prescribing an app

Take two apps and call me in the morningPrescribing code instead of pills, clinician perspective

Joel M Topf, MD

@Kidney_boy

@eajkd

www.Pbfluids.com

Kidometer

KDIGO iPad app

UK Prospective Diabetes Study

An intensive glucose control policy HbA1c 7.0 % vs 7.9 %

reduces risk of

◦ any diabetes-related endpoints 12% p=0.030

◦ microvascular endpoints 25% p=0.010

◦ myocardial infarction 16% p=0.052

A tight blood pressure control policy 144/82 vs 154/87

mmHg reduces risk of

◦ any diabetes-related endpoint 24% p=0.005

◦ microvascular endpoint 37% p=0.009

◦ stroke 44% p=0.013

The benefit from tight glycemic control is less

than the benefit from lousy blood pressure control

Blood pressure control is more important blood sugar control

525,600minutes in a year

4 minutes are assessed with office BP

Gold standard for blood pressure assessment is 24-hour ambulatory blood pressure monitoring

Patient assessed home blood pressures are more than twice as correlated than physician measured office blood pressures.

Home 0.56Office (MD) 0.21Office (RN) 0.31

Little P, et al. BMJ. Aug 3 2002;325(7358):254.

Home blood pressure readings are better than office readings at predicting end-organ damage (left ventricular hypertrophy, atherosclerosis), cardiovascular events and total mortality

but this amazing technology is useless if you forget your numbers…

…no patient ever forgets her phone

Easiest blood pressure diary is the camera phone

• No app to download• You already know how to use it • No cheating• Time and date stamped

Can we go further?Patients titrate insulin based on

blood sugar

Can patients titrate antihypertensive medications based on blood pressure?

Baseline 6 Months 12 Months

125

130

135

140

145

150

155 152.1

139

134.9

151.8

142.4140.1

Systolic Blood Pressure

Intervention Control

Baseline 6 Months 12 Months72

74

76

78

80

82

84

86 85

79.6

77.4

84.5

80.379.5

Diastolic Blood Pressure

The intervention group more medications prescribed

(p=0.001)

◦0.3 at 6 months

◦0.4 at 12 months

fewer clinic visits (NS)

◦3.2 visits versus 3.5 for the control group

improved quality of life (NS)

Pat

ien

ts w

ith

Eve

nts

(%

)

0

5

10

15

20

Years Post-Randomization0 1 2 3 4 5 6 7 8

Primary Outcome Nonfatal MI, Nonfatal Stroke or CVD Death

HR = 0.8895% CI (0.73-1.06)

We pay for tight blood pressure control with acute renal failure, hypotension and low potassium

What I want in a prescription app

Public algorithm

Partners with the physician to choose the appropriate titration strategy

Validated

Approved