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One of the newer things—it’s not really new for those of us in diabetes—I’ve been utilizing it probably for the better part of 20 years, but different iterations is continuous glucose monitoring [CGM]. And the beauty of continuous glucose monitoring is how accurate it is and the fact that if we place a continuous glucose monitor, and there’s professional and personal meeting on placing it for just a short period of time, 10 of 14 days, patient brings the data back to me, I get to look at it I guess to help me make decisions. And then there’s personal. The patients are utilizing personal. For type 2 diabetes right now...we get coverage, whether it be Medicaid, Medicare, or commercial. For type 2 diabetes, for the most part they need to be on multiple daily injections. And one of the things that we’re really working with Medicare on, because Medicare makes a decision and that’s how the world turns, is to look at all people with diabetes, but mostly to look at people who are on insulin period. If you’re on one injection of insulin, basal insulin you should qualify for continuous glucose monitoring, but the whole concept of CGM is just totally explosive in terms of what it can do in helping us manage people with diabetes. What are your thinking on continuous glucose monitoring? I almost don’t see a patient that is wearing it or using it.

: I can’t imagine that you would, because anything that is going to give more data, and accurate data, especially for those patients that have more aggressive or poorly controlled type 2 diabetes. Knowledge is power. These continuous glucose monitoring data is really, incredibly important, especially as we were just talking about for these the basal dosings. I absolutely was so impressed. We were just talking about the article that was in 

Journal of the American Medical Association

] that just very recently came out. And a very large meta-analysis that was going over how you can significantly reduce hemoglobin A1C in as little as 8 months just with the improved monitoring in and of itself. That awareness is essential.

 article, it came out in June 2021, was first of all, we were trying to complete it in the middle of COVID-19. That was one interesting thing. But the other thing is that it wasn’t managed by endocrinology. The patients had to come out of primary care. They could never have owned or worn CGM. They were on programs with just basal insulin. And we would upload it for the primary care provider, and we would tell them what we were seeing. But they were having the conversations with the patients. They were making any adjustments. They were the ones that were having the relationships. The fact that we saw such significant A1C lowering. The other thing is that there was another paper that was published in August of 2021. And what we did in that one was we kept one group on CGM, we took CGM away from the other group, and the increase in the A1C, which you and I would expect for those individuals who were now not on CGM was very significant. To show that even just a on basal insulin, when the patient’s getting that kind of feedback on a regular basis of what happens when I walk, what happens when I eat, what happens when I take my medication as prescribed is remarkable in moving that patient ahead.

: Absolutely. You can see how that would help improve their overall quality of life because they have increased self-awareness. And when you have increased self-awareness, I just feel that you start to do other things that are good for you inherently. This monitoring in places where people live gather, whether it’ a Fitbit or it’s a blood pressure monitor that communicates with your phone, your continuous blood sugar monitoring. There’s many different ways that we’re able to use AI [artificial intelligence] and other smart technology to be able to have real-time data and it’s really incredibly powerful for providers today and equally so for our patients that can come in and say, “Look at me. Look what I did. Look what I was able to accomplish.” Because then they can start to also see that their nutrition can make a difference. Just having that improved awareness is significant.

The other thing we find too is that if a patient does have low blood sugar that impedes their ability to keep getting their blood sugars under control. Because at that time of day someone will feed them, they’ll omit their insulin. They’ll omit their medications if they’ve had an episode or if they have one episode overnight somebody will feed them before they go to bed to make sure their blood sugars are 2 to 300 so they don’t have an episode during the night. These devices have alarms and alerts on them so that if you’re going low, they can let you know so that you can treat it right away.

: Way before. The yo-yo. The yo-yo phenomenon starts to take place.

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A discussion on using continuous glucose monitoring systems to improve the management of type 2 diabetes.

Continuous Glucose Monitoring Systems for T2DM

One of the things that the standards do say, which is totally different than anything we’ve had in years is that we don’t care what the A1C [hemoglobin A1C] is. If your patient is at cardiovascular disease risk, start the medication after metformin. The beauty of the SGLT2 [sodium-glucose transport protein 2] inhibitors and the GLP-1 [glucagon-like peptide-1] is they work when the blood sugars are elevated, especially at the GLP-1s. They have this magic component that I still don’t understand. That when the blood sugars are elevated, they work; when the blood sugar is normalized, they turn themselves off. Neither of these medications, since they only work when blood sugars are elevated, cause hypoglycemia in of themselves. The things that patients hate the most, hypoglycemia and weight gain. And the beauty of these medications is they also provide weight reduction. You’re going to see somewhere between 5 to 8 pound weight reduction with your SGLT2 inhibitors and upwards to 14 pounds with your GLP-1 receptor agonist. With no hypoglycemia unless you have another medication, such as a sulfonylurea, which on these patients you should not be using. Or insulin, we can talk a little bit about that. But in of themselves and weight reduction. And not only are you giving cardiovascular benefit, you’re giving A1C lowering if needed, but there’s so many remarkable things to start these medications. We don’t care if the A1C is 7.2, if they have a cardiovascular risk, you’re going to give them a GLP-1, or if they have heart failure, think about an SGLT2 inhibitor. And of course, if they have kidney disease, you’re going to give them an SGLT2 inhibitor as well. They have some remarkable benefits. And that’s the other reason why. And the A1C lowering, again, depending on the doses, depends on where you start with A1C. If you have an A1C of 9% or 10%, many of these drugs will bring the A1C down to 7%. If not, you can then back load it with insulin or something else if you’re not going to get that patient treatment goal. But they have everything possible for our patients.

They do. Their pleiotropic is really—at the end of the day. And I love the highlight of the weight reduction. That’s probably helped to drive, number 1, when you lose 5 to 10 pounds, that’s usually a half a pill to a full blood pressure pill reduction in what they’re having to potentially take. That’s powerful. That weight loss is significant. And we also know that it helps to reduce their overall inflammatory load.

: Exactly. And all of these things are just phenomenal in what we can offer people with diabetes. Insulin is not the bad guy for our patients, because many of the patients are still going to need insulin. But we do urge providers to use the newer insulins. Some of the longer acting insulins—stay away from the NPH [Neutral protamine Hagedorn] if you can—but use some of the longer acting insulins that do last 24 to 36 hours. They have less peak, less hypoglycemia. And if you are adding an SGLT2 inhibitor or a GLP-1 to insulin, or you bring insulin on, you want to be careful of low blood sugar. If I have a patient who I have on basal insulin and I’m going to add an SGLT2 inhibitor, what I typically do is lower the insulin when I start by at least 20%, look at blood sugars before I titrate the GLP-1 or the SGLT2 inhibitor. And if I can continue to lower the insulin—sometimes if the patient’s only been on 20 units of basal insulin—I can get them off insulin, which I think in of itself is pretty great.

That’s exactly right. In preparation of our discussion today, I love PubMed, you can hop in there and just get yourself updated so quickly. As well as on UpToDate, which is also so helpful. But there was a recent paper that came out in 

That just came out at the end of October. That was a very comprehensive, systematic review on basal weekly insulin, and how it’s the wave of the future starting it early. And it’s all about adherence. For those of us that are spearheading all this chronic disease management, it’s more of the same language. Which is get started early, teach the adherence piece and why it’s so important. And oftentimes we can avoid a lot of this and organ damage that we oftentimes will see if these things aren’t started early enough.

The takeaway message here is being as aggressive as we can with people who have type 2 diabetes [T2DM] and there is a reason to use the new therapies. Make sure they’re on statins, check their blood pressure. And then when you move into the diabetes medications utilize the newer medications. And the truth is every insurance company, Medicare, Medicaid, any commercial will provide both SGLT2 inhibitors and GLP-1. We need to urge people to use them instead of siphon areas. I understand there are places for siphons areas when there’s an insurance issue or cost issue, but mostly they cause hypoglycemia and weight gain, and they’re just nasty. And if we can avoid them, that would be really good.

The benefits of using new therapies, such as SGLT2 inhibitors and GLP-1 receptor agonists, to treat type 2 diabetes.

Benefits of New Therapies Used to Treat T2DM

Let’s discuss some of the new American Diabetes Association guidelines. In 2021 they were updated, and what happened, which is phenomenal history, is back in 2008, there was a problem with some of our medications, the TZDs [thiazolidinediones] and whether they caused an increased risk of cardiovascular disease. At the end of the day, they probably did not. But the FDA said if you’re going to bring a new medication to the market, you could only do it if you did some cardiovascular studies. The medications, which were mostly SGLT2 inhibitors and GLP-1 receptor agonists, had to prove that they did not cause any more cardiovascular issues than a placebo did. I was an investigator for a number of these studies because they were long-term studies. At the end of the day, we made history. In the GLP-1 arena, they were decreasing the risk of MACE [major adverse cardiac event], 3-point MACE: decreasing stroke, heart attacks, and all-around death. And the SGLT2 inhibitors, aside from what they did for the kidneys, decreased risk of heart failure. Now we’re saying, after metformin, way before insulin…your first injectable would be the GLP-1s. For renal and cardiovascular [conditions], we now have 2 medications that help. As the benefit was shown in the research, it was more impressive than some of the first statins that came to market. How are you using these medications? I know that your focus is cardiovascular, but you’re seeing so many patients with diabetes. What would you do in your practice?

: Thank you so much for this. We were excited in cardiology to have these drugs available to us. It’s profound when you can create such a staple for both cardiovascular science, as well as endocrinology. These medications are vital for many of our patients. Typically, when I see a patient who has type 2 diabetes and is not on treatment, and unfortunately, I see a lot of women who fall into this group. What I do is I prescribe them metformin right out of the gate if they have not tried it yet. Then I refer them to our diabetes outpatient center, which is a comprehensive group of endocrinologists, it has a dietician, it has masters-prepared nurses who are all experts in teaching everything from nutrition to medication compliance. They’re good about getting the medications approved too, which is the other piece to it, just like how I’m very good at getting these other nonstatin cholesterol-lowering drugs into the hands of patients. It’s important that we refer. Get them on something and then get them referred. If you don’t have that luxury, then we have the autonomy to get them started. You are absolutely following national guidelines to do so if they’re not meeting their target hemoglobin A1C [glycated hemoglobin]. We’re very fortunate, we’re in an inner-city area, we have a lot of resources. In this instance, I’m always referring and reminding of the dual benefit. And I will elaborate on their cardiovascular risks so that they can utilize those providers who are on the endocrine team for getting these medications preapproved.

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Takeaways of the most recent ADA guidelines in terms of treating patients with diabetes with metformin, SGLT2 inhibitors, and GLP-1 receptor agonists.

Revised ADA Guideline Recommendations for the Treatment of T2DM

I have one more question, and then I want move into some of the diabetes medications. There have been some changes on the use of aspirin therapy. We used to give everybody aspirin therapy. And now they’re saying unless you’ve had a cardiovascular event, we shouldn’t be giving aspirin. However, I always think of type 2 diabetes as an event because the patients are so prone to it. But we’re all looking at each other and waiting for guidance for those patients who have not had a cardiovascular event, do we keep them on aspirin, or do we take them off aspirin?

: The takeaway that came out of the new guidelines was to give aspirin for a few, the important few. As providers, we need to balance the risk/benefit between bleeding and benefits. If your patient with type 2 diabetes is going to have a greater benefit, especially if they need secondary prevention, then yes. They’re usually on some other type of a blood thinner, whether it’s an antiplatelet or a DOAC [direct oral anticoagulant], where the baby aspirin is an important piece to that. If they need purely primary prevention and their blood sugar is well controlled, then that’s a legitimate discussion to be had. But for the person without diabetes, who needs primary prevention, there are not strong data that will sway the curve significantly. Chances are they would not benefit.

Guidance on the use of aspirin therapy in patients at risk of cardiovascular events, based on recently updated guideline recommendations.

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