Considering CAD Risk Factors in Treatment Decisions
Doron Schneider, MD and Jack Leahy, MD discuss the importance of patient BMI and other risk factors for coronary artery disease when weighing treatment options. (12:08)
Dr. Doron Schneider (DS): Hello, my name is Doron Schneider, and I’m a practicing internist at Abington Memorial Hospital in Philadelphia, and today I’m joined by Dr. Jack Leahy [endocrinologist, University of Vermont] to discuss a 38-year-old Caucasian male who presents to his primary care doctor, not having seen the doctor for over 10 years. He presents with fatigue, thirst and has had some recent weight loss. He has an elevated BMI of 36, his blood pressure’s found to be elevated, 150/96, and he reports a family history of cardiovascular disease, The initial exam is otherwise unrevealing, but blood work does show an A1C of 8.6, cholesterol level up at 130, triglycerides are at 350 and after that encounter we diagnosed him with Type 2 diabetes, hyperlipidemia, and hypertension. This patient does have insurance coverage and is started on hydrochlorothiazide and lisinopril for his blood pressure, atorvastatin for his hyperlipidemia, and now remains how to deal with his A1C, which found at 8.6. First step was counseling and lifestyle modification and with a brief, office-based counseling send him on his way to follow up in approximately 8 weeks. Three months later he does show up, and his A1C is down to 8.2 and having had the trial of lifestyle therapy, the next step is to decide how best to manage his Type 2 diabetes.
We’re presented in this case with three possible options. One is monotherapy with metformin. The other is combination therapy, which we’ll get into what that means next, and number three is bariatric surgery.
So, having set the case up in that fashion, I’d like to begin with Dr. Leahy.
Dr. Jack Leahy (JL): Okay, Doron, thanks very much. Let me quickly introduce myself as well. I’m head of endocrine at the University of Vermont so I’m a specialist, but I’m in a very clinical-based program here as well as sort of an academic program.
DS: Thank you.
So now I just did want to highlight that this patient is young, while healthy, he has multiple risk factors for cardiovascular disease and are obese—with a BMI of 36. So the question off the bat then becomes the factors that are weighted by you as a clinician. I’d like to explore them sequentially, First off is the fact that he does have obesity, and this is a marker of 36, which I’d like to explore. Does that mean something different to you as it relates to the options, as does a BMI of 30 or 33 or 40 or 42? We’re presented with three options: metformin, initial combination therapy, and bariatric surgery. So targeting the question of the obesity first, can you help us think through at least in your own mind and your own practice what that number of 36 does to your decision making—if it is a factor in your decision making at all?
JL: You know, I think that’s a really an interesting question and to be truthful to you, I’m not sure that I’ve ever sort of tried to think through that concept, but now that you ask it that way it really leads to some important thoughts for me. I mean, the first issue is you’re presented with a man who has reasonably life-long history of obesity and presumably profound insulin resistance associated with lifestyle habits that have not been optimal. One guess is you have considerable room to try and work with lifestyle changes as well as maybe the surgical changes we’re going to talk about later. That could have a huge impact on effectively treating all of the diseases he first presents with.
You know, this is a fairly common form of diabetes I see in senior citizens who are presenting with reasonably new onset Type 2 diabetes who don’t look anything like this man. They’re really not much overweight. They don’t really have much of a metabolic background and they seem to present more with an insulin deficiency picture (blood sugars kind of bounce all over the place). They really get high after meals. And I tend to think of these patients as presenting more with insulin deficiency [because] they’re outliving their beta cells. And so you think about one kind of therapy, but in this man it’s really sort of the classic sort of insulin resistance: obesity, metabolic kind of patient presenting.
The second thing is, I think, the actual BMI number does have some impact if we’re starting to think about the surgical approach. Typically, the cut off in terms of appropriate patients for gastric bypass surgery, or for some form of gastric reduction surgery, typically starts with a BMI of about 35 along with diabetes. He fits into that. And I think that sort of the last thing to think about in terms of this is that he’s young enough and he’s overweight enough that actually some of these patients do amazingly well with early oral therapy—the kind of glucose toxicity patients that we’ve all seen. For me—at least my anecdotal experience has been that the concept of glucose toxicity (someone who comes in with really high blood sugars) and if they’re not that overweight (especially if they’ve been losing some weight) it looks more really like an insulin deficiency picture, I’m not sure they have quite the same dramatic reversal of glucose toxicity we sometimes see on more overweight patients. So that’s kind of my thoughts on the question.
DS: Very good. And I’d like to try to then isolate not only the BMI as a factor in your decision making, but then also moving to his other risk factors for coronary artery disease. This is typical, and you have someone now that has at last three risk factors for coronary disease with the blood pressure, cholesterol, diabetes, and his gender. How important to you is it in decision making regarding the cardiovascular risk that he presents with the whole package here? In essence if you took a 38 year old that was without risk factors versus now this 38 year old with these risk factors, how does that affect your decision making, if at all, as it relates to the options presented?
JL: Well, this has been the hot topic for the last multiple years in the diabetes world as we try to identify what’s the most effective approach to therapy and in many ways try to define what the therapeutic goals are and try to balance out are we try to fix blood pressure, are we trying to fix lipids, are we trying to fix the blood glucose value. What actually are we trying to do?” I think in many ways we would like to do everything, but having said that, the general prevailing thought process is that probably blood glucose control is more effective at preventing microvascular complications over the long term than maybe blood pressure and lipid control, which is a little bit more focused on macrovascular prevention. Now there’s been some going back and forth on the latter, but that’s probably a reasonable breakdown.
So now we have a guy who’s young. Certainly in this country and around the world the whole sort of phenotype of our patients is they’re developing diabetes and other metabolic diseases younger and younger. Our whole goal was to help them live longer and healthier so in theory this man is going to have 50 years (maybe) of life left, and the dominant thing we need to try and protect him against for long-term health are strokes and heart attacks and cardiovascular disease. That would be sort of the dominant issue we think about with him.
So in terms of trying to prorate, I think we think of trying to fix everything, but having said that from the get go really a crucial issue in him is cardiovascular protection. Clearly, that’s lipid control, and clearly, that’s blood pressure control.
DS: But as it relates now into the decision making regarding the agent or the approach for the diabetes and the management of the glycemic control, assuming that we have started him on his way towards goal with blood pressure and the lipids, which he’s been placed on medication at this point for those conditions, do you factor into your decision making about the approach for the glycemic approach the fact that he has multiple risk factors for cardiovascular disease? Meaning that if he’s 38 and does not have cardiovascular risk factors other than the diabetes, would you pick metformin more so than if you had somebody who had multiple risk factors for cardiovascular disease, would you pick bariatric surgery or is it not a factor at all in the therapeutic approach to the treatment of the diabetes? And again, it’s the what impact is the factor of his being with multiple cardiovascular risk factors have in your approach for glycemic control?
JL: Yeah, I don’t think I’m so methodical to necessarily look at an individual patient and then take the three therapies we’re going to talk about which is monotherapy versus combination therapy versus surgery and sort of move them around on a preferential list based on the number of cardiovascular risk factors. I do agree with you a hundred percent that this patient presents with multiple factors, and it would be optimal to try to identify a therapy that will impact most or all of those factors with a single successful therapy. So that could be his own lifestyle modification efforts. It could also be bariatric surgery. And certainly the claim to fame as people think about, in terms of weight loss or weight reduction surgery, is that you get multiple benefits in terms of metabolic parameters, not simply just a diabetes intervention that one might get with a diabetes drug. But also having said that, I think sort of the feeling is that one can also accomplish multifactorial therapy by using individual therapies against each single element of it. So we certainly have lots of patients who are on blood pressure medicines and on lipid medicines and on diabetes medicines. They may not crossover to have terribly positive effects on one or the other, but you can optimize all of those factors with individual therapies. And for me, that’s okay. I’m goal driven. I’m sort of less driven about necessarily the specific combinations of therapies or how to minimize those combinations of therapies.
DS: Very good. Thank you.
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