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Primary Care: An Ever Changing Landscape Presented by: Penny DeRaps, PhD, FNP-C Maine Nurse Practitioner Association Fall Conference - November 14, 2015 Objectives Review preventative care guidelines for primary care Review new classes of DM medications Review new formulations of respiratory medications Colorectal (CDC and USPTF) 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 CT Colonography every 10 years (ACS approved, or Flex sig every 5 years; or Double contract BE every 5 years (ACS approved; or FIT test yearly (or every 3years if used in conjunction with flex sig; or Colorectal (CDC and USPTF) Continued FOBT yearly (or every three years if used in conjunction with flex sig; or Screening in high risk patients should begin at 40 or 10 years before 1st known diagnosed relative; or 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) Every 2 years mammo for women age 50-74 Earlier screening should be done in direct relation to known family risk or BRCA risk and decided with the patient CBE every 3 years with prvider **ACS says every year mammo after the age of 40, high risk patients should get an MRI or mammo annually Cervical Cancer Screen Age 21-30, pap smear every 3 years, HPV done only if abnormal results 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 Yearly screening in presence of abnormals; If CIN2/3 and hysterectomy; see 3 annual negatives before discontinuing screening Cervical Cancer Screen continued Over age 65, no recommended screening if adequate screening and normal results up to that point ACS essentially similar except that if an abnormal results returns and HPV is positive and your are older that 25, colposcopy recommended Prostate No recommended screening unless patient expresses a clear preference for it Inform patient of limited benefits of screening unless significant risk Evaluate patient’s life expectancy in general Lipid Disorders Strong recommendation to screen men over the age of 35; screen men 20-35 if increased risk Strong recommendation to screen women over 45; screen women 20-45 if increased risk Lipid Disorders Increased risk indicated by the following: 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 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=+ AACE - FBG>126, GTT>200 2hours after ingesting 75 gm oral glucose, hyperglycenia symptoms and random BS>200, AIC>6.5% Diabetes Continued 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 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 Women age >65 Women age <65 with the following risk factors: Caucasian Low body weight Smoker Family History of osteoporosis T2D Complex Metabolic Disease Characterized by Chronic Hyperglycemia “Deadly Octete” 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 T2D Complex Metabolic Disease Characterized by Chronic Hyperglycemia “Deadly Octeth” Continued Pancreatic Insulin Secretions Progressive 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 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 Insulin: Increases glucose disposal and hepatic glucose production Sulfonylurea: Increases insulin secretion Both are associated with risk of hypoglycemia Metformin: hepatic glucose production, intestional absorption of glucose and improves insulin sensitivity by increasing glucose uptake and utilization First Choice Med for Most 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 SGLT-2i: Reduces the amount of glucose reabsorbed by the kidneys Drug in Each Class Insulin, Sulfonylureas, Metformin TZDs – Actos & Avandia GLP-I Tanzeum (albiglutide (1 wk) Injectables below: Trulicity Byetta (duloglutide (1 wk) (examatide (BID) Bydurea Victoza (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 SGLT-2i Farxiga (dapazliflozim) Jardiance Invokana (empagliflozin) (camagliflozin continued Effects of Medications Insulin: Fasting plasma glucose PPG hypoglycemia weight Sulfonylureas: Fasting plasma glucose PPG hypoglycemia weight Effects of Medications Metformin: Fasting plasma glucose PPG Neutral hypoglycemia & weight TZD Fasting plasma glucose PPG Neutral hypoglycemia weight (? Of CHF) continued Effects of Medication GLP-1RA Fasting plasma glucose PPG Neutral hypoglycemia Weight DPP-4i Fasting plasma glucose PPG Neutral hypoglycemia & Weight SGLT-2i Fasting plasma glucose PPG Neutral 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 - 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 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 COPD: Chronic air flow limitation is caused by 1. Small airways disease (obstructive bronchiolitis) and; 2. Parenchymal destruction (emphysema) measured by spirometry Gold (2014) Global Initiative for chronic obstructive lung disease along the standard for diagnosis, management and prevention of COPD 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. 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 Asthma: Advair (Albuteral) Asmanex (Qvar) Breo (Symbicort) Dulera Florent Foradil Pro-air –albuteral – proventil Pulmicort LABA: Foradil Serevert Questions? Thank you!!