Dr Yehuda Handelsman on How DCRM 2.0 Guidelines Refine CRM Disease Management

In an interview with The American Journal of Managed Care® (AJMC®), Yehuda Handelsman, MD, medical director and principal investigator at the Metabolic Institute of America, discusses how the 2022 Diabetes, Cardiorenal, and Metabolic (DCRM) multispecialty practice recommendations differ from the recently updated DCRM 2.0 guidelines for managing patients with diabetes, cardiorenal, and/or metabolic diseases.

He expands upon this topic in his report, “Diabetes, Cardiorenal, and Metabolic Multispecialty Practice Recommendations and Early Intensive Management of Cardio-Renal-Metabolic Disease,” featured in the December 2024 AJMC supplement, “Optimal Management of Patients With Cardio-Kidney-Metabolic Syndrome.”

This transcript has been lightly edited for clarity.

Transcript

How do the DCRM 2.0 recommendations build upon the original guidelines? What specific updates or improvements were made?

In those 2 years—a year and a half, actually—between the 2 of them, there were a lot of advances. We wanted to advance different areas in lipids, for example. We were able to add different medications and also different definitions of who qualifies to get lower goals for lipids.

Just to retract on that for a second, when we developed DCRM, it was during the [COVID-19] pandemic. When we had our first meeting, which was in mid-2021, we could not get anybody outside of the US. So, DCRM was just a US initiative with 30 of the best-known leaders in the different fields, as I said, cardiology, nephrology, diabetes, and so on, but we built it in the US. DCRM 2.0, we added experts from Canada and Europe to see if we can make this recommendation universal. Were we able to adopt those recommendations?

As a great example, that's exactly what happened. We put a group from the US and a group from Europe and Canada together, and they changed all the definition on the goals for lipid management, which is much more appropriate to what we know now on the role of cardiovascular disease, the role of kidney disease and other medical conditions, how much more risk those patients have to get those treatments. We had cooperation between what the US did in DCRM to the rest of the world this year in DCRM 2.0.

A lot of comments [were made] by the people from Europe. On glucose management, we created 2 tracks. Before that, it was, “Oh, you have to give GLP-1 [glucagon-like peptide 1] or SGLT2 [sodium-glucose cotransporter 2].” Now, we have a clear 2 tracks here. One track manages people [in whom] we have to prevent the next event by using GLP-1 or SLGT2. We also spelled out which of those drugs will do what in people with diabetes when it comes to preventing stroke, preventing kidney disease, or managing heart failure, very nicely spread out.

Then, we have the hyperglycemia track. We believe that we don't need to only change the next event, but we have to continue managing the traditional CV [cardiovascular] risk factors, like hyperglycemia, because, long term, if you do not do it, you will get the same issues as before. Same for blood pressure, same for lipids, same for obesity.

Obesity was not defined well in DCRM. It was buried within prediabetes because we said that, actually, [treating] obesity is the preferred management for people with prediabetes. This time, we got a full, just obesity, great slide. If anybody wants to know how to manage obesity, on one slide is how to identify the patient, how to define the patient. Then what are the types of treatments that we have, whether it's diet, medical, procedures, or surgeries, how much each one of them is affecting the patient. Everything on one slide, very easy to do. So, we added obesity.

We also recognize that people with diabetes and people with obesity have by far more lung disease than we knew about. It's not only sleep apnea, which we cover. It's not only obstructive sleep apnea, which is just patients with obesity, primarily, but looking at the whole pulmonary aspect.

Another area that we added that came with some new drugs of recommendation. We always knew that inflammation and managing inflammation is important, but now we have drugs specifically for inflammation that reduce cardiovascular disease. So, we created a whole slide and focused just on that. Then, we perfected the 4 pillars of heart failure management. We actually were very good in defining management for heart failure with preserved ejection fraction that was not as well defined in DCRM. [As] I told you, a lot of changes have happened.

Kidney disease, now we can show people with diabetes and kidney disease, for them, we now also have the fourth pillar, which was primarily developed by Dr George Parker shortly before, sadly, regretfully, he passed. It was already part of the DCRM, we already have it in there, so we have a recommendation of how to manage people that have diabetes and CKD, how to manage people with CKD and no diabetes. All of this, a lot of it is new stuff from the past year and a half, so we've really perfected it.

One of the slides that we have is medications and their attributes. So, where do they benefit? Let's use SLGT2, for example. It will benefit the heart, it will benefit the kidney, but the side effects can be DKA [diabetic ketoacidosis], for example. We also said where it's contraindicated or where it's not contraindicated. We put all this stuff together, and we took a lot of issues that we had, we put some nonindicated that was not quite, so we fixed some of those recommendations. Now, we move to 2 slides of medications because we are covering so many new medications in the cardiorenalmetabolic space.

With those 2 slides, if a health care professional takes 3 or 4 minutes to look at those slides, they will know exactly what good a drug will do, what side effects will do. They can look at it either from across the different conditions and side effects, or they can look at it from a condition like people with kidney disease, what they should do, what they should not do; people with strokes, what they should do, what they should not do, and so on.