 in the trials in my practice maybe a bit more right I'm sure in yours as well H next slide okay so what do the guidelines have to say about all this I'll take the next slide this is a figure from the Kad guidelines the international chronic kidney disease and diabetes guidelines and I I I think this pyramid is absolutely fantastic because because it indicates that of course lifestyle therapy is always foundational diet exercise smoking and weight but right above that is firstline drug therapy consisting of sglt2 Inhibitors and Ace inhibitor ARB these have the longest established benefit in diabetic kidney disease and then on top of that we have gp1 recept Agonist and nonsteroidal mineralocorticoid receptor Agonist additional medications with heart and kidney protection and then after that after we deal with the foundations of the pyramid then we can think about glycemic control and getting that LDL down a target with additional agents statins are foundational of course but you know additional work to do that and then and then blood pressure control just recognizing that all of these agents appear to work independent of their glucose lowering and uh effects right in fact sglt2 Inhibitors in chronic kidney disease by the time you get to egfr less than 30 what really is the impact of that sglt2 inhibitor on serum glucose levels probably not that much but it still has a kidney impact right so that's a it is a new paradigm where we're focused on end organ prevention with these medications okay I'll take the next slide uh again diabetes Canada has upcoming guidelines related to kidney disease and they're going to say roughly the same thing you're going to find that a ARB are foundational sglt2 Inhibitors gp1 receptor Agonist nonsteroidal mineralic cord receptor agonists have antagonist sorry have roles to play in diabetic kidney disease uh the I I encourage you to have a look at those guidelines they also have um a wealth of interesting things for the clinician for example if you were ever a little made made a little anxious by quote unquote mild hyperemia you know oh it's it's in the red but it's you know it's only uh five.2 5.3 do I stop all of their you know their kidney protective agents and uh so the guidelines are going to come right out and say mild hyperemia most nephologist won't bat an ey not to worry too much about that right so I do encourage you to have a look at those guidelines lots of interesting things and again urinal beIN actinin ratio we know is under measured in our in our patients but each of these medications cumul you know individually can be expected to have about a 30% reduction C and urine alumin which has prognostic implications for progression of chronic kidney disease but is also something you can point at and show your patients and say hey I know you're taking additional pill but this is what we see for your kidneys you can actually see that there's a reduction in that leakiness which is really important to us okay okay take the next slide uh here's another resource for you this is the Alberta diabetic kidney disease clinical pathway there's a link right there this presentation will be available on YouTube so you can find the link there you can take a screenshot a snapshot of it now uh this pathway looks a little busy but it's actually pretty reasonable to walk through this was developed with input from users including yourselves uh or individuals like yourselves and this is something that PLP worked on with strategic clinical network uh is now defunct but it lives on the AHS Pathways Hub and it'll it'll walk you through you're deal with diabetes okay are we prioritizing kidney protection heart protection or then A1C optimization and then as the sort of Agents you can think about with hyperlinks to other pages in The PDF where you can look at prescribing information and recommendations and U risk benefit trade-offs tables to talk to your patients about uh one thing about this pathway is it does not yet include some magti but we have a version of this that has a blank spot Force magde we expect to do those Updates this summer okay uh so there's there's a resource for you all uh and that's locally developed I'll take the next slide so let's come back to this case Mr MF uh who has the patient centered priority of avoiding um chronic of avoiding worsening of his kidneys well there's lots of room to add on some additional agents uh you know obviously I don't want to overwhelm him with new pills or injections to take you know I I think definitely sglt2 Inhibitors are would be a good place to start maybe dagly fla in 10 milligrams and then because he is overweight and he is on insulin you know whenever I see someone on insulin you know I'm I'm Keen to see if I can try to wean down that dose of insulin or even if you know get them off of insulin and sometimes with additional therapy we can do that and that's a much safer set of medications to be on so we might start OIC here as the next step to see about um uh reducing his insulin doses as well while maintaining a better or similar glycemic control okay I'm going to stop there but I'm going to ask for the next slide and pass it over to Donna for her thoughts so typical patient that we see in our practices right um and I always think of that pyramid I love that pyramid illustration that Darren Illustrated uh going back to that um you know really lifestyle is key with this fellow and we don't know a whole lot uh there may be information uh maybe that is known but um I find a lot of times the big problem is the diet and I have a lot of diabetics and Darren knows of steel cut oats and things that raise sugar cuz they're not eating any protein or any anything with it and its uh diets are you know restrict any fat and you know we've gone that way so now we're seeing more high blood sugars and people don't know what they should eat the other factors here is is does this person smoke and that is a very big one you know that we could address and then alcohol can also contribute to elevated blood blood pressure so when I have patients whose blood pressures are not coming down I always revisit the alcohol question cuz sometimes you know I didn't detect it on previous times exercise can also have a good impact and walking after a meal now with patients that have early kidney impack I really like the kidney Pathway to guide me and I will refer to a nephrologist so he I probably would have had referred to a nephologist as soon as his album and creatinin had gone 60 or or his glol filtration rate goes down um I want to really work with him on optimizing medications now this is an older fellow and uh something that often happens with our patients is we continue medications when they're no longer useful we also um have to consider starting at lower doses in our older patients uh you know because it puts them more at risk if we go right to the regular dose and they have multiple medications on board so I would look at his medications and and think you know where am I getting the most bang for my bucket and discuss with him uh what better choices there might be and it certainly in this case the sglt2 and the GP I think are much better options for both the heart obesity kidney and blood sugar the other Med is uh the other blood sugar loow medication not so good good you know and I would stop that uh other factors in this fellow he's obese uh you know and other things to think about would be does he have liver impacted from the Obesity uh liver functions be good to look at and is there sleep apnea so lots to think about here next slide this is a illustration of a tool that I really liked when it came out now it is caveat is it is getting a little old uh it hasn't updated um you know information on more new drugs uh that really have improved impact but it can guide you as to which uh meds to focus on prioritizing and stopping uh it it gives you little happy faces so you can see which drugs improve symptoms and you can see most of the drugs we give don't improve symptoms but uh some of them reduce the risk of future illness and that's the key here the other problem is some of them can cause harms and certainly insulin in this fellow uh can be a concern we have a fellow that's obese and as you know it makes him more hungry and and can contribute to that so I find something like this useful to think about which medications I might look at reducing or stopping and what's nice about it is it tells you how you you can stop the medication can you stop it suddenly or do you have to gradually stop and it gives some advice about that next slide so when dealing with elephants and all of our patients are elephants we have to do one spoon at a time right we're not going to spend the whole day with that patient to correct the situation it's going to take time uh we give little bits we share ideas we bring them back and it's not one person that can do it all I can do it all so I find uh Team approach is really important but when you have a team and the patient is included in that team you need to be on the same page and I found there are some excellent tools uh diabetes Canada has resources that you can pull and develop a care plan with your patient and a bring the team together to agree to that plan and optimize it to that individual Patient next slide this is an example of what I'd call a care plan and on this plan it shows you know what you and the patient and your team uh decide to focus on you know and you you can send the patient home with this you know a copy of this and so that everybody is on board and is focusing on the same thing and this needs to be updated with each visit or or over time uh now it can be difficult ult to have this paper separately you know so what I like to do is uh I I built a lot of this our team built it into our electronic medical record next slide so with Med access we have a goals page and on the goals page we were able to uh input a lot of this information so that when patients come in you can look at your goals page and if you see a red you know oh that's not being me and and you can prioritize what you're going to focus on in that visit uh and everybody has access to that information so that the team is aware of what the plans are often I've had residents in training come and complain that they don't know what's going on with the charts they come to see patients diabetes isn't even in the medication you know or in the profile so they don't know uh how to manage the patient you know and that puts our patients at risk you know we we often know our patients and maybe we can manage but if we have somebody else that's covering our practice or that without these uh treatment plans and and and goals um often they don't know what the aims are if you don't have access to a goal sheet in your EMR in the profile you might be able to write in your own goals I've done that with my uh cancer patient because I don't have uh the ability to do that on the gos page but there are ways to use your EMR smartly next slide so we talked about the individual we're going to move on to information and data and we're we're going to look at the panel you know so when we try to improve practice we need to know more than the patients that we're seeing we need to understand the panel next slide years ago I think in about 2009 a number of us were research directors in Family Medicine across Canada and we were frustrated that our learning Health Systems did not have resources for us to do uh appropriate research or quality improvement or surveillance on our practices we just don't have uh the infrastructure funding so we got together and we obtained funding and developed the first Canadian multi- disease electronic medical record surveillance system across Canada and this is in pretty well every Province and and coming up in Saskatchewan as well as the Northwest Territories is being developed next slide so what uh sipson which is this pan Canadian network does is it has a number of uh practice-based learning and research Networks Works across Canada working with family physicians uh to take data out of electronic medical records structure that data and enter it into a relational database for point of care uh information on Sur that can be used for surveillance quality improvement and research and the individual networks can provide the participating Physicians with feedback back on how they're doing as well as can provide them information uh so that they can link back to their individual patients Alberta has two practice-based learning and research networks contributing uh napan is the northern one and that's the one I'm the re director of uh and then in Southern Alberta we have sapin it's sugary napkin is nicer though starts with N sorry I I we do compete with each other next slide so napon uh is able to let you know uh how well your chronic conditions are coded in your problem list and this is really important this is what I call meaningful use of your electronic medical record if you don't have chronic conditions like diabetes in your problem list when somebody comes to cover for the practice practice it's not easily seen and they don't know if the patient has diabetes uh We've developed 24 validated case definitions for those different chronic conditions including blood pressure COPD Asma and so on we can tell uh the Physicians uh which patients have not been entered that we think have the conditions so that we can help them update their electronic medical record and then they have a a disease registry that they can use to see how their diabetics are doing and to do panel level uh Management on next slide now going back to the individual we've been very lucky to to collaborate with PLP and PLP has provided excellent resources so that we've been able to develop reports on numerous chronic issues that we send to our participating Sentinels and this is an example of a report around diabetes and renal uh failure and you can see in this report it illustrates how the physician which is the dark blue is performing in terms of scl2 prescribing compared to their practice compared to the overall Network and we can provide uh that physician um who has not been prescribed sglt2 so they can do Improvement and we have done that with um various pcns we've worked with PCN to help them improve profiles as well as some of them have done quality improvement in this area next slide Darren has really used this resource and has done quite a few Publications on how we are prescribed in um our patients with diabetes and renal failure and how we're meeting other targets and you can see we're not prescribing sglt to Inhibitors as much as maybe we should be you know and we see a lot of um sometimes areas where we're not doing as well now that's not because we're bad family physicians not at all that has a lot to do with these crazy policies that impact our ability to optimize care to our patients and Darren has even published using the sipson data and and or data across Canada on three provinces and how various prescribing occurs in the different provinces and these outdated policies have a negative impact on our care which can hopefully change things next slide this is just a pictorial of what a family physicians can do if they're interested in research they can just join the network and get information about projects they can contribute data to the network they can be involved in quality improvement and they can collaborate on research projects such as Darren even has next Slide the College of family physici sorry the College of Physicians and surgeons requires practice Improvement uh program requirements that we have to report on and we get that every year so there three uh projects that we need to complete over fiveyear cycle and um the key elements are Illustrated here there is a a template to to develop an action plan you know that can help get you started and there's a link to the college's resources next Slide the Federation of medical regulatory authorities of Canada developed a fstep system for improvement and you can see the steps here this is a process you know to assess your practice create a learning plan then implement it evaluate and then recommendations for future and how you can change things this um has been implemented across Canada through the various regulatory bodies and you can see it's aess it's not something you can sit down and do in a day it's something you have to do over time and uh the my lifelong learning plan facilitates each of these five steps so it can help you next slide it's a free online tool and there's a link to it here um and it can help you complete your improvement cycles for the three required Qi projects it's accredited for up to 36 Main Pro Plus for the practice driven it's accredit credited for up to 24 Main Pro Plus credits so you can do one on optimizing prescribing in your patients with diabetes and renal failure so that's an excellent topic for you to consider next slide you can register you know just scan this QR code or link here and this will be available as well when you go revisit this presentation next slide and Darren take it home so I I think I'd like to conclude with the following key messages uh first sglt2 Inhibitors ferone and stide reduce residual cardi renal risk and that's really important we live in a an ERA with a luur of options and I suppose we might be limited by side effects and what our patients can tolerate in terms of how many pills you want to eat in the morning uh but there are lots of options now that we could apply to reduce uh kidney risk which really is heart and kidney risk in the future uh monitoring of potassium is important particularly with ferone um with most of these agents we can expect and tolerate an egfr dip between 20 and 30% as the upper limit and consider the upcoming diabetes Canada guidelines or using the Alberta diabetic kidney disease pathway bearing in mind that that will hopefully be updated this summer to include stide to help guide your cardiorenal risk reduction dealt with diabetes and chronic kidney disease and finally monitoring your quality of diabet of Kidney Care in your practice might be a very accessible cpsa quality improvement project using some of the resources that Don has described I think we're ready to take questions we're ready to take questions so I think our first uh responder was very early on Jennifer coppins uh is fully in support of the sgt2 and GP uh however as we all know the process Blue Cross offers so wondering if there's any progress here so um we now have a generic sglt2 inhibitor that's dagin and that is a regular benefit under Blue Cross if they have Blue Cross funding you can prescribe dagly Lain and there's no paperwork that needs to be uh filled out so that's a big deal and that happened I think in uh the end of 2023 um you know o wasm piix magti gp1 receptor Agonist continues to require special authorization and you do have to fill out that form um you know A1C above Target you know tried to trial on Metformin or tried met foran uh tried some Second Line agent uh um inappropriate for insulin usually most patients who look like Mr MF I can you know that's that's pretty easy to sort out for um but yeah to be fair though uh in our own research work we've demonstrated that special authorization requirements roughly cut uh prescribing by half in patients for whom there is end organ benefit so yeah we know this this definitely is an issue that special authorization hasn't necessarily caught up with where the evidence is and thanks Darren Choice lamb says thank you uh she has a question regarding the keto pyramid and wonders if uh about choosing metformin as Foundation versus the newer agents like sglt2 Inhibitors and your suggestions what an initial medication should be oh that continues to be hotly debated question uh I think in someone with end Oregon uh comorbidities where there's that hard and organ benefit we probably have better evidence of cardio kidney protection with sglt2 Inhibitors than we do with metformin and uh the American guidelines for example have gone that way you know uh use the most appropriate agent and you they're less stuck on starting with metform and for whatever reason my my feeling is the Canadian guidelines will probably come out and stick with metformin as first line therapy because it's you know relatively safe lots of experience with it and it did show cardiovascular benefit in the UK PDS that that subpopulation of that trial um you know the question you describe is is is still debated to this day and uh that's that that is an individualized decision I will point out that metformin does have a host of side effects including GI side effects diarrhea hypomagnesemia uh B12 deficiency and so occasionally I get a patient referred to me and they're you know they've just been putting up with diarrhea for years and then when when I hear this I say well why don't we try stopping them at Foreman giving them permission to do that because a lot of people will never ever stop their mform and that was the very first medication their diabetes doctor put them on and giving them permission to do that sometimes really improves their quality of life um so I you know I'm sorry to say I don't have a a firm firm answer for that to that question for you uh and that that Still Remains an individualized Choice uh but I could see it both ways I would definitely prioritize getting those impactful agents on board Ace ARB sglt2 Inhibitors uh smati ferone and if metformin is going to get in the way of that you know there's a good argument to be had for starting on something else uh for very practical concerns though a lot of our special authorization Blue Cross forms require that patients already be on Metformin so our hands might be tied there thanks and Terry kilo and hopefully I didn't wreck your name sorry uh says I have a patient with diabetes and high ACR and a normal Glo filtration he is on an SGL 22 and we started kendia he did great on that however his wife's plan that covered the drug was lost so we applied to NH nihb for coverage it was denied as we need to say we consulted with a nephologist the patient doesn't really need to be referred to nephology clinic at this point we just need to say we consult it with a nephologist how do you recommend what we do on this wow um what a horrible spot that puts you in um because one way of doing it is to um boy I I think there's a telephone consult service you can use uh don I don't know if you remember the name of it um but but it might be it might be good for non-urgent consult quick phone phone advice where where the turnaround time is you know you you need is within like 24 hours or something as opposed to Urgent consult advice where you call the you know whoever's on call for the hospital right um but you know I got to say I can't imagine you know this is a easy call to make like hey I don't want to bother you during your busy day you know um so that that's really challenging when when when the insurance companies give you you know um restrictions like that that seem a little unreasonable if he has Blue Cross coverage that that's not a criteria for Blue Cross coverage but I suppose he's probably not above the age of 65 so that's that's a challenge um I you know what I I think you got to do the best to to meet that criteria and you might try to use a use a telephone consult service is IT specialist link is is that the is that the consultation service specialist link um um and I can't remember um it's electronic too like there was one you could do through email if I remember right um you know so there there is EC consult I think um you know and I I've done it with Nephrology not NE with Urology but um I can't advise how to do that remember I'd have to look into that what a what a challenging spot right um yeah I okay good to know that that's a thing gee it's frustrating it's common these kind of problems there's an anonymous re Quest EST uh please comment on drug induced hyper calmia what level did you mention would be acceptable as being safe and how often should it be the potassium be monitored yeah yeah so you know I mean the monograph says when you're starting something like fero and you monitor after about four weeks uh you know and and a mild degree of hyperemia you know 5.2 5.3 up to 5.3 uh would be considered reasonably safe in so here here's here's the caveat in a stable patient uh so obviously if someone has something acute going on and then you catch the hyper K but they're they're not eating they're not drinking they're not peeing good they've just taken a bunch of ibuprofen you know who who knows right like that's that's a bit of a you know work in progress like that's Dynamic um but presuming your patient is well and stable you know a mild hyperemia you know I I've had the experience where the nephologist just kind of shrug and ignore that right um you know there is a personal risk risk threshold involved and uh you you you know of course you know you may or may not be as comfortable with that and um you know you could consider dose reducing the ferone or adding sglt2 inhibitor which tends to have a dtic and lower lowering potassium effect so that's a good combination to have with ACE inhibitors in ferone to try to to try to blunt that right so um there are some options there and Cheryl Carl asks do you have any thoughts about Monero versus GP 1 ra Inhibitors yeah that's a a hotly debated uh okay that's an interesting question as well so tepati or Manjaro was a dual Agonist so um if I'm not mistaken in addition to the gp1 receptor Agonist it also contains a Gip Agonist and um as a result it is actually in the trials and they they've done head-to-head trials against um diabetes dosed Stites OIC and in these trials even at the beginning doses of tepati it was Superior in terms of weight loss and A1C reduction so on these two criteria it is a superior medication but here's the big butt uh the heart and the kidney outcomes uh have yet to be clearly established in the cardiovascular and kidney Trials of tepati so so if if you believe right off the bat that there's going to be a class effect sure you could use tepati you know in a patient like MF I'm a bit more conservative I I like to wait to see the evidence I think tepati is fundamentally a different sort of medication and so for for a patient like MF I I will continue to use some agatite because that's where I have the proven heart and kidney benefit uh but certainly in in a patient who um uh with no such compelling indications if they have funding for epetite you know then and they're able to deal with the current dosage you know Administration form right like as far as I know it's still vile and syringe because they haven't gotten the pens to us yet I'm not sure if that's still true or not there are plans to get the pens out to us soon um then yeah that could be very reasonable option or someone who's maxed out some agatite and continues to need more weight loss more he want C reduction you know that could be a very good option right and we have one last question from Jennifer cins and it's what's the cost of then her own ah okay um yeah um about the same maybe a little bit more expensive than brand on-brand um sglt2 inhibitor uh so I I don't know the exact cost off hand but I I think it's somewhere in the ballpark of a 100 you know maybe a little bit more than that per month uh but you know just check with your pharmacist or look it up on the idbl so just Google idbl Alberta and that'll give you the interactive drug benefit list because it's Blue Cross listed now all fer sell at the public list price which is found on the uh idbl online uh so sorry I actually don't don't don't know the exact um uh list price off hand yeah yeah good question though you know that's important for our patients you know we you know I mean it's worth remembering that even even with coverage Blue Cross coverage there is Cay there is a there is a copay it's capped but it's per prescription and so if they get their prescriptions filled every month that does add up right well and that's it we got all our questions so we've uh and we had an excellent webinar with all of you thank you so much for your input now remember on March the 4th we have another similar webinar but this time you're going to bring your challengeing cases so think of a case and send it to nandini you've got the email link right there please send it in by February the 25th and we're going to make a very interesting presentation with our excellent presenter Darren right and uh we'll hopefully be able to answer lots of questions or and maybe even create new ones so thank you everybody um remember to fill in your evaluations we do appreciate the feedback it helps us to improve these sessions and uh I hope you have a wonderful day and week and uh see you later and thank you Donna for moderating this and and for your fantastic insights hopefully we'll see you all next time yeah