Treating Type 2 Diabetes with Comorbidities

Jennifer B. Green, MD: You have mentioned the importance of understanding as best we can the array of complications that our patients may have when we’re choosing medications for them, or the types of complications for which they may be at greatest risk. That’s a key message in the diabetes and cardiology care guidelines in recent years. Sometimes that gets a bit difficult and complicated to implement. We have one example at our institution where we’re fortunate enough to have 1 central location where diabetologists, cardiologists, some GI [gastrointestinal] doctors, and perhaps a nephrologist occasionally, are all located at the same physical place and can see our very high-risk patients with multiple complications or comorbidities to devise a unified treatment plan. But unfortunately, most of our patients who need to go to that clinic can’t or don’t have the capacity. Do you have any care model at the Cleveland Clinic that would be applicable to other locations or institutions that you could share with us, or any tips or tricks to providing this complicated care that we know our patients will benefit from?

Dennis Bruemmer, MD, PhD: Yes, Jennifer. Here at the Cleveland Clinic, we’re quite fortunate because our preventive program has a longstanding history over the past 20 years in cardiology. We’ve actually already had endocrinologists and cardiologists working side by side for many years. Our prevention program includes cardiology, endocrinology, cardiac rehab, nutrition, exercise physiologists, and close collaboration with obesity medicine, nephrology, and psychiatry. We have psychiatrists in our preventive program, because not infrequently, patients need to be able to take care of themselves and then can manage their condition appropriately. Depression is quite common in patients with diabetes. It affects about 30% of the patients. The ideal environment is a comprehensive program.

For specific patients with cardiac diagnoses, post-CABG [coronary artery bypass graft], or post-MI [myocardial infarction]—patients at high risk—we have a clinic where cardiologists work side by side with an endocrinologist in the same clinic setting, with 30 minute appointments for each. First, the cardiologist addresses cardiac problems, maybe hypertension and dyslipidemia, and then the endocrinologist in this particular clinic mostly focuses on more complex insulin treatment regimens for patients who are on multiple daily injections of insulin. Of course, in those particular patients I mentioned, we normally push for agents with cardiovascular benefit, SGLT2 inhibitors, and GLP-1 receptor agonists.

This concept of multidisciplinary care has been talked about for many years, but it hasn’t been implemented for many years. We’re just starting to build these programs. I worked in cardiology 20 years ago, then I worked as an endocrinologist and as a cardiologist, so I’ve seen both sides. For many years, the collaboration left a lot to be desired with diabetes treatment in the cardiac patient population. This has changed because the cardiology colleagues are recognizing that these new drugs and agents that we have available really affect outcomes, so this is a new approach that provides a lot of opportunities. These medications now become cardiovascular medications, particularly in the heart failure field. That has brought cardiology and endocrinology much closer together, which is good. We’re developing algorithms and care paths. As we mentioned, it’s difficult because care needs to be so individualized for patients. There’s an inherent challenge to come up with an algorithm that can be used for a midlevel provider in an outpatient community practice, so it becomes so much more challenging. But this is something we’re working on. We’re trying to expand our programs to community cardiology as well.

Jennifer B. Green, MD: Thank you, Dr Bruemmer. And I’d like to thank everyone for watching this HCPLive® Peers & Perspectives. If you enjoyed the content, please subscribe to the e-newsletters to receive upcoming Peers & Perspectives and other great content right in your inbox. Thank you very much.

Transcript edited for clarity.