Individualizing Treatment in Type 2 Diabetes Mellitus - Episode 1
Peter Salgo, MD: Hello. Thank you for joining us for this MD Magazine® Peer Exchange® entitled, “Individualizing Treatment in Type 2 Diabetes Mellitus.” Despite the availability of newer, more effective therapies, the management of type 2 diabetes mellitus remains challenging and complex. In addition, patients with type 2 diabetes often have multiple comorbidities that further necessitate an individualized approach. This MD Magazine® Peer Exchange® is going to focus on the underlying challenges in diabetes management, including discussions on the nuances of clinical decision making and the role for the newest treatment options.
I’m Dr Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and I’m the associate director of Surgical Intensive Care at New York-Presbyterian Hospital. Joining me for this discussion are: Dr Vivian Fonseca, professor of medicine and pharmacology, Tullis-Tulane Alumni Chair in Diabetes, and chief for the Section of Endocrinology at Tulane University Health Sciences Center in New Orleans, Louisiana; Dr Robert Henry, professor of medicine, and director, at the Center for Metabolic Research at the University of California, San Diego; Dr Julio Rosenstock, director of the Dallas Diabetes Research Center, and clinical professor of medicine at the University of Texas Southwestern Medical Center at Dallas; and Dr Carol Wysham, clinical professor of medicine at the University of Washington, and an endocrinologist at the Rockwood Center for Diabetes and Endocrinology in Spokane, Washington. It’s lovely to have all of you with us today. We have a very big topic to discuss, so why don’t we start by discussing the need for a personalized approach to diabetes management. This isn’t one-size-fits-all, is it?
Vivian Fonseca, MD: Absolutely. Everybody is different and we need to take that into consideration when choosing goals and treatments for diabetes.
Peter Salgo, MD: Let’s be clear. I was taught in medical school that the goal is to get the sugar down and keep it down, right? That’s it, we’re done.
Vivian Fonseca, MD: It depends what you mean by down.
Peter Salgo, MD: What do you mean by down?
Vivian Fonseca, MD: “Too down” is bad for you, so you need to choose the right thing for the right person, depending on whether they’ve just been diagnosed or had it a long time (while the problems have previously had hypoglycemia, which is bad). You’ve really got to personalize it, and we have tremendous choices today. The science is strong. We need the art of medicine to choose the right medicine for the right person.
Peter Salgo, MD: OK. But again, I want to go back to the first part. He’s talking about different goals for different people. Are there different goals? I thought the goal was to get the sugar down and keep it at a reasonable level. Where’s the challenge in that, individually?
Carol Wysham, MD: If you look at your patients that are young and healthy, and are hopefully going to enjoy a full life, you want to have their blood sugars down to as close to normal as possible to minimize that long term. Even slight hyperglycemia over a very long term period is likely to result in complications.
Julio Rosenstock, MD: Yes, but young is a relative term. What we mean by “young” is with the early diabetes—when diabetes is recognized early and when diabetes is diagnosed. Obviously, in young, one of the things that we need to take into consideration for personalized medicine is life expectancy—how many years the person is going to live and the chances of developing microvascular or macrovascular complications. But the point, here, is that we need to be more proactive when we diagnose diabetes (when it’s newly diagnosed).
One of the good things that, now, practitioners have is the ability to measure A1C, which is much easier to help diagnose diabetes. If, routinely, people are going to measure A1C (let’s say, every 6 months or every year), and it’s about 6.5%, then that makes the diagnosis “diabetes.” The point is to be more aggressive and intervene at the beginning when the diagnosis is made so we can get whatever target we’re going to have. If the patient is somebody who has cardiovascular disease, has comorbidities, has some medical issues, then we’re not going to be that aggressive in getting the A1C down below 7%.
Peter Salgo, MD: Do you all agree about that? If somebody has heart disease, don’t be so aggressive? Why?
Julio Rosenstock, MD: The issue is deciding what kind of tools you’re going to use. If you’re going to use insulin, and so on, where you may have hypoglycemia, you have to be a little bit more cautious. But, if somebody has cardiovascular disease, we, now for the first time, have drugs that have shown that they reduce the cardiovascular risk and reduce cardiovascular events. For instance, as I was saying, when you diagnose somebody with diabetes, we’re more aggressive using first-line therapy with metformin. But with the evidence that we have with the EMPA-REG OUTCOME data with empagliflozin, a SGLT2 (sodium-glucose co-transporter-2), I can envision that in the future, we’re going to be more proactively using the combination of metformin and an SGLT2 in newly diagnosed patients with cardiovascular disease.
Robert Henry, MD: Peter, I think we should go back and define what “personalized medicine” is.
Peter Salgo, MD: Yes, I would like you to do that.
Robert Henry, MD: Medicine, to me, has always been personalized. However, we first started defining this concept in this business a few years ago. Previously, there were only 1 or 2 treatments. Insulin and sulfonylureas were our mainstay for many, many years. Each patient was personalized to those therapies, and you obviously did the best you could with those under the conditions you had. But now, today, we’ve gotten more than 10 classes of medications that are routinely used, and each of them has its unique positives and benefits. I think when we personalize treatment, we’re talking about using medications that are suited to that individual’s personal case. A little bit of what Dr Rosenstock is saying is that in an individual with heart disease, you would look at drugs that have now shown to prevent or delay heart disease. Now this is common because we’ve had so much discovery in the last 2 decades.
Vivian Fonseca, MD: But that’s personalizing the treatment.
Carol Wysham, MD: Treatment, yes.
Vivian Fonseca, MD: You need to personalize the goals as well. The goal that we choose on A1C (because that correlates best with long-term outcomes), is to prevent complications. If you’ve got no complications, then a goal of 6% or 6.5% is appropriate. If, on the other hand, you already have all of the complications that are irreversible, and you’re at risk for side effects of medication, then a higher goal (maybe closer to 7.5% to 8%) would be better.
Carol Wysham, MD: That is exactly the point that I think needs to get out there. If I have a 78-year-old patient with an A1C of 6.5% and they want to take metformin at that point, and if they want to test their blood sugars at that point, that’s very appropriate. But I’m going to counsel them. They’ll get education. We’ll monitor them. To try to get a 78-year-old down below 6% is not giving them any benefit.
Julio Rosenstock, MD: Well, not even 6%. Below 6.5%, or below 7%. If I have a 78-year-old person with diabetes and some cardiovascular disease, I would be satisfied with an A1C between 7% and 7.5%.
Carol Wysham, MD: That’s the point.
Vivian Fonseca, MD: Some of us are not far away from 78 years old, so let’s look at it in terms of life expectancy. You could have a very fit, healthy 78-year-old, who tolerates 1 or 2 medications very well without any side effects and is looking forward to living to 100 years old. Let’s hope we all get there.
Julio Rosenstock, MD: Yes. That’s why we need a little bit of a crystal ball. We should use our clinical judgment, estimate comorbidities and potential life expectancy, and also focus on the support system. It’s important that this disease is something that family needs to be a part of.
Robert Henry, MD: And to remember that the patient has to be able to accept and understand the therapies that you’re going to be talking about, because as we’re going to discuss, it’s complex.
Peter Salgo, MD: I was going to say that back in the day, when there were only a few therapies available, it was pretty easy, right?
Vivian Fonseca, MD: Take this pill. Take these 2 pills.
Peter Salgo, MD: You’re making it sound very complicated.
Vivian Fonseca, MD: But Bob is raising a very important concept—shared decision making with the patient. You discuss with the patient, “This is why I’m choosing this goal. Are you okay with it?” “This is why I’m choosing these therapies. Do you want something different?”
Transcript edited for clarity.