PEER PERSPECTIVES

Collaboration and the diabetes care team: Treating patients with T2D and established CVD

Studies show that even when treating to standards of care for type 2 diabetes (T2D) and cardiovascular disease (CVD), about 1 out of 6 patients may still experience an adverse CV event such as a heart attack or stroke.1

Watch as 4 health care professionals discuss a therapy that addresses both T2D and CV risk reduction, and how important collaboration is among the health care team to help patients reach their goals.

The team of diabetes experts

John E. Anderson, MD

John E. Anderson, MD

INTERNIST

PROFESSIONAL ROLES

Private practice in Internal Medicine and Diabetes, The Frist Clinic

Former President, The Frist Clinic

Former President of Medicine & Science, ADA


MEMBERSHIPS

Member, Joint AHA/ACS/ADA
"Get with the Guidelines" Task Force


ACHIEVEMENTS

Winner of the Banting Medal for Scientific Achievement

LOCATION

Nashville, Tennessee

Helen L. Baron, MD

Helen L. Baron, MD

ENDOCRINOLOGIST

PROFESSIONAL ROLES

Assistant Professor of Clinical Medicine
University of Southern California (USC)

Chief Clinical Fellow, LAC + USC Endocrinology

Director of the Bone Mineral Density Unit, USC
Keck School of Medicine, Division of Endocrinology

USC Cardio–Thoracic (Heart & Lung) Transplant Team
Keck Hospital


HONORS

Speakers Bureau, American Diabetes Association
Greater Los Angeles Area, July 2013 - Present

LOCATION

Los Angeles, California

Ronald D'Agostino, DO, FACC, FACP

Ronald D’Agostino, DO, FACC, FACP

CARDIOLOGIST

PROFESSIONAL ROLES

Cardiologist, Long Island Cardiovascular Imaging and Consultants

Clinical Assistant Professor in the Department of Cardiology 
Hofstra Northwell School of Medicine    


HONORS

Fellow, American College of Physicians (FACP)

Fellow, American College of Cardiology (FACC)

LOCATION

Lake Success, New York

Melissa Magwire, RN, CDE

Melissa Magwire, RN, CDE

REGISTERED NURSE/CERTIFIED DIABETES EDUCATOR

PROFESSIONAL ROLES

Registered nurse, Shawnee Mission Physicians Group-Endocrinology & Diabetes Associates 


MEMBERSHIPS

The American College of Cardiology:
Roundtable on Managing Cardiovascular Risk in Diabetes Planning Committee

American Association of Diabetes Educators


ACHIEVEMENTS

Chairperson/speaker, Taking Control of Your Diabetes National Conference

LOCATION

Shawnee, Kansas

VIDEO 1

Evolving treatment in diabetes to incorporate CV risk reduction

With [the] strong connection between type 2 diabetes and cardiovascular disease, it is increasingly important for diabetes therapies to have positive CVOT outcomes to address this CV risk.2

Ronald D'Agostino, DO, FACC, FACP

Ronald D’Agostino, DO, FACC, FACP

CARDIOLOGIST

 

  1. Wick A, Newlin K. Incretin-based therapies: therapeutic rationale and pharmacological promise for type 2 diabetes. J Am Acad Nurse Pract. 2009;21(suppl 1):623-630.
  2. Holst JJ, Vilsbøll T, Deacon CF. The incretin system and its role in type 2 diabetes mellitus. Mol Cell Endocrinol. 2009;297(1-2):127-136.
  3. D'Alessio D. The role of dysregulated glucagon secretion in type 2 diabetes. Diabetes Obes Metab. 2011;13(suppl 1):126-132.
  4. Drucker DJ. The biology of incretin hormones. Cell Metab. 2006;3(3):153-165.
  5. Drucker DJ, Nauck MA. The incretin system: glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes. Lancet. 2006;368(9548):1696-1705.
  6. Nauck M, Stöckmann F, Ebert R, Creutzfeldt W. Reduced incretin effect in type 2 (non-insulin-dependent) diabetes. Diabetologia. 1986;29(1):46-52.
  7. DeFronzo RA, Eldor R, Abdul-Ghani M. Pathophysiologic approach to therapy in patients with newly diagnosed type 2 diabetes. Diabetes Care. 2013;36(suppl 2):S127-S138.
  8. Zander M, Madsbad S, Madsen JL, Holst JJ. Effect of 6-week course of glucagon-like peptide 1 on glycaemic control, insulin sensitivity, and β-cell function in type 2 diabetes: a parallel-group study. Lancet. 2002;359(9309):824-830.
KEY TAKEAWAYS
  • Treating patients with T2D is a collaborative effort that may involve a number of specialists
  • The 2008 FDA mandate for all diabetes treatments to include CVOTs helped provide data solidifying the connection between T2D and CVD3
  • It’s important to inform patients that additional CV risk may remain even when A1C is at goal4
  • A medication is available for adults with T2D and established CVD that states in the label that it improves glycemic control and reduces the risk of MACE5

MACE= CV death, nonfatal MI, or nonfatal stroke

VIDEO 2

Diabetes treatment guidelines and addressing CV risk

 

  1. Wick A, Newlin K. Incretin-based therapies: therapeutic rationale and pharmacological promise for type 2 diabetes. J Am Acad Nurse Pract. 2009;21(suppl 1):623-630.
  2. Holst JJ, Vilsbøll T, Deacon CF. The incretin system and its role in type 2 diabetes mellitus. Mol Cell Endocrinol. 2009;297(1-2):127-136.
  3. D'Alessio D. The role of dysregulated glucagon secretion in type 2 diabetes. Diabetes Obes Metab. 2011;13(suppl 1):126-132.
  4. Drucker DJ. The biology of incretin hormones. Cell Metab. 2006;3(3):153-165.
  5. Drucker DJ, Nauck MA. The incretin system: glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes. Lancet. 2006;368(9548):1696-1705.
  6. Nauck M, Stöckmann F, Ebert R, Creutzfeldt W. Reduced incretin effect in type 2 (non-insulin-dependent) diabetes. Diabetologia. 1986;29(1):46-52.
  7. DeFronzo RA, Eldor R, Abdul-Ghani M. Pathophysiologic approach to therapy in patients with newly diagnosed type 2 diabetes. Diabetes Care. 2013;36(suppl 2):S127-S138.
  8. Zander M, Madsbad S, Madsen JL, Holst JJ. Effect of 6-week course of glucagon-like peptide 1 on glycaemic control, insulin sensitivity, and β-cell function in type 2 diabetes: a parallel-group study. Lancet. 2002;359(9309):824-830.

Every health care professional who works with adults with type 2 diabetes has a slightly unique approach to treatment. That’s why guidelines from various organizations and associations are helpful, so that we can use evidenced-based research to make informed treatment decisions.

John E. Anderson, MD

John E. Anderson, MD

INTERNIST

KEY TAKEAWAYS
  • Before 2017, treatment guidelines for diabetes standards of care did not provide management algorithms that addressed CV risk in addition to glycemic control6
  • With the results of the FDA-mandated CVOTs, ADA and AACE updated their guidelines to include information on treating patients with T2D that also address CV risk3,7
  • Every health care professional who works with T2D has a slightly unique approach to treatment
  • Sharing results from the LEADER trial with your patients may help when discussing Victoza®

VIDEO 3

Patient identification

For me, the exciting challenge of diabetes is understanding the disease process, knowing all of the different treatment options available, and not connecting the patient to the treatment until after I’ve had the chance to sit with them, and see who they are and what they need.

Helen L. Baron, MD

Helen L. Baron, MD

ENDOCRINOLOGIST

 

  1. Wick A, Newlin K. Incretin-based therapies: therapeutic rationale and pharmacological promise for type 2 diabetes. J Am Acad Nurse Pract. 2009;21(suppl 1):623-630.
  2. Holst JJ, Vilsbøll T, Deacon CF. The incretin system and its role in type 2 diabetes mellitus. Mol Cell Endocrinol. 2009;297(1-2):127-136.
  3. D'Alessio D. The role of dysregulated glucagon secretion in type 2 diabetes. Diabetes Obes Metab. 2011;13(suppl 1):126-132.
  4. Drucker DJ. The biology of incretin hormones. Cell Metab. 2006;3(3):153-165.
  5. Drucker DJ, Nauck MA. The incretin system: glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes. Lancet. 2006;368(9548):1696-1705.
  6. Nauck M, Stöckmann F, Ebert R, Creutzfeldt W. Reduced incretin effect in type 2 (non-insulin-dependent) diabetes. Diabetologia. 1986;29(1):46-52.
  7. DeFronzo RA, Eldor R, Abdul-Ghani M. Pathophysiologic approach to therapy in patients with newly diagnosed type 2 diabetes. Diabetes Care. 2013;36(suppl 2):S127-S138.
  8. Zander M, Madsbad S, Madsen JL, Holst JJ. Effect of 6-week course of glucagon-like peptide 1 on glycaemic control, insulin sensitivity, and β-cell function in type 2 diabetes: a parallel-group study. Lancet. 2002;359(9309):824-830.
KEY TAKEAWAYS
  • With new data being released, treatment for adults with T2D is evolving
  • For many health care providers, treating T2D and CVD go hand in hand2
  • Not all GLP-1s are the same, and Victoza® is the only GLP-1 RA recommended by the ADA to lower CV event rates and mortality in adults with T2D and established CVD3
  • If patients are concerned about starting an injectable treatment, consider using a sample and providing instructions right in the office

VIDEO 4

Collaboration and the diabetes care team

 

  1. Wick A, Newlin K. Incretin-based therapies: therapeutic rationale and pharmacological promise for type 2 diabetes. J Am Acad Nurse Pract. 2009;21(suppl 1):623-630.
  2. Holst JJ, Vilsbøll T, Deacon CF. The incretin system and its role in type 2 diabetes mellitus. Mol Cell Endocrinol. 2009;297(1-2):127-136.
  3. D'Alessio D. The role of dysregulated glucagon secretion in type 2 diabetes. Diabetes Obes Metab. 2011;13(suppl 1):126-132.
  4. Drucker DJ. The biology of incretin hormones. Cell Metab. 2006;3(3):153-165.
  5. Drucker DJ, Nauck MA. The incretin system: glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes. Lancet. 2006;368(9548):1696-1705.
  6. Nauck M, Stöckmann F, Ebert R, Creutzfeldt W. Reduced incretin effect in type 2 (non-insulin-dependent) diabetes. Diabetologia. 1986;29(1):46-52.
  7. DeFronzo RA, Eldor R, Abdul-Ghani M. Pathophysiologic approach to therapy in patients with newly diagnosed type 2 diabetes. Diabetes Care. 2013;36(suppl 2):S127-S138.
  8. Zander M, Madsbad S, Madsen JL, Holst JJ. Effect of 6-week course of glucagon-like peptide 1 on glycaemic control, insulin sensitivity, and β-cell function in type 2 diabetes: a parallel-group study. Lancet. 2002;359(9309):824-830.

With over 25 years of experience in the diabetes space, I know how important it is for these patients with type 2 diabetes to receive comprehensive care that may include a number of different specialists.

Melissa Magwire, RN, CDE

Melissa Magwire, RN, CDE

REGISTERED NURSE / CERTIFIED DIABETES EDUCATOR

KEY TAKEAWAYS
  • Sometimes, it can take a “village” to care for patients with diabetes
  • For some patients, the diabetes care team may include a cardiologist, nephrologist, endocrinologist, and more
  • Educating patients may help facilitate the discussion between various specialists on the diabetes care team
  • Regular communication with other specialists on the diabetes care team—through phone calls or quick discussions—may help when making treatment decisions

Change the course of treatment with Victoza® for your patients with T2D and established CVD

Landmark CVOT

Reduce the risk of MACE for your adult patients with T2D and established CVD8

The Victoza® patient

See what patient types might benefit from a GLP-1 RA that reduces A1C and CV risk

References:

  1. Shepherd J, Barter P, Carmena R, et al. Effect of lowering LDL cholesterol substantially below currently recommended levels in patients with coronary heart disease and diabetes. Diabetes Care. 2006;29:1220-1226.
  2. Low Wang CC, Hess CN, Hiatt WR, Goldfine AB. Clinical update: cardiovascular disease in diabetes mellitus. Atherosclerotic cardiovascular disease and heart failure in type 2 diabetes mellitus-mechanisms, management, and clinical considerations. Circulation. 2016;133:2459-2502.
  3. American Diabetes Association. Standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1):S1-S172.
  4. Fruchart J, Davignon J, Hermans MP, et al. Residual macrovascular risk in 2013: what have we learned? Cardiovasc Diabetol. 2014;13(26):2-17.
  5. Victoza [package insert]. Plainsboro, NJ: Novo Nordisk Inc; August 2017.
  6. American Diabetes Association. Standards of medical care in diabetes-2017. Diabetes Care. 2017;40(suppl 1):S1-S135.
  7. Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm–2018 executive summary. Endocr Pract. 2018;24(1):91-120.
  8. Marso SP, Daniels GH, Brown-Frandsen K, et al; the LEADER Steering Committee on behalf of the LEADER Trial Investigators. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375(4):311-322.

Selected Important Safety Information

WARNING: RISK OF THYROID C-CELL TUMORS

  • Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors has not been determined.
  • Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk for MTC with the use of Victoza® and inform them of symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Victoza®.

Indications and Limitations of Use

Victoza® (liraglutide) injection 1.2 mg or 1.8 mg is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus, and to reduce the risk of major adverse cardiovascular (CV) events (CV death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes mellitus and established CV disease.

  • Victoza® is not a substitute for insulin and should not be used in patients with type 1 diabetes mellitus or diabetic ketoacidosis.
  • Concurrent use with prandial insulin has not been studied.

Important Safety Information

WARNING: RISK OF THYROID C-CELL TUMORS

  • Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors has not been determined.
  • Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk for MTC with the use of Victoza® and inform them of symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Victoza®.

Contraindications

  • Victoza® is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to Victoza® or to any of the product components. Serious hypersensitivity reactions including anaphylactic reactions and angioedema have been reported with Victoza®.

Warnings and Precautions

  • Risk of Thyroid C-cell Tumors: Patients should be referred to an endocrinologist for further evaluation if serum calcitonin is measured and found to be elevated or thyroid nodules are noted on physical examination or neck imaging.
  • Pancreatitis: Acute pancreatitis, including fatal and nonfatal hemorrhagic or necrotizing pancreatitis, has been observed in patients treated with Victoza® postmarketing. Observe patients carefully for signs and symptoms of pancreatitis (persistent severe abdominal pain, sometimes radiating to the back with or without vomiting). If pancreatitis is suspected, discontinue Victoza® promptly and if pancreatitis is confirmed, do not restart. Victoza® has been studied in a limited number of patients with a history of pancreatitis. It is unknown if patients with a history of pancreatitis are at a higher risk for development of pancreatitis on Victoza®.
  • Never Share a Victoza® Pen Between Patients, even if the needle is changed. Pen-sharing poses a risk for transmission of blood-borne pathogens.
  • Hypoglycemia: When Victoza® is used with an insulin secretagogue (eg, a sulfonylurea) or insulin, serious hypoglycemia can occur. Consider lowering the dose of the insulin secretagogue or insulin to reduce the risk of hypoglycemia.
  • Renal Impairment: Acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis, have been reported postmarketing, usually in association with nausea, vomiting, diarrhea, or dehydration. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment.
  • Hypersensitivity Reactions: Serious hypersensitivity reactions (eg, anaphylaxis and angioedema) have been reported post-marketing. If symptoms of hypersensitivity reactions occur, patients must stop taking Victoza®; treat promptly per standard of care, and monitor until signs and symptoms resolve.  Do not use in patients with a previous hypersensitivity reaction to Victoza®. Anaphylaxis and angioedema have been reported with other GLP-1 receptor agonists.  Use caution in a patient with a history of anaphylaxis or angioedema with another GLP-receptor agonist because it is unknown whether such patients will be predisposed to these reactions with Victoza®.
  • Acute Gallbladder Disease: In the LEADER trial, 3.1% of Victoza® vs. 1.9% of placebo-treated patients reported an acute event of gallbladder disease, such as cholelithiasis or cholecystitis. The majority of events required hospitalization or cholecystectomy. If cholelithiasis is suspected, gallbladder studies and appropriate clinical follow up are indicated.

Adverse Reactions

  • The most common adverse reactions, reported in ≥5% of patients treated with Victoza® and more commonly than in patients treated with placebo, are nausea, diarrhea, headache, vomiting, decreased appetite, dyspepsia, and constipation. Immunogenicity-related events, including urticaria, were more common among Victoza®-treated patients (0.8%) than among comparator-treated patients (0.4%) in clinical trials.

Drug Interactions

  • Victoza® causes a delay of gastric emptying and has the potential to impact the absorption of concomitantly administered oral medications. Caution should be exercised when oral medications are concomitantly administered with Victoza®.

Use in Specific Populations

  • Victoza® has not been studied in patients with type 2 diabetes below 18 years of age and is not recommended for use in pediatric patients.
  • Victoza® slows gastric emptying. Victoza® has not been studied in patients with pre-existing gastroparesis.
  • Victoza® should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Additional Important Safety Information

In 5 placebo-controlled clinical trials of at least 26 weeks’ duration, hypoglycemia requiring the assistance of another person for treatment occurred in 8 Victoza®-treated patients (7.5 events per 1000 patient-years). Of these 8 Victoza®-treated patients, 7 patients were concomitantly using a sulfonylurea.

In the pool of 5 placebo-controlled clinical trials, withdrawals due to gastrointestinal adverse reactions occurred in 4.3% of Victoza®- treated patients and 0.5% of placebo-treated patients. Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2 to 3 months of the trials.

Please click here for full Prescribing Information including Boxed Warning.