State of Diabetes Care in 2020 with Robert Busch, MD

Decades ago, a diagnosis of type 2 diabetes was life-altering, especially for older adults with comorbidities. Now, in the wake of rapid pharmaceutical and technological advances, diabetes management has become far less challenging and a much less daunting proposition for patients and clinicians, alike.

In the past 30 years, the management of diabetes has been transformed. What were once common complications have become rare for most patients and disease management is continuous instead of a visit-to-visit process. Much of this is due in part to technology in the form of continuous glucose monitors and other advances, but a great part is also thanks to advances in pharmacologic therapies many would have considered unimaginable not long ago.

With the approval of exenatide in 2005, GLP-1 receptor agonists (RA) began their ascent into treatment algorithms for diabetic patients. Over the next 15 years, trials like LEADER, HARMONY OUTCOMES, and SUSTAIN-6 illustrated the class’s ability to reduce major adverse cardiovascular events and, based on these results, it became obvious the class was useful beyond the spectrum of HbA1c control and weight loss.

Similar to GLP-1 RAs, SGLT2 inhibitors were once seen as an agent only used to manage HbA1c and promote weight loss. Few, if any, could have predicted what SGLT2 inhibitors have demonstrated in multiple clinical trials and dozens of sub-analyses in regard to renal and cardiovascular benefits. Through efforts of investigators and the results of trials such as EMPA-REG OUTCOME and DAPA-HF, perception of the class has been revolutionized.

While GLP-1 receptor agonists and SGLT2 inhibitors cemented their role in diabetes management in recent decades, new emphasis on LDL-C and triglyceride management have brought forth revelations related to different classes that have also added to the clinician’s armamentarium.

Initially approved as an adjunctive therapy for patients with hypertriglyceridemia, icosapent ethyl (Vascepa) saw its position in the management of diabetes and atherosclerotic cardiovascular disease (ASCVD) changed forever as a result of the REDUCE-IT trial. With an approval for reducing the risk of myocardial infarction, stroke, coronary revascularization, and unstable angina requiring hospitalization in adult patients with triglycerides levels of 150 mg/dL or greater in December 2019, icosapent ethyl’s place in treatment algorithms became even more obvious.

While many are still awaiting the results of its outcomes trial before drawing a firm conclusion on bempedoic acid (Nexletol), the potential of the lipid-lowering agent was recognized by the FDA in the form of an approval as an adjunctive therapy for patients with heterozygous familial hypercholesterolemia (HeFH) or ASCVD on maximally-tolerated statin therapy. Further adding to combination bempedoic acid/ezetimibe (Nexlizet) received approval for a similar indication less than a week later—making it the first non-statin, LDL-C lowering combination ever approved by the FDA.



For more on how the latest information related to these classes has impacted care of diabetes in real-world settings, HCPLive® invited Robert Busch, MD, practicing endocrinologist and director of clinical research with Albany Med’s Community Endocrine Group, to take part in an HCPLive House examining the state of diabetes care in 2020.