1. The ABCs of CAD Prevention Gina Ryan, PharmD, BCPS, CDE Clinical Associate Professor Mercer University College of Pharmacy and Health Sciences

2. Program Disclosures Gina Ryan has received a CE grant Ortho McNeil.

3. Case A Your favorite cousin, Selena, is a 42- year old female. She is overweight (BMI 37kg/m 2 ) and does not like to exercise because it messes up her hair. Her doctor told her she had pre- hypertension and pre-diabetes. Your grandmother had diabetes and died from heart failure. Your aunt, her mother, died of an MI at 45. Selena comes to you to ask you to recommend something for weight loss. She doesn’t want to die young.

4. Metabolic syndrome is comprised of which of the following disorders a. insulin resistance and elevated blood pressure b. elevated blood pressure and Type 1 diabetes c. insulin resistance, elevated blood pressure, abdominal obesity, and dyslipidemia d. hypoglycemia and dyslipidemia

5. Metabolic syndrome is comprised of which of the following disorders C insulin resistance, elevated blood pressure, abdominal obesity and dyslipidemia

6. Metabolic Syndrome Risk FactorDefining Level abdominal obesity men women waist circumference >40 in >35 in triglycerides>150 mg/dl HDL cholesterol men women <40 mg/dl <50 mg/dl blood pressure>130/85 fasting glucose>100

7. Metabolic Syndrome - ABCs ABCs A – Antiplatelets & A1c - blood glucose B - Blood pressure C - Cholesterol

8. Antiplatelets Aspirin Clopidogrel Prasugrel

9. Antiplatelets Secondary Prevention All patients with history of stroke or heart attack Dose ACS - ASA 81-325 mg + clopidogrel PCI - ASA + prasugrel Chest 2008;133(6) supplement 71S-109S

10. Antiplatelets Primary Prevention BP<150/90 Men –45-79 yo with >10% risk* Women –55-79 yo with >10% risk –Dose – 81 mg Chest 2008;133(6) supplement 71S-109S *usually 3

11. A1c A- A1c glycosylated hemoglobin – for diabetes reports glucose average over 6-8 weeks normal 3-6% goal in diabetes <6.5-7% Nathan et al Diabetes Care 2006;29:1963-1972.

12. B - Blood Pressure JAMA 2003; 289: 2560-2572 JNC VII optimal <120/80 pre-hypertension 120-140/80-90 Stage 1 140/90-159/99 Stage 2 >160/100 First-line Treatment beta blockers, HCTZ, ACE inhibitors

13. C - Cholesterol Total Cholesterol <175 mg/dl HDL-C >60 mg/dl VLDL-C (TG) <150 mg/dl LDL-C 0 risk <130 mg/dl >2 risks <100 mg/dl CAD <70 mg/dl Circulation. 2002;106:3143-3421 Grundy et al Circulation. 2004;110(2):227-239 Statins are first line

14. What can Selena do? Weight loss –How much? a.5-10% b.11-20% c.21-30% d.>30%

15. A5-10% How much weight loss?

16. What can Selena do? Weight loss – How fast? What is the maximum rate of safe weight loss? a. 1-2 lbs per month b. 1-2 lbs per week c. 5 lbs per week d. 30 lbs by Labor Day

17. What is the maximum rate of safe weight loss? B 1-2 lbs/week

18. What can Selena do? Weight Loss – How to? Choose the correct option. In order to loose weight Selena needs to a. Reduce her carbohydrate intake, but she can eat as much fat as she wants b. Reduce her fat intake, but she can eat as much carbhydrates as she wants c. Reduce her calories so that she burns more energy than she consumes d. Mediterranean Diet – high veggies and poultry & fish

19. DIRECT Dietary Intervention Randomized Control Trial RCT, 2 yrs N=322 All groups consumed same amt of calories KgLDLadherence Low fat & Restricted cal -2.9-0.0590% Mediterranean & restricted cal -4.4-5.685% Low CHO -4.7-378% Shai et al NEJM; 359:229-241

20. What can Selena do? Exercise How much and how often? _____ minutes per day ____ days per week at least. a.15 ; 2 b.30; 5 c.45; 6 d.60; 6 –What intensity?

21. Minimum amount of exercise for weight loss B 30 minutes per day 5 days per week

22. Weight-Loss Surgery BMI >35-40 kg/m 2 Laparascopic vs Laparotomy Weight loss 40-88% of presurgery wt Mortality -0.3% Serious complications – 4.1% Cost – $17, 000- 26, 000 Curr Probl Surg 2010; 47:79-174

23. Preventing Diabetes Metformin Diabetes Prevention Program –RCT, N=3234, – IGT –Metformin reduces risk diabetes – by 31% –Diet/exercise reduces risk by 58% DPP Lancet NEJM 2002;p 393

24. Preventing Diabetes Rosiglitazone DREAM Trial RCT, N=5,269, IFG + IGT, 3 yrs primary endpoint – death or diabetes rosiglitazone & life style recommendations reduced risk by 60% vs placebo & life style recommendations DREAM Lancet 2006; 368:1096

25. Preventing Diabetes ACE Inhibitors Secondary analysis of trials suggest ACE inhibitors may prevent diabetes a DREAM Trial - Prospective Analysis b –N=5,269, IGT + IFG, 3 yrs –ramipril didn’t prevent new onset DM –rampril did increase odds of normoglycemia a Hansson et al. Lancet 1999;353:611-6; NEJM 2000;342:145-53; Abuissa HJ Am Coll Cardiol 2005;46:821-6 b NEJM 2006; 355:1551-1562

26. Preventing CVD ASA Indications –MI – use ASA and clopidogrel –10-yr risk of cardiac event >10% Use ASA 75-100 mg/day –http://hp2010.nhlbihin.net/atpiii/calcula tor.asphttp://hp2010.nhlbihin.net/atpiii/calcula tor.asp Hirsh et al. Chest 2008; 133:71S-105S.

27. Weight Loss Drugs Agent$/30 day $ for 1 lb weight loss Phentermine5410 Sibutramine110141 Exenatide*230535 Orlistat2734 *Off label use Murno et al BMJ 1968;1:352, Buse Clin Ther 29:139, Jones et al. Int J Obes Relat Met Disord. 1995;19:41, Sjostrom L et al Lancet 1998;352:167-173. Drug Store.com for pricing accessed June 12, 2008

28. What would you tell Selena? Group Caucus –What questions would you ask Selena –What do you think Selena should do for her ABCs ? –Should she be given drugs now?

29. Case B Your store has contracted with a 3 rd party payor to provide MTM for its insured. You were chosen to oversee this process.

30. Case B 48-year old white male, KL, with history of hypertension and dyslipidemia. The following meds are on his prescription profile: irbesartan/HCTZ 300 /12.5 and atorvastatin 10 mg po qd. NKA wt 278 Ht 5’8”

31. What information would you like to have about KL?

32. A lipoprotein is a. a lipid soluble sphere that carries cholesterol and triglycerides through the body b. a protein that binds albumin c. an important protein involved in binding drugs d. eliminated by the kidney

33. A lipid soluble sphere that carries cholesterol and triglycerides through the body lipid soluble sphere that carries cholesterol and triglycerides through the body A lipoprotein is

34. High density lipoprotein cholesterol (HDL-C) carries mostly ___________ from the ______ to the _______. a. cholesterol; periphery; liver b. cholesterol; liver; periphery c. triglycerides; periphery; liver d. triglycerides; liver; periphery

35. A HDL-C carries mostly HDL-C carries mostly cholesterol from the cholesterol from the periphery to the liver. periphery to the liver. reverse cholesterol transport

36. Low density lipoprotein cholesterol (LDL-C) carries mostly ___________ from the ______ to the _______. a. cholesterol; periphery; liver b. cholesterol; liver; periphery c. triglycerides; periphery; liver d. triglycerides; liver; periphery

37. B Low density lipoprotein Low density lipoprotein cholesterol (LDL-C) carries mostly cholesterol from the cholesterol (LDL-C) carries mostly cholesterol from the liver to the periphery. liver to the periphery.

38. Very-low density lipoprotein cholesterol (VLDL-C) carries mostly ___________ from the ______ to the _______. a. cholesterol; periphery; liver b. cholesterol; liver; periphery c. triglycerides; periphery; liver d. triglycerides; liver; periphery

39. D Very-low density lipoprotein cholesterol (VLDL-C) carries mostly triglycerides from the liver to the periphery. Very-low density lipoprotein cholesterol (VLDL-C) carries mostly triglycerides from the liver to the periphery.

40. What would you like to do for KL’s ABCs? 48-year old white male Meds: atorvastatin 10 mg, irbesartan/HCTZ 300 /12.5 NKA wt 278 Ht 5’8” A – BG within wnl B – 156/96 C – TC – 223, LDL- 148, HDL – 43, TG -160 FM history father died at age 53 of MI Social – drinks and smokes cigars at Saturday night poker games, walks to mailbox and at work.

41. Reviewing KL’s ABCs

42. Case C Your second MTM patient, RT is a 58 year old female with history of type 2 diabetes, hypertension, elevated cholesterol. Last year she had an MI. Her blood pressure is 148/82, her last cholesterol was taken 6 months ago.

43. RT’s pharmacy profile 4/4/10verapamil SR 240mg po qd #30 4/4/10HCTZ 12.5 mg qd #30 4/4/1070/30 human insulin 50 qam and 70 qpm # 40 ml 4/4/10simvastatin 10 mg po qd #30 2/17/10HCTZ 12.5 mg qd #30 2/17/1070/30 human insulin 50 qam and 70 qpm # 40 ml 2/17/10verapamil SR 240mg po qd #30 2/17/10HCTZ 12.5 mg qd #30 1/2/10simvastatin 10 mg po qd #30 1/2/1070/30 human insulin 50 qam and 70 qpm # 40 ml 1/2/10verapamil SR 240mg po qd #30 1/2/10HCTZ 12.5 mg qd #30 1/2/1070/30 human insulin 50 qam and 70 qpm # 40 ml

44. What additional information would you like to have about RT?

45. A1c and CVD Clinical Trials ACCORD, ADVANCE, VADT Large RCTs, T2DM Compared A1c <6.5% to A1C 7-7.9% Results A1c<6-6.5 did not decrease CVD events N Engl J Med. 2008;358(24):2545-2559. N Engl J Med. 2008;358(24):2560-2572. N Engl J Med. 2009;360(2):129-139.

46. What would you like to do for RT’s ABCs? Please work in a group and develop your MTM plan.

47. RT’s Info 58 year old female s/p MI, wt 187 Ht 5’6” A – A1C 7.5% type 2 DM B – 148/82 C – TC – 178, LDL 112, HDL 33, TG 165 (6 months old) Social – drinks socially, neg smoking Meds: verapamil SR 240mg po qd HCTZ 12.5 mg qd 70/30 human insulin 50 qam and 70 qpm simvastatin 10 mg po qd

48. Reviewing RT’s ABCs http://hp2010.nhlbihin.net/atpiii/calculator.asp

49. Summary Controlling blood pressure and cholesterol Aspirin therapy Blood glucose control is important in preventing microvascular complications

50. Questions