The Collaborative Management of T2DM



Paul Thompson, MD: What about the collaboration between cardiologists, endocrinologists, primary care doctors, and nutritionists? How do you manage that? For example, you’re an endocrinologist. You can clearly change the drugs, and the primary care doctor is not going to be upset. What are your thoughts about cardiologists doing that? Do you have an opinion about it?

Robert Busch, MD: The fear that some cardiologists have is that they’re going to cause hypoglycemia. First of all, if they’re not on insulin or sulfonylurea, they’re not going to have hypoglycemia, so that’s a nonissue. You can’t get the sugar very good, as you were mentioning before, if they’re not on insulin or sulfonylurea.

I would welcome my cardiologists doing that, but in my area, and we have a lot of cardiologists here, I have never seen a patient come to me on an SGLT2 [sodium-glucose co-transporter 2] inhibitor or GLP1 [glucagon-like peptide 1] agonist. More importantly, I don’t even see it suggested in the note. You are very well versed on treatment of heart failure with reduced ejection fraction and prevention of heart failure in the DECLARE trial with dapagliflozin. I don’t know why they don’t use it a lot more. These drugs are very safe. It may be because they don’t know the dose of Diflucan [fluconazole] to treat the yeast infection. With SGLT2 inhibitors, you have to talk to the patient about how they’re going to urinate a lot the next week. You ask what they like to drink. You want them to drink something without calories. Do they have yeast infections? Is the man uncircumcised, so he can get a yeast infection? It takes a little time to discuss that with the patient. Once you’re comfortable with it, these are your drugs, as well as mine. It’s like saying, “I’m not going to use a statin because you can get muscle aches, and I might have to look at your liver test once in a while.”

Paul Thompson, MD: That’s a very important point, though, to make sure patients understand. Some patients will not want to use SGLT2 inhibitors because of the risk of genital yeast infections. As for the point about being circumcised or uncircumcised, I remember how upset my nurse was the first time I started asking patients about that, but it’s a very important point to make sure that people keep themselves very clean in that area. That’s the biggest drawback.

Robert Busch, MD: That’s exactly right.

Paul Thompson, MD: It’s a big concern to many of us. Your point is extremely well taken. These drugs can be used without a great deal of worry, as long as patients are not on sulfonylurea or insulin. These are smart drugs. GLP1 agonists are smart drugs. They’re not going to go beyond what you want that sugar to be. I try to seek hemoglobin A1C levels under 6%, frankly. You can get them without causing trouble. People lose weight and they feel better.

Transcript Edited for Clarity

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