2) She is a member of UKCPA Diabetes & Endocrinology committee @UKCPADiabetes & works across #diabetes, #endocrinology, & emergency/acute care in Secondary Care. She is currently involved in development of regional guidelines & education to support medicines optimisation for PLWD
— @CKD_ce (@ckd_ce) September 13, 2022
3b) Past programs still eligible for credit can be found at https://t.co/jFwbLEcQSS. Faculty disclosures and accreditation statement are at https://t.co/PHlIppl6Yw.
— @CKD_ce (@ckd_ce) September 13, 2022
5a) How many people with T2DM have CV disease?
— @CKD_ce (@ckd_ce) September 13, 2022
6a) How many adults with diabetes have been diagnosed with CKD?
— @CKD_ce (@ckd_ce) September 13, 2022
7) So it’s already clear #cardiovascular #renal & #metabolic conditions are interconnected & frequently co-exist, ➡️the #CaReMe approach, a collaboration among British Cardiovascular Society, The Renal Association, & Association of British Clinical Diabetologists (@ABCDiab) pic.twitter.com/sXgCWx8MuK
— @CKD_ce (@ckd_ce) September 13, 2022
9) Case 1 – 55 ♀️. Her past medical history includes #LVSD, #T2DM and #CVA, thus illustrating that link between conditions. pic.twitter.com/V6JNDDpmcV
— @CKD_ce (@ckd_ce) September 13, 2022
11) Her latest HbA1c is 60mmol/mol (7.6%), stable. She has no oedema or SOB but describes hypoglycaemia awareness. Her #eGFR is 55.
— @CKD_ce (@ckd_ce) September 13, 2022
What are priorities when treating her?
a. BP control
b. ⬇️risk of diabetes complications by⬇️HbA1c
c. Optimising HF treatment
d. All of the above
13) It’s difficult, but it may be possible to tackle more than one aspect at once. Let’s consider her BP first. We
— @CKD_ce (@ckd_ce) September 13, 2022
have multiple options:
👉Increase her #thiazide diuretic
👉Increase her #CCB
👉Increase her #Sacubitril_valsartan
14b)
— @CKD_ce (@ckd_ce) September 13, 2022
👉⬆️#Sacubitril_valsartan: this could help her #BP and #HF – so is a better dual approach & a possibility
Another poll: What class of agents might you consider that might help all the priorities for this person?
16) There’s most support for a #flozin #SGLT2i, as these have shown to⬇️risk of #CV_death, #HHF, & improve #HF symptoms. In this pt, w/ eGFR >45ml/min, #SGLT2i will also improve glycaemic control.
— @CKD_ce (@ckd_ce) September 13, 2022
It’s time to #flozinate – both empagliflozin & dapagliflozin are licensed in #HFrEF
18) But wait! There are a few things we need to do before we start an #SGLT2i. pic.twitter.com/wzK0HwOxVx
— @CKD_ce (@ckd_ce) September 13, 2022
20) How do we assess #DKA risk & check if a person it is at increased risk, do you ask? Well, @NICEComms have some pointers:
— @CKD_ce (@ckd_ce) September 13, 2022
👉Pt has had a previous episode of DKA
👉Pt is unwell with intercurrent illness
👉Pt is following a very low carbohydrate or #ketogenic diet
21b) What’s a ketogenic diet?
— @CKD_ce (@ckd_ce) September 13, 2022
A very low carbohydrate, high fat diet that is designed to induce ketosis.
These can put people at an ⬆️risk of DKA so need to be cautious if initiating an #SGLT2 inhibitor in these cohorts.
22) OK, so we have established our pt is not on a ketogenic or low carb & she is not acutely unwell. Last thing: previous DKA.
— @CKD_ce (@ckd_ce) September 13, 2022
I advise exploring the #diabetes history in general and other factors that may guide diabetes type. The patient explained the following: pic.twitter.com/jGqMf2sGWm
23b) Answer: No, this person has potentially had a previous DKA and therefore could have #T1D & not #T2D.
— @CKD_ce (@ckd_ce) September 13, 2022
So what do we do next? Hold off starting a #flozin.
25) If a #T1DM diagnosis is confirmed, ensure the person is recoded, informed of the difference in diagnosis and unfortunately, she can’t have an #SGLT2i due to #DKA risk – unless on specialist advice that benefits outweigh risks, noting this is off-label.
— @CKD_ce (@ckd_ce) September 13, 2022
27a) That’s Case 1⃣ all wrapped up! Come back tomorrow for more!
— @CKD_ce (@ckd_ce) September 13, 2022
For more information see:
👉Empagliflozin in HF NICE TA – https://t.co/Mw6w1lzgrh
👉Dapagliflozin in HF NICE TA – https://t.co/RvLIWgANNK
👉NICE NG28 Type 2 Diabetes in Adults – https://t.co/BD94RSsc7W
28) Welcome back, it’s day TWO of #accredited #tweetorial on challenging case presentations for the management of patients with #cardiometabolic disease, #CaReMe #FOAMed. I am @claireyrivs and I work with the @GoggleDocs 🇬🇧
— @CKD_ce (@ckd_ce) September 14, 2022
31) Here are the case details: pic.twitter.com/UatJM2qKhY
— @CKD_ce (@ckd_ce) September 14, 2022
33) What is your preferred next pharmacological option for this person, considering those priorities?
— @CKD_ce (@ckd_ce) September 14, 2022
35) 👉Insulin. Ok, now we are talking, this could be an option. Would help HbA1c, but again causes weight ⬆️which is something to avoid.
— @CKD_ce (@ckd_ce) September 14, 2022
👉GLP-1. Bingo! This could be a great option for this person. Let’s explore further how do GLP-1 agonists fit into the #CaReMe picture.
37) This gives us a couple of options:
— @CKD_ce (@ckd_ce) September 14, 2022
👉Do a switch of an agent – but we have just discussed the other options
👉Adding #insulin
👉Adding a #GLP1_RA
39) And as a result they exert beneficial effects on the #CV system pic.twitter.com/CJma85g3IT
— @CKD_ce (@ckd_ce) September 14, 2022
41a) Currently liraglutide has a NICE TA for managing overweight and obesity. Available here: https://t.co/rO4CSMc9cq. pic.twitter.com/NwrYjZJc4z
— @CKD_ce (@ckd_ce) September 14, 2022
41c) w/an initial BMI of
— @CKD_ce (@ckd_ce) September 14, 2022
👉=/>30 kg/m2 (obesity) or
👉=/>27 kg/m2 (overweight) in the presence of at least 1 wgt-related comorbidity (e.g., hypertension, #T2D, or dyslipidemia).
Our patient’s BMI is 34, so in 🇺🇸 he could potentially receive semaglutide even if not diabetic.
43a) So under these new proposed criteria our patient in future would qualify for #semaglutide for weight management as part of a tier 3 service. This is based on evidence from the #STEP1 #RCT ➡️pts taking semaglutide lost on average, 12% more of their body wgt vs placebo.
— @CKD_ce (@ckd_ce) September 14, 2022
44) So, key points from this case:
— @CKD_ce (@ckd_ce) September 14, 2022
👉Weight management and diabetes and intrinsically linked
👉Both independently increase CV risk
👉GLP-1 agonists can be used for both diabetes and obesity but with different criteria and different brands
46) WELCOME BACK! I am @claireyrivs, I work with the @GoggleDocs, and it’s day THREE of our #accredited #tweetorial on challenging case presentations for the management of patients with #cardiometabolic disease, #CaReMe #FOAMed. Only one case to go for your pic.twitter.com/qX6qu3GvpS
— @CKD_ce (@ckd_ce) September 15, 2022
48) Are you see some themes in these cases? Here our priorities are #BP, #HbA1c,➕slowing progression of CKD.
— @CKD_ce (@ckd_ce) September 15, 2022
What next steps could help with these clinical priorities?
a. ⬆️ACEi
b. Add another pharmaceutical agent
c. Adjust HbA1c🎯for individualised care
d All of the above
50) Re #HbA1c – it’s important to not be guided by just a pure number. Individualised care (this pt is 81, remember) is at the heart of lots of guidelines, including NICE NG28, which includes the following patient decision aid:
— @CKD_ce (@ckd_ce) September 15, 2022
🔓https://t.co/cLNfDUb268 pic.twitter.com/GqMF2v6IlW
52) So we have assessed frailty & established our pt is a fit older adult so no de-escalation is needed. So what do we do next?
— @CKD_ce (@ckd_ce) September 15, 2022
What drug could we add in to improve morbidity and mortality in CKD and T2DM for this patient?
53b) This is being studied in EMPA-KIDNEY, the largest #SGLT2i trial in #CKD to date, studying efficacy & safety of empagliflozin in adults with CKD who are frequently seen in clinical practice but who have been under-represented in previous SGLT2i trials
— @CKD_ce (@ckd_ce) September 15, 2022
53d) Meanwhile, for our 🇬🇧 learners (and generally quite similar for 🇪🇺), here’s what the NICE NG28 Guidance say about adding in SGLT2 therapy in T2DM with CKD: pic.twitter.com/XAlScUivEY
— @CKD_ce (@ckd_ce) September 15, 2022
55) What are the key points for drug initiation here for this person? Well, they are the same as on day ONE – checking DKA risk, ketogenic/low carb diet and counselling on sick day rules! (If you need to, look back at tweets 19-24)
— @CKD_ce (@ckd_ce) September 15, 2022
57) So, 🔑 points from this case:
— @CKD_ce (@ckd_ce) September 15, 2022
🔑#CKD and #T2D are linked
🗝️SGLT2 inhibitors can be used for both indications
🔑Don’t forget about assessing #DKA risk & counselling on sick day rules
59) Final points: throughout any consultation, remember #languagematters!
— @CKD_ce (@ckd_ce) September 15, 2022
🔓https://t.co/U9UdIrnJTw pic.twitter.com/e2A1BDQAe4
60) And that's it–you have just earned 0.75h CE/#CME! Go to https://t.co/BdFjXocgba to claim your credit, & FOLLOW US for more education by #tweetorial all🆓all by EXPERT authors! I am @Claireyrivs of @GoggleDocs. Be sure to follow @cardiomet_ce also–esp my fellow #pharmacists! pic.twitter.com/2aMMhfPDZC
— @CKD_ce (@ckd_ce) September 15, 2022