BBS - From Sugar Highs to Fat Fries: The latest in Diabetes and Lipid Management Feb 11, 2025

追加: 2026-05-19

[00:00:28]e e hello and good morning welcome to the second webinar from our Beyond blood sugar titled from sugar highs to Fat fries the latest in diabetes and lipid management webinar our series hosted by the office of lifelong learning and the physician learning program at the University of Alberta of note on March the 4th we'll have our third webinar focused on your dilemas that's not just Physicians that's all Ali Allied health professionals so think of your real life cases that you're dealing with and send them to us and we'll 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 and the director of quality improvement in the department of family medicine as well as a medical director in the physician learning program and L3 learning program The Physician learning program and office of lifelong learning are committed to providing reliable updates and resources for clinicians Health Care Professionals and everybody committed to providing the best clinical care for our patients housekeeping we're going to start 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 Stony Denny iqua and obij lands that are now known as part of treaty 67 and 8 and homeland of the matey the University of Alberta respects the sovereignty lands history languages knowledge systems and cultures of all First Nations mate and Inuit Nations for more housekeeping information I would like to to to let you know a little bit about the features please use the chat feature if you have a question about technical difficulties or the L3 programs or Services unless otherwise instructed if you have a question for speakers please use the Q&A the question and answer feature of the webinar look at what has already been asked and upvote those questions that you would like answered we cannot guarantee that we will be able to respond to all of your questions but a recording of the webinar will be sent by email to all of you who have registered participants can claim CME credits and complete a personal development activity using my lifelong learning plan tool for more information visit the QR code on the screen this activity has not been formally reviewed by the Canadian family physician college or the Royal College however it is eligible for non-certified credit main Pro Plus participants can also earn additional certified credits by completing a linking to learning exercise so today we're very pleased to welcome Dr Darren Lao and me we will provide an update from sugar highs to Fat fries the latest in diabetes and lipid management Dr Darren Lao is an assistant professor a diabetologist general internist and a clinical epidemiology at the University of Alberta Hospital and the K Clinic Darren is also an acting medical director in the physician learning program and the L3 program a apart from his incredible research on outcomes of medical therapy in adults with diabetes he enjoys sharing the newest greatest things in Diabetes Care with anyone who will give him the time of day so do that thank you very much for your time and welcome everybody to our PLP webinar hi all thanks for that introduction Donna um you know I am just going to take a moment to screen share the slide deck here I think it's this one alrighty I hope everybody can see it and in the meantime I realize I need to be able to see the chat where did that go there we go okay perfect good um okay um as as Donna said I'm I'm Darren Lao I'm um at the University of Alberta K Edmonton clinic and it's my pleasure to be here today with uh with Donna to talk with to you about uh dislipidemia Management in adults with diabetes uh I do now have a disclosure um I recently I have become involved in a small investigator initiated research project that has received a small number of dollars from a buyer Pharmaceuticals the maker of um panon or cenia otherwise I have no I have no other disclosures uh to present and I have no disclosures so here are objectives for today uh first we're going to discuss approaches for managing D idemia to reduce cardiovascular risk in high risk individuals including the role of newer agents so we' be talking about things as well like pcsk9 Inhibitors and icosapent ethyl and again the point here isn't necessarily to treat numbers the name of the game is cardiov vascular risk reduction uh we are going to discuss and debate practical prescribing of things like statins and numer agents and the barriers encountered in real life and we might then contemplate how we ensure that all the patients in our practice benefit from dyslipidemia management so the uh the Big Goal here is that you take away something you do something a little differently in your own practice but you know the icing as if you can figure out how to do it for more than one person person in your practice and we have some tools for you this is the motivating case and this is a case I get very frequently in practice um you know I run a very small academic practice at K Edmonton Clinic it's um it's a bit Boutique a major source of referrals for me is actually cardiologists so you know there's a number of local cardiologists here who know me and send me their tricky patients who they can't get to LDL values that they're looking for or who have diabetes and high a1c's so this is a typical patient I might see a 57y old male who's had an N stemi about 6 months ago uh he's East Indian uh he had a single stent put in but there are multiple residual 40% atherosclerotic lesions and so those would not be considered flow limiting and he doesn't have any symptoms of angina his EF um on the out on the echocardiogram during this admission was 55% so no real heart damage from this episode thankfully his past medical history is consistent uh it consists of hypertension dyslipidemia type 2 diabetes and of course coronary artery disease and here are his medications aspirin tegr or prista pendil Forin gide Baza and EMP gazin he's a university mathematics lecturer and he does have a family history of early onset cardiovascular disease and diabetes uh his physical exam findings and his laboratory investigations are shown there okay uh I do want to like last time I don't know how many of you were here for the talk last time on Kidney Care uh but I do like to have some interactivity so I am going to let you guys you all in the audience digest these Labs digest these numbers and comment on things you notice things you think need to happen for this individual things you're concerned about sky the limit and there's two ways to comment you can raise your hand and we can grab you to to say a thing or two or you can put in the chat and the chat been opened up for this purpose so take a moment and go ahead have a look through now I got to figure out how I can see participants on my on my zoom how do I do this it worked when I wasn't screen sharing oh there we go perfect there is one hand oh here we go um AB man uh you have a hand raised are you able to mute and go ahead okay so I'll just go through the values that you shown us I'll start at the top there uh uh his uh his blood pressure is not on target would want a blood pressure VI of the age of Life uh you know whether diabetic got diabetes sorry not uh so that's not on target we need to work and get that better the next on the list is CMI again that is again off I want that under under 24 pre 18 to 24 uh the A1C is not out out of out of B so sorry the is not controlled you need to work and get it better now uh is GFR I think for now looks fine us is pretty good so we St fa but if we don't work hard on this diabetes we may get to trouble well you've highlighted a number of things so far I'm curious if you could pick one next thing that you want to talk to this patient about what would it be I probably would start with your sugar okay youd start with you know blood pressure is certainly a problem uh because I mean both of them are critical to preservation of B is uh is is kidney but also that's very fair and and I know this is a talk that's meant to talk about dyslipidemia but we have to remember that cardiovascular risk reduction is a holistic is a holistic thing and so yeah we need to control the other cardiovascular risk factors so blood pressure is important and in this patient we would Target 130 over 80 for the diabetes uh but the other important one whoops come on uh the other important one as you pointed out is yeah A1C reduction and so you look at this patient and you think what am I going to do from a diabetes or an A1C perspective you know there's a couple of easy answers here and those easy answers would be don't forget sglt2 inhibitor and glp1 receptor Agonist he's already on ampa 10 but empa 10 is kind of like the Cardiology dosing of empa gazin you could go to empa 25 and with his preserved GFR like excellent GFR he'd actually have some pretty good blood sugar lowering from making the switch from empa 10 to empa 25 for sure and then consideration of stide gp1 receptor Agonist and I I like these options because no matter what they're A1 is you know I'm going to be doing this for cardiovascular risk reduction right in the context of a patient- centered conversation and so that's and that's something we'll come we'll talk about more yeah but absolutely absolutely thank you thank you for that just one uh one observation I don't know you guys are in in albata but here I'm in discussion and sometimes there have problems with these some of these medications in terms of coverage uh you know we have es you know St some2 the yeah yeah abolutely what you have in ALA how are you doing there where well so man you should be aware that dag glyphen is generic so it's probably covered by Blue Cross as a regular benefit it is in Alberta I imagine in Saskatchewan there may be something similar I don't know um skatan I'm not sure how the how the insurance system works in Saskatchewan but that that that's that's a fact of life we do struggle with this yeah and and talk a little bit more about that later yeah um any any other um any thoughts from uh from other members of the audience yeah if if you don't want to pipe up feel free to type something in the chat anything about this case any any any interesting thoughts any considerations for what to have what to do next how would you approach this case is it too early for audience participation hi I see a hand up from ja Pai go ahead ja uh just wondering why the patient is only on metform in 500 bid Fair Point might have been that that's a good question uh maybe it wasn't tit trated Maybe medication side effects yeah that's um but you know what I if I were to look at that medalist the more glaring feature would be why the patient's only on pravastatin 20 right I think that's the more glaring feature here and um we do see this a lot usually for me you know I mean pravis stattin and Simba stattin you know Prav stattin being lower potency Simba stattin be moderate potency statins you know they they were more common uh about decade ago but these days when I see someone on pravastatin 20 like a low dose of a low moderate potency Statin it's almost certainly a tip off that they've had stattin related side effects so now we know okay this might be a barrier to to cardiovascular risk reduction is this that this individual has had sattin related issues yeah nand writes could rotate prava to a toris Statin absolutely absolutely um when I have a look at this case one thing that strikes out is you know what dis lipidemia targeted Target am I am I aiming for J you you can mute your your mic please H but thanks for that comment um and okay so this lipid panel might be typical of of a lipid panel I see and um we we often see this the LDL unable to estimate what does that mean and how do I deal with with it okay well LDL continues to be the centerpiece of lipidemia management because it has been for a very long time and because it shows good prediction of future cardiovascular risk LDL referring to one of fraction of lipoprotein particles that are atherogenic and circulate in the blood and because intervening on it can make a difference so these are data from experimental trials so the Statin trials and the metanalysis of the meta analysis of them show that every one millimolar reduction in LDL achieved with Statin therapy reduces cardiovascular Risk by 20% and again this is highquality randomized Control Data and in fact there really is to our knowledge no lower limit in adults of how low you can drive an LDL uh for example in the 48 trial of a pcsk9 inhibitor ldlc was actually lowered to.9 Millar on average compared to 2.3 in Placebo arm and there is still a 15% relative risk reduction in cardiovascular outcomes and in that trial some individuals actually had LDL less than 0.4 Miller molar per liter so LDL does Remain the main state of our targeting for dyslipidemia management and cardiovascular risk reduction but with the triglycerides are high sometimes the lab assay is unable to estimate an LDL fraction apart from total cholesterol uh but moreover if the triglycerides are high some of the um cholesterol in these LDL particles is actually replaced with triglycerides leading to smaller more atherogenic particles and as a result the same LDL might not mean the same thing for cardiovascular risk it might actually underestimate cardiovascular risk in the context of a high triglycerides I do see we have some comments um uh I'm going to come back to the case in a second uh but uh you know I just want to okay I'm just going to finish this thought here uh so there are a range of other non-ldl atherogenic lipoprotein particles in the bloodstream they include things like IDL and vldl and so together you might consider targeting a non-hdl cholesterol which is the sum of all the atherogenic lipoprotein particles in the blood and because it captures these other particles non-hdl cholesterol actually demonstrates Superior prediction of cardiovascular risk versus LDL cholesterol and is more often a available in the context of high triglycerides and so our primary prevention targets for LDL are 2.0 secondary prevention we target 1.8 millimar per liter these are straight out of the CCS guidelines for non-hdl cholesterol we would Target 2.6 for primary prevention 2.4 for secondary prevention um sometimes if the triglycerides are quite High we can't measure any any of these we go to APO B so APO won't be reported on your lipid panel but you can order it separately for your patient is covered by Alberta Health H and the point here is that every atherogenic particle has a single apob Moy stuck to it so APO actually represents the best indicator of atherogenic particle numbers and predicts CV risk better than non-hdl cholesterol where the results are different and for APO B we would Target 0.8 for primary risk reduction and 0.7 for secondary risk reduction okay some comments here uh from bishnu EF is 55% beta blocker is it needed you know that is a good question uh patients are often started on beta blocker uh after acute cardiac events based on evidence uh that actually predates our current ERA of you know ACE inhibitor ARB and these sorts of things so this is hotly debated by the cardiologist I think current practice is to have people on it but then to be willing to deprescribe after about a year's time uh would look to reduce BMI going over lifestyle yes Donna is going to talk more about that for sure for sure uh okay [Music] so um in terms of LDL okay so if we if we look at this patient and we look at the math here uh we can see his non-hdl cholesterol is actually blipping High total cholesterol minus HDL cholesterol gives us 4.08 which is a far cry from the target of 2.4 in this patient so we've got a lot more work to do what can we do to get more LDL or non-hdl cholesterol lowering in this individual well Statin therapy continues to be the main state of treatment and again that's based on really good evidence from multiple trials that statins make a difference uh in diabetes specifically we have the card's trial of a torvis Statin and the numbered need to treat over four years there was 32 which is amazing H but again the hint here he's on prava Statin the hint here is that he's had Statin related side effects in the past it's worth knowing that Trials of this have been done and 80% of Statin side effects would be what you could consider nobo side effects so they're actually observed in patients who were treated in Placebo with Placebo as opposed to with the Statin and are indistinguishable either on symptom intensity or relief with stopping after you withdraw the quotequote agent so the placebo right these things don't actually distinguish um whether someone's in the placebo arm or in the stattin arm if they have muscle aches as a side effect and in fact for individuals who have side effects on Statin in these trials 50% of them over 50% some estimates as high as 80% are successfully able to restart Statin therapy and continue it long term okay that's not to say that these side effects aren't real you know I I I live in a tertiary care environment so by the time patients are referred to me for these sorts of things they've had multiple trials and they're really struggling I I get it you know this many patients do have real or practically real side effects on these agents uh but my Approach is typically to get a detailed history of what stattin they've been on in the side effects and to retrial high potency Statin therapy even at lower doses to begin with um and then any Statin is better than no Statin so this table here is provided for your reference is just an indicator of the average LDL relative reduction you expect to see with different statins and again prava Statin would typically be considered one of the lower moderate potency statins compared to Rua stattin or TVA stattin and this guy's had a heart attack you really want to try him on a TVA Rua maybe even starting at the lower doses there but there are some patients who you don't get to Target on Statin therapy or who really don't tolerate Statin therapy and so what are your next lines of therapy um is it a m is something we always go to and that's because it's inexpensive uh there is cardiovascular outcome data showing that it makes a difference although that that difference is actually relatively speaking fairly small okay it does work it lowers LDL cholesterol uh but really depending on how far away they are from Target I I I use as itmi for sure but you know I might I might I might go to it if there's only a little ways to go to get to Target or if it's required by drug insurers very often drug insurers will require someone to be on a Zid M before thinking about other agents uh but the new kit on the Block and we've had great success in in my clinic and in D lipidemia clinic at the U OFA Edmonton Clinic with pcsk9 Inhibitors so these are typically injectable agents they're monoclonal antibodies um that reduce expression of the uh HMG coas in a different manner than Statin therapy uh and the the two big ones the older ones on the market now are evolocumab marketed as ratha and alur roab marketed as praluent so these are very effective agents as I mentioned earlier in the fora trial um some people actually got their LDL down less than 0.4 millimar per liter which is you know spectacularly mind-boggling in terms of the degree of of LDL lowering uh and so these are some data from the for8 trial and the Odyssey outcomes trial uh both of these trials enrolled uh individuals with cardiovascular disease and additional cardiovascular risk factors so high-risk patients um yeah high-risk patients uh and and you can see in these individuals treatment with evab and alirocumab um I apologize for the difference in the ax so just watch out for that uh but does did produce uh M major adverse cardiovascular event benefit with Hazard ratios indicating a relative risk reduction of about 15 to 20% um over three years in the 48 trial number need to treat would be about 50 so that's that's favorable uh by considering that this is residual cardiovascular risk after attempts to optimize everything else pcsk9 Inhibitors though are again injectable agents this is what ratha looks like this is what praluent looks like uh they they're very well tolerated uh from a sa perspective um you know I mean there were side effects in the trials but they tend to be balanced uh between intervention so the pcsk9 inhibitor and Placebo so things like naso faringitis or influenza like symptoms or mygas or aralas they did occur but again they were similar between groups and no differences for the Key Safety outcomes of rabdom mysis or elevated as alt or ck levels uh you I do note that about 2% so what is that 150 individuals have injection site reactions with these agents as you might expect uh in my practice somebody with terrible muscle aches on multiple statins on even lowd do statens I've had individuals go on evab and aliab and for them it's like injecting water but the next LDL is is cut down by easily by half or more so I I've had a great luck with these agents again recognizing that I'm an academic practitioner with a low volume practice but we've had good luck with these agents in in getting LDL down uh funding is going to be an issue though and so private if they have private insurance yeah you can get coverage for secondary risk reduction it's a bit of paperwork it's a bit of work on the patient's part and on your part but if they have private insurance benefits if through work for example or maybe they maintain their work rated coverage after retirement you know that's you got a good chance of getting this covered for secondary risk reduction unfortunately public Blue Cross will only cover it for familial hyperemia according to probable or better on the Simon broom or Dutch lipid Network criteria you can look these up to see if your patient qualifies as a rule of thumb you know they if they've demonstrated an LDL greater than five at any point in the past you got a pretty good chance they're going to be probable on these criteria and you're going to get coverage that way and other other elements of these um criteria include things like a really strong family history of premature cardiovascular disease now you might have noticed that this patient had elevated triglycerides um 3.2 okay uh triglyceride lowering is now is still a little controversial right so you know a moderate hyper triglyceridemia might be 1.7 to about 5.6 or so moderate to severe up to 11 severe is definitely 11 or 12 or higher and you know at at the point of being 11 or 12 or higher you really worry about acute pancreatitis risk that patient needs a fibrate for sure but for lower degrees of hyper triglyceridemia which we commonly see uh the pancreatitis risk isn't really a thing and we're more interested in cardiovascular risk reduction uh so we know that elevated triglycerides is associated with cardiovascular risk it's a big risk factor but the evidence is quite mixed on whether treating that H triglycerides like getting it down actually improves cardiovascular risk so for example we have a recent fibrate trial with Pema fibrate uh where the Hope was that this would confirm in high-risk High triglyceride individuals that lowering their triglycerides with pmop fibrate would reduce cardiovascular risk but that was not borne out in the trial uh some trials beared out some don't the ones that don't suggest that it might be borne out in the subgroup of individuals with really high triglycerides this is a bit of a mixed bag for fibrates and triglyceride lowering in terms of reducing cardiovascular risk still a reasonable thing to do for individuals with high with really high triglycerides like 2.3 or above but that's at your discretion certainly something that you have to do above 11 because of the pancreatitis risk right um but we do have a new agent that's indicated in individuals with high triglycerides and this is icosapent ethyl so omega-3 fatty acids are another class of uh medication so to speak where we really don't recommend it for cardiovascular risk reduction most omega-3 preparations are mixed and have not shown consistent benefit in the randomized trials with the exception of the jealous trial which used a fraction of the omega-3 fatty acid the aosip aosip pentanoic acid fraction and actually did meet its cardiovascular end point so building on that we have in uh 2017 the reduced trial and this was a trial of a new synthetic drug product called icosapent ethyl which really is icosapent noic acid but synthe sized and purified so not not really talking about fish oil anymore this is truly a new drug product uh it's administered as two grams uh B and they come in these one gr tablets so it's kind of like being El metformin um and you know it's four four capsules a day and this trial was Placebo controlled against mineral oil it enrolled individuals with high risk features so previous cardiovascular disease or age 50 plus with diabetes and additional risk factors and they all had had an elevated triglyceride of greater than or equal to 1.7 as well as reasonable LDL on Statin therapy okay and the reduced trial actually showed again cardiovascular benefit in individuals treated with icosapent Ethyl at about 5 years the number need Tre to treat was 28 which is actually quite remarkable interestingly enough the cardiovascular benefit seems to be unrelated to the degree of triglyceride lowering as so it might not actually work by lowering triglycerides it might work by other mechanisms including membrane stabilization in atherosclerotic plaque and there is actually Imaging evidence placebo control trial Imaging evidence showing that icos pen ethyl can reduce low attenuating plaque whereas Placebo given patients actually showed an increase in low attenuating plaque over 18 months in the coronary arteries and of course that's that's not the hard calcified stuff that's the stuff that we care about it's young it's fresh it can pop and cause acute myocardial infarctions uh in terms of safety we do note that there is an increased risk of apib and hospitalization for apib in patients treated with hosen ethyl that risk was 5.3% versus 3.9% over the course of the trial uh but most of us worry about aphid because of the implications for stroke and again icos pent ethyl was associated with a net reduction in major adverse cardiovascular outcomes including stroke um yeah this is a very expensive medication costing about $300 a month but it is actually Blue Cross funded for seniors uh age 45 Plus for secondary risk reduction in individuals with triglycerides greater than 1.7 on Statin therapy but of course this is a patient- centered conversation to have because it does increase pill burden remarkably I want to pause there we've talked about triglycerides and LDL lowering any other thoughts from the group when I look at this patient I just want to H shout out to our talk from last three weeks ago I do notice that the the egfr is quite good but hey this patient has albam andura so addressing cardio um renal risk might be a consideration H I've refer you to our previous talk in the series but it's important to remember that ACE inhibitors ARB sglt2 Inhibitors stide and ferone are agents that might be IND that would be indicated here for both kidney and heart risk reduction so cardiorenal risk reduction in the interest of time I'm going to do a bit of summary now so cardiovascular risk reduction what are our medical options now uh please do consider tracking this lipidemia tracking the lipid panel in your high-risk individuals and I point this out because I know there's debate in the primary care World about whether you should treat the target the way I typically do the way Specialists typically recommend or whether you should prescribe and forget I think these debates are maybe more prevalent in the primary prevention world but for a patient that's high risk like this I definitely think you can make an argument for treat to Target because this will help engage your patients if they see their ldls getting better on therapy it might improve medication adherence it identifies when and where you need to intensify therapy you can document the benefit of the therapy you put them on which is actually quite important for the newer agents for funding purposes and if you treat to Target if you're monitoring the LDL this gives you a chance to improve the quality of care in your overall patient panel and now Statin therapy is inexpensive effective and it's safe and Remains the Cornerstone of CV risk reduction along of course with risk factor reduction and Ace and ARB therapy but I'd like to point out that pcsk9 Inhibitors are additional highly effective agents for lowering LDL and of course icosapent e lowers triglycerides and reduces cardiovascular Risk by other mechanisms and is indicated for hyper triglyceridemia for secondary risk reduction how often should we monitor after starting statins um you know I it whatever is practical in your practice is the answer to that question uh I typically monitor every 3 to six months uh you should see the effect of starting selling on statins or I costen ethyl or um pcsk9 himer within within a month actually u i do recognize patient centered concerns here I've just talked about you know a whole bunch of different medications and uh I I'll be honest they are a financial burden and they're a massive pill burden and my my patients often come to me and say Doc holy moly do you see the handful of pills I have to swallow every morning H so I I do really have honest conversations about what patients are willing to spend or tolerate to prevent CV cardiovascular disease H recognizing that we do have the phenomenon of marginal gains as we go along but residual cardiovascular risk is a real deal right and so some advocacy and some having some some having of honest conversations and risk evaluations with your patients is necessary so that you avoid this outcome depicted on the left side and so that your practice looks a little bit more like this on the right side okay over to you Donna okay so something we didn't talk about here is metabolic syndrome and you may or may not be aware that not all diabetics have metabolic syndrome and not all Slim healthy looking people do not have metabolic syndrome so metabolic syndrome consists of three out of five criteria and uh I'm showing a table from a table from a paper that we published where we developed an algorithm to identify patients in the EMR who have metabolic syndrome you can see that this fellow checks five out of five you know so he clearly had metabolic syndrome and had it before he developed diabetes and I find often if we address this early on we can even prevent diabetes so lifestyle modifications are huge uh both uh after they develop diabetes but even if you can do it before so metabolic syndrome has risks for numerous other conditions as well next slide you know so with this fellow I think it would be really important to look at lifestyle you know maybe he's drinking if he's consuming a lot of alcohol that could certainly be a big factor in his uh elevated triglycerides but so is the sugar content in the food and people don't realize how much sugar they're often eating uh he may not be exercising at all and then of course he might be smoking next slide there are a lot of other things to consider um when you have metabolic syndrome you're more at risk for fatty liver disease and we know that causes therosis and I've had patients with liver transplants due to this you know so it's important to look at liver function you may want to look at other things like sleep apnea and others next slide so with this fellow uh again if he's drinking alcohol I really try to get him off all of the alcohol and smoking a diet uh Mediterranean diet and DASH diet work you know lower carbs uh there's restrictive feeding that can be beneficial as well and increasing fiber in the day um he really should optimize his medications the Statin there's something going on there so you find out it maybe didn't tolerate it start at a lower dose maybe I find sometimes I have patients they started off on the highest dose and they don't like it and stop you know so I often titrate it up he should be on an ACB which he is glycoside not good not good for metabolic syndrome uh be better to increase the sglt uh too and possibly add on a CHP uh you can use both and that could benefit him quite a bit I'd work with the cardiologist on whether he needs his antithetic uh therapy and for how long as well as what other lipic lowering con considerations we might have next slide I find with uh a lot of these patients we're dealing with a lifestyle and behavioral change and uh something that works very well grounded in in the science is motivational interviewing however that takes an inordinate amount of time and it's not something a lot of us can do in our our practices uh I found brief action planning worked very well and can be done uh at a regular visit uh I'm showing a screenshot and there's a link that you can go to learn how to do this and it really is around I having the patient identify what they are willing to do to change what they're interested in changing uh and then uh evoking from them um you know what uh what they will do as well as how confident they are they can do it and and it works you through a process of increasing that and the likeliness of improving their behaviors next slide having a treatment plan is really important for both you and the patient and I find it it's really helpful if there's something that can be written out that could be handed to the patient as well as for you to share with your team and to keep on the chart uh so that everybody is on the same page and this is something you'd update at regular visits and the diabetes Canada has an excellent care plan that you could tailor for this use next slide now we're talking about an individual patient but often uh it's important to know how we're doing in our panel and uh this is around getting data and information and looking at improving our care next Slide the Canadian Primary Care Sentinel surveillance network was developed by a number of research directors of practice-based research networks across Canada in Departments of family medicine and we developed the ability to extract point of care data from the electronic medical record structure it and use it for uh surveillance quality improvement and research next Slide the Northern Alberta Primary Care research network is a network that's contributing data to the sipson uh and it can provide information to participating Physicians and nurse practitioners in the network uh in Southern Alberta there's sapin the Southern Alberta Network that also does this next slide so this is an example of uh information we uh can look at for individual physician The Physician is the light the dark blue uh this is what's coded in their problem list and this physician you can see 100% of their diabetic patients are in their problem list that means that they have a disease registry they can look up easily in their EMR who has diabetes and whoever is coming to see those patients can see on the chart that that patient has diabetes uh good data management is really important to good care next slide we also provide Physicians with um reports PLP and napkin are working together so we can provide point of care information on how the physician is doing and these are an example of a few uh reports that Physicians could re receive on on their uh care The Physician is the dark blue color and you can see in the diabetes and uh diabetes with renal failure how many of them are optimized and that physician was able to improve uh medications to their diabetics with renal failure using the data and and uh inviting those patients in through quality improvement Statin use in adults with diabetes in the network is not not very good you know so we know most of our diabetic patients probably should be on a Statin and overall it's around 60% and you can see here this ph's around over 80% you know with the information from the data next slide so I encourage you to consider about uh contributing to family medicine and Primary Care research and this is a it shows the mountain on how you can contribute just through being engaged contributing data and uh joining the network next slide another excellent resource uh is the Health Quality Council of Alberta and you can see a very similar report on the lipid this is the same physician uh where that physician is achieving 80% of uh Statin prescribing in their diabetic patients over 40 as compared to around 60% of those patients in the PCN panel so again uh these sources of data can really help you uh improve practice and you can use them for improvement as well and Reporting where you have to to the college next slide so the College of Physicians and surgeons require us the clinicians to do three quality improvement projects over a 5e year cycle and the practice driven Qi project uh can really benefit from use of these uh information sources and you need to use data develop an action plan and ideally it could be facilitate it by someone in your PCN but not necessary you can do it on your own and then you implement and reevaluate next Slide the Federation of medical regulatory authorities of Canada developed this uh five-step system for improvement so this is the process this is how you go about improving and it's grounded in the canmed roles so Improvement you can't do in ch a day you have to first understand what the problem is assess it then you develop a learning plan you implement it test it and evaluate the outcome and and uh you can capture that information in the my lifelong learning plan next slide so this is a free online tool that can help you facilitate and capture the information that you need to document when you are reporting on your quality improvement activities and the great thing about this it's also got main Pro Plus credits so family docs for your practice-driven project you get 24 Main Pro Plus credits and for the personal development and standards of Care Improvement projects you get six next slide so to register or get more information about this uh tool that you can use for your quality improvement you can scan this code or visit the link and this will be included in the webinar information that's passed out next slide and Darren take it away okay so in summary uh this talk was about cardiovascular risk reduction high-risk individuals with dyslipidemia specifically focused on in individual with diabetes but not necessarily limited to such an individual and uh I guess my take on points would be as follows a holistic approach to Patient centered care including lifestyle modification and behavioral assessment and risk reduction is important uh as Donna's mentioned and as I think um let's see as Baba's mentioned as well in the chat uh Statin therapy Ace ARB and other risk factor reduction so getting that blood pressure down A1C down Etc they these things continue to remain foundational for medical care they're the basis on which other things are added if you need them pcsk9 Inhibitors and iosa Pen ethyl are new agents for secondary risk reduction uh but of course addressing residual risk with these agents does require monitoring advocacy and balancing patient centered concerns including very real concerns about side effects pill burden and affordability uh resources are available H so if you need help with prescribing Pathways and knowing what the cut cut offs are Canadian cardiovascular Society has an excellent version of their dyslipidemia guidelines in a little booklet it's very pictoral so you can just walk your way through them and uh that's available on the Canadian cardiovascular Society guidelines we'll put a link to that for you and some resources that we'll email out to you after this talk H and of course there are additional resources for practice assessment benchmarking and to help you develop targets for practice level Improvement as Donna has just discussed I'd like to thank you all for your time today and if you have any other questions or comments please feel free uh don't forget we're doing this again March 4th there's another one of these talks last in the series number three and uh we haven't had any cases so far the point of this is diabetes dilemma bring your own cases I mean Don and I will have cases as well and uh you know I'm happy to talk about my other passion is continuous glucose monitoring so we'll have something but even better if we can address the things that bother you in clinical practice so please the dilemmas you encounter you know get them out to us in anonymized terms in general terms please we don't need to violate patient confidentiality for continuing medical education uh but please please please get them out to us H we'd be pleased to discuss your cases as a group okay it's kind of like the chance to have a consult without having a consult you know what I mean uh I see messages and a hand raised um yes yes we'll move on to the question and answer uh and there's some uh question in the question Q&A so we encourage you to put in uh your questions and the first one is do look at L lipoprotein a for your patients regarding cardiovascular risk and how do you manage it that's to you I knew that was going to come up I knew that was gonna come up here I have a slide on it right lipoprotein a is going to be a big thing in the future but right now it's it's it's interesting so the the idea of light Po protein a is that lipoprotein a concentrations really vary by among people and and they vary in ways that are not affected by lifestyle and Statin therapy in fact lipoprotein a is primarily genetically determined and actually there is some very clear differences uh from populations to populations across the world that might account for some the ethnic differences we see in cardiovascular risk apart from environment and diet and these sorts of things um so having an elevated lipoprotein a is a risk factor uh but it's not at this time a modifiable risk factor so you might do it to pin down someone's cardiovascular risk better because if it is elevated above a 100 nanomolar per liter uh that person has a 1.5 to twofold increased risk of cardiovascular disease on top of their risk prediction based on LDL cholesterol and other Framingham type risk factors me right so you know you might measure it once in in a patient's lifetime to help with cardiovascular risk assessment and then to enlist them for additional cardiovascular risk reduction for example uh but that role of lpay is going to change in the future because we do have therapies targeted against LP little a in Trials right now so it may in the future be something we can Target with therapy in which case lpay might become something you monitor more routinely the way we might do a non-hdl cholesterol and LDL cholesterol but right now its role is mostly in understanding cardiovascular risk and it's recommended to be measured once in a lifetime because it's primarily genetically predetermined and not affected by Statin therapy or lifestyle I hope that answers your question and the other is from Bishi bandery I hope I pronounce names okay uh it's more common acetam well to tolerate it no side effects um iset has a side effect profile that's very similar to statins uh muscle aches are an issue with Zam I find that it's not a guarantee that someone with muscle aches on statins will also have muscle aches on a Zam in my in my experience it tends to be you know it's it's it's not a guarantee um I do have individuals who are like on the sneaking by on the lowest dose of pravastatin who do tolerate a ZM quite well but equally I've had individuals who have had muscle aches as a problem on on both types of Agents um so it it is worth trying uh but you know what part of part of doing this is having a practice where you can have that followup and have these conversations and bring people back in a timely fashion to re-evaluate the outcomes of you know uh Trials of withdrawing of medication rechallenges you know so this becomes quite a journey with your patient right you know from a practice organ ization perspective you know even at the Specialty Care level I find this challenging it's not straightforward and we have a question from David Ugo chuku uh what level of uh urinary creatinin uh should be or should not catch the physician's eye in the previous CB incident I'm asking this in respect to balancing the pill loads of the patients when they are con concerned yeah yeah that that's fair look you know when okay you know I mean I I I know diabetes cidis says you know you have CKD above two you know most nephrologists say CKD above three right we have some individuals who have like a 4.5 you know or who who kind of have up and down and sometimes it's you know 1.5 some sometimes negligible sometimes it's for you know yeah are we going to go full hog on cardiorenal risk reduction these individuals so that's a judgment call you know at least they should be on Ace ARB sglt2 inhibitor if they have diabetes in my mind those are the the easy ones to put on right um but um you know definitely when we get into the double digits that is like okay got to fix that you know because above 30 is considered severe Al manua you know when we get into the hundred it's nephrotic range but above 30 it's considered severe right even above three it's considered moderate by kigo you know than International guidelines so yeah there's probably a gray Zone H in there but when we when we start to get above five or so I I really do start to push treatment that's that's personal but I recognize I I do recognize the struggle though because we've just talked about essentially five or six different classes of medications you know injections and pills there's some negotiation that has to happen here clearly uh some some patients value cardiorenal risk reduction more my father-in-law uh had a parent that went through dialysis and he is hard set to avoid it and he tracks his creatinin like nobody's business H so I I have him maximized well with his doctor right and Brienne banister says if we're treating to Target and once a patient is at or near Target how often if at all do you repeat the lipids at Target or at or near Target right um your practice May differ it just deter you know the my pet peeve is when patients come to clinic and they haven't done their blood work and they promise oh I'll do my blood work this afternoon like that's not helpful because then I get in my inbox but I don't have the opportunity to talk to you about it until next time I see you or I have to call out okay so this is where Road hits rubber right and um you know as a rule of thumb for stable adults with diabetes my practice I measure comprehensive blood work for diabetes so you know A1C lipid panel uh creatinin urinal AB crin ratio I usually do check electrolytes and CBC differentials while I'm still a general internist right um but I um you know I'll do that every six months for stable patients uh for patients where I'm actively managing because the A1C I check every 3 months you know then that's that's how I tack on the lipid panels um you know in for an individual where you're starting a pcsk9 inhibitor very often the insurance company will say something like you get four month four week Supply and then you got to reapply for Renewal okay so at the renewal they'll want to see evidence that that LDL has come down or the non-hdl cholesterol has come down H so you might actually need to repeat that lipid panel within four weeks to make that evidence happen right so so it varies but as a rule of thumb if I'm actively managing someone three every three months because that coincides with the A1c and I think a lot of it depends on so much on the case if they don't have many comorbidities in that uh you may not need to repeat very often at all right so a question from Roma Captain is is it true that Statin therapy May raise LPA I have not encountered that in my reading but now that you've raised it for me I will look into it um it is true the Statin therapy probably increases sugars by a tiny amount there is some signal for that um not enough that I think it's makes a appreciable impact on treatment of diabetes though uh and overall the name of the game is cardiovascular risk reduction right um I haven't encountered that it is also true that FIB rates may raise LDL by by a small amount and so there's some debate with that trial that I was had mentioned earlier The prominent trial whether there could be some issues related to higher average LDL in the treatment home um yeah I wish I had more to say about that um sorry but you were talking about LP little a right so actually yeah my understanding is LP little a is not affected by Statin treatment it is primarily genetically determined um so I I I don't I don't think that's a consideration I I'll I will look into it I haven't encountered it I I you know if you've encountered some evidence email it to me darren. at U alberta.ca okay we're gonna have a conversation um but I my understanding is LP littlea is not affected by Statin therapy and then we have a Anonymous attendee who says How likely are you to take this patient of glycoside and increase the dose of sglt2 or reduce or adding gp1 AG considering the risk of hypoglycemia and beta blocker masking hypoglycemia and no cardiovascular benefit with glycoside exactly that right right yeah I love it thank you for thank you for pointing that out you got to come up here you should be up here yeah and then we had one hand up and that was Rebecca bondar hey Rebecca oh mistaken hand maybe yeah maybe we have another comment from the anonymous attend twice in recent memory have had patients with no coronary artery disease history have their statins reduced on Hospital discontinued because they're low LDL around 1.1 have you seen this or can you explain the rationale yeah um I I I I don't know the context of those cases it may be it may be a much older individual where the attending physicians were really thinking about deprescribing agents um we have to strike that balance of pill burden and side effect burden in our older individuals for whom life expectancy is limited and the incremental or marginal benefit of you know therapies like this becomes a bit smaller when competing and and they did have a history of coronary of cardiovascular disease yeah um [Music] I yeah yeah um yeah so they there it may it may also have been a patient- centered concern as well you know like the idea is they should probably stay on a stat 100% but do you need to stay on a stat and at the same dose if the patients for example quite an older individual who's concerned about myopathy or muscle wasting right and again we don't have great evidence that you know like they statens are safe right but we do get patient center concerns about this all the time and if they ldls 1.1 it might be a patient center decision to relax the dose but to discontinue it fully seems uh you know unless they were truly Having side effects or they were really worried about side effect about pill burden you know I mean I I hope there were some conversations that happened um for that patient um because uh you know our current evidence suggests that again you can lower LDL down to 0.5 and uh there has been no way evidence that it increases the risk of things like dementia for example yeah and people have looked at this so it is it would be safe to have an LDL 1.1 and and you know what the cardiovascular risk reduction because if they're functional individuals you know I mean statins help prevent Strokes too yeah it's weird well I think that is our uh Q&A and our webinar so so thank you everyone for uh your great in involvement in this webinar and we appreciate your feedback there is a QR code on the screen please uh take your time to give us feedback it helps us improve and develop even better webinars so thank you again and remember to bring your questions send your questions to us and we'll get that incorporated into our March the 4th webinar