Improving Management of Type 2 Diabetes Mellitus - Episode 2
The MD Magazine Peer Exchange "Improving Management of Type 2 Diabetes Mellitus" features a panel of physician experts discussing current best practices to treating and managing patients with T2DM that generally includes lifestyle modifications as well as medication. The mechanisms of action, patient selection criteria, and side effects for various oral medication classes are included in the discussion.
This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.
The panelists are:
Peter L. Salgo, MD: Let’s talk about some of these overall approaches. We’re all familiar with the A1C at this point, even my interns are. It used to be your blood sugar is high. Now it’s your A1C. How often do you measure this A1C? Actually, it’s a chronic measure, so how often do you have to look at it?
Pamela Kushner, MD: In my practice, we’re looking at everybody’s A1C every 3 months. I think it’s a good way to reinforce what that patient is doing in their life, and whether the treatment plan is working and they’re on the right treatment plan. However, I would add that I don’t only look at A1C; that’s a small part. And I think that’s part of where we see diabetes management evolving, so that I’m also looking at 2-hour postprandial, fasting, before you go to bed. I’m looking at different measurements.
Peter L. Salgo, MD: But do you do that all every 3 months, at the same time as you get the A1C, or less frequently, more frequently? What do you do?
Pamela Kushner, MD: Well, the approach that I do is, I don’t like people coming in and showing me a fasting blood sugar that they’re making up as they go along, and you’re looking at every day. That’s not valuable to me, so I have people do like seven different measurements in a week, and those seven different measurements are at different times.
Peter L. Salgo, MD: But that’s complex. Can patients actually do that?
Ralph DeFronzo, MD: Yes, they can and, in fact, I think the critical part is really not the A1C. If I’m starting a newly diagnosed patient on a medication, I want to know what’s happening before 3 months. So, home blood glucose monitoring, I think is critical. I personally talk to the patients at least once a week. I know many physicians don’t have the time to do that, and if I’m starting someone on insulin, in particular, I’m talking to that person on a daily basis. They have my home phone number. Usually, I have them call me at night. I need to know whether I need to adjust the medication, particularly if it’s insulin. My goal is to make sure you don’t get on insulin—but many of my patients are on insulin. And then depending upon what the oral agent is that I’m starting the patient on, I need to know whether it’s working and I don’t want to wait 3 months to find out. So, I think if you want long-term control, the A1C is fine. Once the patient is stabilized, I don’t think you need to get it every 3 months.
Peter L. Salgo, MD: Let me, if I can, parse this out. I understood what you were saying. A1C is a really good way to follow long-term once somebody is stabilized. It’s not an acute-phase reactant. It’s not something that’s going to change in the next 22 minutes, right?
Pamela Kushner, MD: Correct.
Peter L. Salgo, MD: It was explained to me in my youth; it’s what’s bathing the red cells over a long period of time, and that’s what’s changing things.
Pamela Kushner, MD: Let’s not get off A1C. I have a question for you. Would you say that the A1C reflects the first 6 weeks or the last 6 weeks most effectively?
Ralph DeFronzo, MD: It’s mostly reflecting the first 4 to 6 weeks. We talk about every 3 months, but, in fact, you’re going to get the great majority of the A1C effect in the first 6 to 8 weeks. We say 3 months because then, of course, you see the full effect. And we also need to remember that there are some things that make the A1C less accurate.
Pamela Kushner, MD: That’s very important.
Ralph DeFronzo, MD: People, for instance, depending upon where you live, sickle cell anemia, different types of thalassemias—all that can be important. So, there are racial differences. The A1C is a little bit different between Caucasians and African Americans, but the glucose is always the same. If you’re measuring the glucose, you’ll get the answer pretty quickly, and then you’re going to confirm what you’ve done.
Pamela Kushner, MD: Do you check a CBC every time you check an A1C?
Ralph DeFronzo, MD: No, but I usually do it at the beginning. This issue of anemia is, if they’re anemic to begin with, of course, it’s a problem. But, unless there’s some reason to believe that the patient has lost blood—and usually that’s pretty obvious—I don’t necessarily check the hematocrit.
Peter L. Salgo, MD: I hear a lot of noise over from the right side of this table. You guys have been very quiet. Either you agree with them or you think this is all ridiculous. Do you want to weigh in on this?
Robert Busch, MD: The A1C is very important, but, as we know, the lower the A1C, the less microvascular disease. Patients with diabetes die of heart attacks and strokes. So, my chief taught us if you just treat A1C, you don’t treat lipids and blood pressure, you get a lot of dead people with 20/20 vision. But sometimes we can be so focused on sugar, and where’s the ACE or ARBs for the blood pressure, and where’s the statin?
Peter L. Salgo, MD: I know what a lot of clinicians are wondering because diabetes is tricky. I mean, if somebody comes in with an A1C of 8, everybody is ringing the alarm bells and everybody is going to try to treat this, right? And you get the blood sugar, and the blood sugar is what? The 130 postprandial or 130 fasting? That’s bad, too. So, what do you go after first and how do you get there? And is the A1C simply confirming what you’re doing with your oral hypoglycemics and your insulin, or is it something that you’re tracking of and by itself? What do you think?
Robert Busch, MD: Well, if the A1C is high and it’s accurate, you’re certainly going to be treating that. But, in terms of what you’re treating with—just like with the first rule of medicine—first, do no harm. I think none of us here would want to risk hypoglycemia in a patient, and we have a tantalizing array of drugs. We have Dr. DeFronzo’s ominous octet: choose any of the above as long as you don’t cause hypoglycemia.
Ralph DeFronzo, MD: Dr. Busch made a very good point I think needs to be emphasized: that diabetes type 2 is two different diseases. It’s a disease of the microvasculature and, there, clearly glycemic control is the most important thing. It’s also a disease of the macrovasculature. And the risk factors for the macrovascular complications—heart attack and stroke, as Dr. Busch points out—are very, very different. And both need to be treated aggressively and simultaneously.
Peter L. Salgo, MD: And we’re going to get to all of that. But it didn’t escape my notice in all of this discussion: the patient is in the middle of it all. Everybody is talking about getting phone calls at night, talking to people at the gym, talking to families. So, how do you talk to a patient that, perhaps for the first time, is in your office to see what to do about diabetes? And say a lot of this is on you? I mean, don’t the patients say, “No, no, no, doctor. I’m paying you. It’s on you.”? How do you get them off of that?
Ralph DeFronzo, MD: I think Dr. Kushner made an important point earlier. Clearly, the patient has to be at the center of this. And if the patient doesn’t understand that what you’re doing today is going to make a difference 10 or 20 years now, you’re going to lose. I think the second most important part is the family. So, if the husband has diabetes and he comes home, and then the wife decides to cook things that really are detrimental, you lose. We now have over 500 kids in our pediatric diabetes clinic with type 2 diabetes. There it’s even more crucial that we have the family members involved. So, I agree with Pam, that it has to start with the patient. Then you need to have the family support, and then we need to have all of this other structure. And, quite frankly, we as physicians are usually too busy to spend a lot of time with the patients. As Dr. Miller said, the CDE—the nurse educator or whoever that person is, could be the physician assistant—is the other critical person who can sit with the patient and really find out what’s going on.
Peter L. Salgo, MD: Which brings us right back where we started on this whole question, which is the MD or the physician could be at the apex of this, but there’s a large body of help that needs to be integrated as we go further down the triangle. And that brings us to lifestyle modification, right? I mean, nobody wants to change their life. “Doctor, give me a pill, and I really want to eat that key lime pie.” That can’t happen, can it?
Jeffrey Miller, MD: Well, I guess we’re all human, and I always tell my patients anything in moderation is probably okay. Anything obviously extreme is not okay. And this is where I personally rely very heavily on the nutritionist to provide that necessary support, the knowledge of which I really personally do not have.
Peter L. Salgo, MD: I remember there was a patient who had a particular religious group with which she was affiliated and for whom eating together was a very important part of her life. And when she discovered she has hyperglycemic and had to back away from these communal meals, she was under a lot of pressure. There’s a lot of this out there, isn’t there?
Robert Busch, MD: Sure. A lot of people’s social lives is where they’re going to be eating, and it impacts greatly on them if everyone is eating whatever else and they’re on low-carb diets. And I know the lingo now is not diet and exercise; it’s healthy eating and physical activity. It takes some of the stigma away.
Peter L. Salgo, MD: Oh, it’s PC for the same thing, isn’t it? Come on.
Robert Busch, MD: It is, but how you’re approaching the patient, if it’s an individual thing with each patient, you know what the buzz words are of how you can get your message across.
Peter L. Salgo, MD: But without patient buy-in, nothing you’re going to do is going to do anything.
Pamela Kushner, MD: It took us a long time to figure that out, because for years, we’ve been having a paternalistic, materialistic approach to “You’ll do this, and if you don’t do this, that’s what’s going to happen.” And finally we figured out that doesn’t work. You need to have shared decision making, shared responsibility. And that is an important role that the clinician can play, to help that patient understand the importance of their role. And what I try to tell patients is I try to take the blame away, even though I was educated in a time when blaming was a good thing to do. I try to really give that patient some…Make that patient feel more empowered and say each day, each food, each meal, each choice you make gives you an opportunity to have a healthier day and perhaps a healthier future.
Peter L. Salgo, MD: Does that work?
Pamela Kushner, MD: It works very well because what it is, is it helps that patient not blame themselves, but plan ahead. I try to do what I can to empower that patient to work with other members of the team.