The Future of T2DM Management



Robert Busch, MD: Coming attractions in our field include what’s called a GLP1/GIP [glucagon-like peptide 1/glucose-dependent insulinotropic polypeptide]. Eli Lilly and Co has 1, and the other companies are developing them. They have more weight loss benefit than the current GLP1 agonists, and they’re doing cardiovascular trials. There will be higher doses of some of the drugs that will facilitate more weight loss. It will be more than the usual 5% to 10%. Maybe you’ll have 15% to 20% weight loss with a once-weekly injection. That will be coming out down the line. Since you mentioned heart failure with preserved ejection fraction, the data for SGLT2 [sodium-glucose co-transporter 2] inhibitors in patients with preserved ejection fraction will be out. We already have them for reduced ejection fraction. That’s when cardiologists will take over our field, because they’re not going to let that pass. They might let HFrEF [heart failure with reduced injection fraction] pass, but we don’t have a lot of treatments for HFpEF [heart failure with preserved injection fraction], from what I’ve understood. Is that correct? I don’t know, what are the other treatments for heart failure with preserved ejection fraction?

Paul Thompson, MD: We treat them like they have heart failure. That’s it. We just want to make them asymptomatic as best we can, but we don’t have a strategy to treat those patients.

Robert Busch, MD: One thing you mentioned before about preventing diabetes in the prediabetic was shown in the heart failure with reduced ejection fraction study with dapagliflozin, an SGLT2 inhibitor. When they treated nondiabetics, they had benefit, as well. Silvio Inzucchi, MD, showed that those patients were less likely to progress to diabetes. He used it in the prediabetic. It’s not in the drug’s label, but you and I as clinicians can do what is appropriate for the patient. I’ve used SGLT2 inhibitors in prediabetics, particularly if they have heart failure, to treat the heart failure. By the way, I’m probably preventing your diabetes.

If I told my chief of endocrinology 30 years ago that I’d have a pill that could lower weight, blood pressure, A1C [glycated hemoglobin], prevent heart failure, treat heart failure, and prevent kidney disease with no hypoglycemia, they would fire me for fantasizing. SGLT2 inhibitors do all of that in a pill. GLP1 agonists complement that with their cardiac benefit and weight loss. We have extraordinary drugs. They should be used by all of our medical colleagues, not just by the endocrinologists.

Paul Thompson, MD: Do you think metformin is on its way out, or will it still have a strong role?

Robert Busch, MD: Last week, metformin wasn’t doing well with the generic that was carcinogenic. Because it’s inexpensive with a little weight loss and no hypoglycemia, it is the no. 1 drug we prescribe. That would be like you being told that atorvastatin has a carcinogen in it. That’s not every metformin, but with the other drugs having heart benefits, more weight loss, and more outcome data, metformin won’t end up being in the front line down the line.

Paul Thompson, MD: The big seller is the amount of weight loss that patients get. People who come in with type 2 diabetes tend to be obese. They’ve been trying to lose weight. It’s hard to do it when you have insulin resistance, and then you’re putting them on a drug in which they can lose weight.

Robert Busch, MD: Yes, thanks. You covered the gamut.

Paul Thompson, MD: We covered the gamut. You’re a great speaker. I want to thank everyone for joining us on this HCPLive® presentation discussing the interface between cardiology and endocrinology with respect to insulin resistance and diabetes. I want to thank Dr Busch for a very insightful discussion, and I want to thank the audience for joining us. I hope you found it useful and informative.

Transcript Edited for Clarity

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