Transcript Primary Care: An Ever Changing Landscape

Primary Care: An Ever
Changing Landscape
Presented by:
Penny DeRaps, PhD, FNP-C
Maine Nurse Practitioner Association
Fall Conference - November 14, 2015
Objectives
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Review preventative care guidelines for
primary care
Review new classes of DM medications
Review new formulations of respiratory
medications
Colorectal (CDC and USPTF)
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Colonoscopy every 10 years beginning at age 50 until age 75 and then
continued or not based on shared decision making. More frequent
screening based on results and scope; or
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CT Colonography every 10 years (ACS approved, or
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Flex sig every 5 years; or
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Double contract BE every 5 years (ACS approved; or
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FIT test yearly (or every 3years if used in conjunction with flex sig; or
Colorectal (CDC and USPTF)
Continued
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FOBT yearly (or every three years if used in conjunction with flex
sig; or
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Screening in high risk patients should begin at 40 or 10 years before
1st known diagnosed relative; or
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Research is being done to evaluate other tests (stool DNA, FIT, CT
scan) in use with adult populations starting at age 40
Breast Cancer Screening
(USPTF)
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Every 2 years mammo for women age 50-74
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Earlier screening should be done in direct relation to
known family risk or BRCA risk and decided with the
patient
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CBE every 3 years with prvider
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**ACS says every year mammo after the age of 40, high
risk patients should get an MRI or mammo annually
Cervical Cancer Screen
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Age 21-30, pap smear every 3 years, HPV done only if abnormal
results
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Over 30 pap smear and HPV testing together or separate every 3
years; if abnormal repeat screening again in 1 year if low grade;
colposcopy if more concerning abnormality
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Yearly screening in presence of abnormals; If CIN2/3 and
hysterectomy; see 3 annual negatives before discontinuing
screening
Cervical Cancer Screen
continued
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Over age 65, no recommended screening if adequate screening and
normal results up to that point
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ACS essentially similar except that if an abnormal results returns
and HPV is positive and your are older that 25, colposcopy
recommended
Prostate
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No recommended screening unless patient expresses a
clear preference for it
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Inform patient of limited benefits of screening unless
significant risk
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Evaluate patient’s life expectancy in general
Lipid Disorders
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Strong recommendation to screen men over the age of
35; screen men 20-35 if increased risk
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Strong recommendation to screen women over 45;
screen women 20-45 if increased risk
Lipid Disorders
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Increased risk indicated by the following:
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Diabetes
Personal history of CHD or non-coronary atherosclerosis (AAA, PAD,
coronary artery stenosis)
Family history of CV disease before 50 in males, age 60 in females
Tobacco use
BMI greater than 30
Screen every 5 years for those not on statins, adjust per patient risk and
how close they are to abnormal
Screen every 5 years for those not on statins,
adjust per patient risk and how close they are to
abnormal
Diabetes
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National guideline clearinghouse) In higher risj patients
(determined by age, BMA, diet, physical activity, previous
high FBG or gestational diabetes, family history) check ACI
every 3 years; if very high risk, check annually.AIC is preferred
but can do a GTT or FBS greater than 125 on two separate occasions,
HgAIC>6.5=+
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AACE - FBG>126, GTT>200 2hours after ingesting 75 gm
oral glucose, hyperglycenia symptoms and random
BS>200, AIC>6.5%
Diabetes
Continued
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If positive, need urine microalbumin yearly, dilated eye
exam annually, annual lipid profiles if not on statins, foot
exams yearly, bladder dysfunction screening, bowel
dysfunction screening, HTN and ACVD
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Screen AIC every 3 months after initiating therapy, have
patient keep logs of BS in between until stable then
decrease blood sugar checks. Can wean down to every 6
months AIC goal <110 FBS, <140 post prandial
Osteoporosis
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Women age >65
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Women age <65 with the following risk factors:
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Caucasian
Low body weight
Smoker
Family History of osteoporosis
T2D  Complex Metabolic Disease Characterized by Chronic
Hyperglycemia “Deadly Octete”
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Liver:
Hepatic glucose production
 Insulin resistance results in glucose over production as fating insulin
increases
Pancrea Glucagon Secretion:
 Increases glucagon secretion from alpha cells in pancreas
stimulates  in hepatic glucose production
Lipolysis in Adipose Tissue:
 Insulin resistance in fat cells leads to  lipolysis and the resulting elevated
levels of free fatty acids stimulate hepatic glucose production,  insulin
resistance in muscle & liver and impair beta cell function
Glucose Reabsorption in Kidney
 The kidney reabsorbs more glucose and that exacerbates circulating
glucose
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T2D  Complex Metabolic Disease Characterized by
Chronic Hyperglycemia “Deadly Octeth” Continued
Pancreatic
Insulin Secretions
Progressive
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decline in beta cell functions leads to  insulin resistance
Glucose Uptake in Muscles
resistance in muscles results in impaired glucose uptake  excess
glucose remains in blood
Insulin
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Incretion Effect
Glucoregulatory
effects of incretion hormones produced by gut are diminished
Neurotransmitter
Neurotransmitter
Dysfunction
Dysfunction contributes to increase food intake  obesity
Classes of Medication to Treat T2D
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Insulin: Increases glucose disposal and hepatic glucose
production
Sulfonylurea: Increases insulin secretion
Both are associated with risk of hypoglycemia
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Metformin:  hepatic glucose production,  intestional
absorption of glucose and improves insulin sensitivity by
increasing glucose uptake and utilization
First Choice Med for Most
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TZD: Increases sensitivity to muscle, fat and liver
thiazoladinedione. To insulin; reduces hepatic glucose
production
Classes of Medication to Treat T2D
GLP
– 1RA: Glucagon-like peptide-1 receptor agonist
Increase
insulin secretion and decreased glucagon secretion; slow gastric
emptying and decreased food intake
DPP-4i
– Dipeptidyl Peptidose -4 inhibitor
Prolongs the life of post prandial incretins resulting in increased insulin and
decreased glucagon
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SGLT-2i:
Reduces
the amount of glucose reabsorbed by the kidneys
Drug in Each Class
Insulin, Sulfonylureas, Metformin
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TZDs – Actos & Avandia
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GLP-I Tanzeum (albiglutide (1 wk)
Injectables
below:
Trulicity
Byetta
(duloglutide (1 wk)
(examatide (BID)
Bydurea
Victoza
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(examatide) ext-rel (1 wk)
(liraglutide) (daily)
DPP-4i
Nesina
(alogliptin), Onglyza (saxasliptin), TrajeuTa (linaglyptin)
Januvia
Combos
(sitagliptin
& Metiform
Kazona;
Jentadueto, Kiombiglyze XR & Jamumet & XR
Drugs in Each Class
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SGLT-2i
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Farxiga (dapazliflozim)
Jardiance
Invokana
(empagliflozin)
(camagliflozin
continued
Effects of Medications
Insulin:
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Fasting plasma glucose
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PPG
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hypoglycemia
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weight
Sulfonylureas:
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Fasting plasma glucose
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PPG
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hypoglycemia
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weight
Effects of Medications
Metformin:
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Fasting plasma glucose
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PPG
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Neutral hypoglycemia & weight
TZD
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Fasting plasma glucose
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PPG
Neutral

hypoglycemia
weight (? Of  CHF)
continued
Effects of Medication
GLP-1RA
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Fasting plasma glucose
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PPG
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Neutral hypoglycemia
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Weight
DPP-4i
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Fasting plasma glucose
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PPG
Neutral
hypoglycemia & Weight
SGLT-2i
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Fasting plasma glucose
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PPG
Neutral
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hypoglycemia
weight
continued
COPD
The following COPD Pocket guide can be
downloaded from the COPD website by going to:
COPD
COPD Pocket Consultant
2 Major Diseases Treated with Respiratory Medications
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COPD - Asthma
Asthma: A chronic condition in which a person’s airway becomes inflamed,
narrow and swollen, producing extra mucus which makes it difficult to breathe.
This can trigger coughing, wheezing and shortness of breath. This can range
from mild to life threatening. It can progress over time if under treated and can
cause fibrosis
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COPD:
A common preventable and treatable disease characterized by
persistent airflow limitations that is usually progressive and associated with an
enhanced chronic inflammatory response in the airways and the lungs to noxious
particles and gases. Exacerbations and co-morbidities contribute to the overall
severity in individual patients.
2 Major Diseases Treated with Respiratory Medications
COPD - Asthma continued
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COPD: Chronic air flow limitation is caused by
1.
Small airways disease (obstructive bronchiolitis) and;
2.
Parenchymal destruction (emphysema) measured by spirometry
Gold (2014)
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Global Initiative for chronic obstructive lung disease along the standard
for diagnosis, management and prevention of COPD
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Gold stages 1-4
Now some changes, but it remains that GOLD stage 2 have a steeper
decline in FEV than those with more severe disease.
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FEV1/FVC represents the proportion of a person’s vital capacity that
they are able to expire in the first second of forced expiration
Medications
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Asthma:
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Advair
(Albuteral)
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Asmanex
(Qvar)
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Breo
(Symbicort)
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Dulera
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Florent
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Foradil
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Pro-air –albuteral – proventil
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Pulmicort
LABA:
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Foradil
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Serevert
Questions?
Thank you!!