(Adnkronos) –
• From Lombardy, territorial experiences compared: from the collaboration between ATS Bergamo and ASST Papa Giovanni XXIII, the establishment of a working group which laid the foundations for the establishment of a metabolic cardio-renal PDTA. From the Nephrology and Dialysis of ASST Santi Paolo e Carlo, the proposal for a working group to formulate a new diagnostic and therapeutic path.
• The new drugs available: important results and largely simplified appropriateness verification in the Lombardy Region with the unification of the therapeutic plan
Milan, 17 October 2024 – Diabetes and chronic kidney disease: the new SGLT2 inhibitor drugs are able to protect the kidney, reduce cardiovascular diseases related to chronic disease and delay entry into dialysis both in early treatment (of approximately 12 years) and in advanced disease (around 6 years), but only a third of diabetic patients, net of the large undeclared population, access these new drugs in Italy. From Lombardy, the discussion between experts, organized by Motore Sanità with the unconditional contribution of Boehringer Ingelheim and Lilly – “Kidney disease and diabetes, the scientific evidence that pushes towards organizational innovation. Focus on SGLT2i” – highlighted how fundamental the collaboration between hospital specialists and local specialists is, primary and secondary prevention, the role of the service pharmacy and the hospital pharmacy in the management of the two pathologies, as well as the proposal and birth of new PDTAs, the result of synergies between professionals implemented to guarantee the best diagnosis and treatment path for the patient.
Chronic kidney disease is a public health problem affecting a large portion of the population. It represents one of the most widespread and progressively expanding chronic-degenerative pathologies, in fact it is estimated that around 10% of the world’s population is affected by it. Chronic kidney disease often coexists with other chronic diseases, such as diabetes mellitus and cardiovascular disease, and shares many risk factors with these diseases. In our country there are over 4 million patients with chronic kidney disease and of these 50,000 are on dialysis and 50,000 are kidney transplant recipients. In the last 25 years, mortality from chronic kidney disease has increased by more than 40%. It has been calculated that through prevention and early diagnosis, the possibility of delaying the start of dialysis by at least 5 years in even just 10% of patients would allow the NHS to save hundreds of millions of euros. The economic impact for the NHS is heavy: at least as many indirect costs must be added to the direct annual cost for a dialysis patient of between 30,000 euros (peritoneal dialysis) and 50,000 euros (hemodialysis). Despite these numbers, due to its silent onset, there is still little awareness of the disease and there is no effective and rapid prevention.
Hospital experiences of taking charge and best practices
The collaboration and connection between the two corporate entities, ATS Bergamo and ASST Papa Giovanni XXIII, has borne important fruit: the establishment of a working group which has laid the foundations for the establishment of a metabolic cardio-reno PDTA (CRM) which, as explained by Massimo Giupponi, General Director of ATS Bergamo, will be presented on 24 October on the occasion of “Prospettiva Salute”. “The next steps will be to bring the PDTA to the territory, involving all local actors”. According to the General Director of ATS Bergamo, it is necessary to pay attention to the organizational aspects and involve the territorial actors according to the specificities of each one and that each of them recognizes this specificity on the part of the others, using tools and working methods that make the path transparent and capable to engage everyone. “Our hope – concluded Giupponi – is that it will be a PDTA that does not remain on paper but is an example for intervening on all the other pathologies that require such extensive and qualified participation”.
In the complex Nephrology and Dialysis structure of the ASST Santi Paolo e Carlo, directed by Professor Mario Cozzolino, approximately 3,000 patients suffering from chronic kidney disease are followed. “The care of this complex patient takes place with a referral from the general practitioner, cardiologist specialist and/or diabetologist. In this process of taking charge and care, the role of the nephrologist in the multidisciplinary and multi-specialist management of this complex patient is a “central” role, as coordinator of the dietician, nurse, psychologist, OSS, care-giver, general practitioner and other medical specialists.” Professor Cozzolino then focused on the role of prevention: “Once renal disease has been identified, measures should be implemented aimed at the early management of patients who are candidates for renal failure, establishing clinical criteria that allow identifying the moment, the specialist and the structure that will have to provide the most appropriate intervention”. The proposal put forward by Professor Cozzolino is a working table to formulate a new PDTA on chronic kidney disease. “We must move from the individual service to the evaluation of the overall system of personal care. The PDTA is a highly relevant tool in the context of the reorganization of the national health system”.
Roberto Trevisan, Director of UOC Endocrine Diseases 1, Diabetology ASST Papa Giovanni XXIII of Bergamo and Associate Professor of Endocrinology Department of Medicine, University of Milan Bicocca brought the experience of the department he directs. “The patient with chronic kidney disease is taken care of by our complex Endocrine Diseases-Diabetology structure and is reviewed at least once a year to re-evaluate the cardio-reno-metabolic situation and the therapy in progress. At least 1500 of the 3500 type 2 diabetics in our care have chronic kidney disease often associated with atherosclerotic disease.” Regarding the role and value of multidisciplinarity and multi-professionalism, in case of complex situations a day service is activated which allows for the accurate evaluation of the cardio-reno-metabolic situation. Best practices: “apply the guidelines as early as possible in order to treat patients optimally. We also invite many patients to participate in international clinical trials on new molecules that could further reduce their global risk” concluded Professor Trevisan.
The strategic role of the territory: synergy between specialists and the role of pharmacies
Chronicity, a game that must be played on the territory, and collaboration between the various actors for the optimal management of the patient: the watchwords, according to Fabrizio Oliva, President of ANMCO. “Faced with a situation that is emerging which is that of chronicity, there is a need for collaboration between the various actors involved in the treatment process – explained Professor Oliva -. Collaboration between specialists is a path that must be brought to the territory, because chronicity is a game that is mainly played here, where telemedicine can make a great contribution to the treatment path of these patients. In the area there is first and foremost primary prevention in which it is important to intercept the carriers of risk factors (hypertension, dyslipidemia, diabetes, obesity) and detect the presence of renal dysfunction early, and in this the general practitioner is a companion of an important trip. In the context of secondary prevention, close collaboration is also necessary between specialists (cardiologist, nephrologist, diabetologist). As regards new therapies, we have drugs that have proven to be able to have an impact from a prognostic point of view and the data we have today are excellent, so we must continue to encourage their use”. In this regard, Giuseppe Caravella, Pharmacy Director IRCCS Policlinico San Donato, recalled that the verification of the appropriateness of the new drugs currently available has been greatly simplified in the Lombardy Region with the unification of the therapeutic plan “A virtuous example that other regions can follow ” said the director.
The role of the service and hospital pharmacy in the management of kidney disease and diabetes
In the management of kidney disease and diabetes, the pharmacy plays a fundamental role “first of all with the dispensing of innovative medicines, and then, in synergy with the doctor, it represents a concrete support to facilitate and improve the patient’s adherence to therapy chronic” said Manuela Bandi, urban vice president of Federfarma Milan, Lodi and Monza Brianza. “In fact, in the pharmacy, citizens can carry out first-instance tests, which allow them to effectively monitor their state of health, just as they can consult on a daily basis with professionals capable of assisting them in correctly taking the medicine”. “The clinical pharmacist in the hospital represents a great opportunity for the management of drug therapy and not only, in patients with chronic kidney disease and diabetes, in fact the treatment of subjects suffering from chronic pathologies requires not only close monitoring of adherence to therapy but also correct and constant information – Giuseppe Caravella highlighted this role -. Aspects that the clinical pharmacist can help manage, both through close collaboration with clinicians and through counseling activities to be carried out, for example, during the dispensing phase of the therapy. Finally, it is necessary to invest in collaborative projects between the hospital pharmacist and the pharmacists who operate in the area in order to allow 360° care of patients suffering from chronic kidney disease and diabetes”.
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