Individualizing Treatment in Type 2 Diabetes Mellitus - Episode 5
Peter Salgo, MD: You mentioned you’ve got a palette of options out there, expanding by the second, as far as I can tell. And the poor primary care doctor has to keep up. What do you do about all that?
Vivian Fonseca, MD: You look at the pathophysiology and the treatments available. The first step is pretty easy—diet and exercise, plus metformin. Metformin has stood the test of time. It’s very affordable and it’s easy to get. Everyone has access to it. That’s relatively easy. The problem comes when metformin is no longer working as the patient’s disease has progressed, and that happens quite often, unfortunately. Then, you have to consider where the patient is at. There’s no point in choosing and adding on a therapy that lowers A1C by .5% if the patient’s A1C is 9.5%. You need to choose the appropriate therapy in terms of efficacy and in terms of risk. Do they have an erratic lifestyle? Are they, maybe, at risk of hypoglycemia? Are they living alone? Is cost an issue? Do they need to lose weight.? These are all considerations.
Carol Wysham, MD: Do they have heart disease? Do they have kidney disease? Yes, they all make a difference.
Vivian Fonseca, MD: Established heart disease. Risk of heart failure. Do they have kidney disease? All these things count.
Peter Salgo, MD: So why doesn’t somebody lay out, for us, a road map, if you will. What are, right now, the available non-insulin hypoglycemic agents?
Julio Rosenstock, MD: There are multiple options. In oral agents, you have sulfonylureas, you have glitazones, you have DPP-4 (dipeptidyl peptidase 4) inhibitors, and you have SGLT2s (sodium-glucose co-transporter-2s), and other little ones that are not worth mentioning. Those are the choices, but one thing is going to happen. In the end, formularies are going to decide. What is in the formulary? What has been approved in the system?
There has to be some priorities there. For sure, sulfonylurea is still being used because it is extremely inexpensive, despite the fact that it gives you weight gain and hypoglycemia. And over time, you lose control. DPP-4s are being used widely, but they are expensive. They are not very robust in reductions. We’ve seen that studied over time—you lose control. And then you have the SGLT2s, with the evidence that it reduces cardiovascular events in people with cardiovascular disease, reduces weight, and reduces blood pressure. Yes, we made a big change when we said “more aggressive lifestyle intervention plus metformin.” I see the day, very soon, when the recommendation is going to be that you start with a combination of metformin and SGLT2. Why to wait until metformin fails to add? You’re going to lose time. If I get diabetes, I will start with metformin and SGLT2.
Vivian Fonseca, MD: But you’re a rich man with good insurance.
Julio Rosenstock, MD: No, I’m a Medicare guy.
Vivian Fonseca, MD: My poor patients who are restricted by formulary are often forced to take a sulfonylurea. When I try to rationalize it, I think it’s OK, provided the they don’t get hypoglycemia. If they do, I stop it immediately. I talk to them about it when starting it. It’s very effective for a period of time.
Carol Wysham, MD: Vivian, I actually think that our patients, given the data that we’ve seen in the literature, would do better if we had cost as an issue—to go directly to basal insulin.
Vivian Fonseca, MD: Basal insulin requires a lot more testing.
Carol Wysham, MD: It does.
Vivian Fonseca, MD: And insulin has become quite expensive.
Carol Wysham, MD: Well, you can use NPH (isophane) insulin at Walmart. We know that if you put the sulfonylurea in that place for 2 years, by the time they’re ready for insulin, you have a harder time getting there. They have greater weight gain and greater risk for hypoglycemia.
Vivian Fonseca, MD: Going back to insulin though, insulin isn’t going away.
Julio Rosenstock, MD: I’m an insulin guy for many years, and I believe that insulin is there. There’s no more “natural” intervention than insulin itself. If you lack insulin, you replace insulin. One of the little things that we always have done with people who were newly diagnosed, when teaching them to prick their fingers to check the blood sugar, is that we tell the medical assistants to give them a little shot of saline in the belly. The patients will say, “The finger prick hurts more than the injection.” And we just tell them, “We’re not going to start that, but eventually, soon, we’re probably going to use insulin. We’re going to give you some time.” That stigma of the injection goes away.
Peter Salgo, MD: OK. But, again, we have noninsulin options. You’ve all been talking about the generics of this, but let’s get very specific. Tell me how you would sort of peel these layers off. Somebody is sitting in front of you and you want to start, perhaps, with a noninsulin option. How do you go about the decision-making process?
Vivian Fonseca, MD: I agree with Julio. If you have somebody who’s had a heart attack not long ago, is tired, maybe short of breath, and they have risk of heart failure, I would choose an SGLT2 inhibitor.
Robert Henry, MD: You wouldn’t pick a thiazolidinedione. I’m trying to give you some balance. There’s things that you’ll pick, and there’s things that you won’t pick.
Vivian Fonseca, MD: There may be an instance where you might pick a thiazolidinedione. The IRIS study showed that people who had a prior stroke had very good outcomes with this. In somebody has failed on metformin, and they’ve had a stroke, I would consider a thiazolidinedione provided there’s no contraindication. Again, you’ve got to go into appropriate indications and also contraindications of every one of these drugs.
Transcript edited for clarity.