Lifestyle is the Cornerstone of Treating Patients with Type 2 Diabetes; Medication Helps

Susan Cornell, PharmD, CDCES, FAPhA, FADCES, AssociateDirector of Experiential Education, Midwestern University, College of Pharmacy, Illinois, gets candid with Pharmacy Times at the APhA Meeting & Exposition about rising cases of type 2 diabetes, obesity, and accessibility to beneficial lifestyle factors and medications.

PT Staff: Can you highlight some of the major updates to the Standards of Medical Care in Diabetes- how will it impact of medication management for diabetes and comorbidities care?

Susan Cornell, PharmD, CDCES, FAPhA, FADCES: So I'm really excited about the changes with the guidelines this year because I've been predicting this for gosh, I'm going to say at least 5, if not 7 years. But finally, and I will say this very happily, Metformin is no longer first-line therapy. Now I know folks are probably going, “Whoa, what is she talking about? Why is she happy about that?” Metformin, a good drug in its time (and just like the rest of its us) it's getting older. And you know, it's time for retirement. SoMetformin is now approaching its retirement age. And not to say that it's retiring from managing diabetes and letting the “New Kids on the Block” step up, but it's moving on and it has a side gig post-retirement. So it's not going away, but it's no longer in the spotlight. What we're looking at is, again, many people have more than diabetes. So we have to, when we're working with people with diabetes, we have to look beyond just sugar— we need to look at obesity; we need to look at cardiovascular disease, and kidney disease, and liver. There’s a big uptick in nonalcoholic fatty liver (NAFL) [and] the obesity rates are going through the roof. So I think one of the biggest things is we have to address all of these conditions at 1 time. So the short-acting glucagon-like peptide 1 (GLP-1) receptor agonists, the sodium-glucose co-transporter 2 (SGLT2) inhibitors, are really coming to the forefront as first-line therapy, either by themselves or in combination together. So I think that's where we're going to see big changes coming down the pipeline, because we're treating more than just sugar.

PT Staff: In what ways is diabetes driven by health inequities?

Susan Cornell, PharmD, CDCES, FAPhA, FADCES: Great question. You know, there's so much there's so many people that struggle with diabetes to begin with, [and] struggle with access to care. I work in an underserved community clinic; I work with people that don't have insurance, or they're underinsured, and they struggle. And sometimes they just don't even have access to a doctor. And with the fact that we have a shortage of primary care providers, getting an appointment with a provider can be 3, 4, 6 months. And that's a lot of wasted time. So this is where I do believe pharmacists can really step up to the plate to help people to better manage their diabetes, not only in the terms of medication, but also in lifestyle. And if we think about it, lifestyle is really a lot of management of diabetes— it's 90% of managing diabetes and drugs are always added to lifestyle. So drugs are not replacing lifestyle, they're added to lifestyle. But let's think about this. Some people live in neighborhoods where it's not safe to go out walking. So how do we expect someone in a bad neighborhood, or you know, an unsafe neighborhood to get out? And exercise? You know, there are food deserts, there's food insecurity, there's housing insecurity. So again, we must learn how to do, as I like to say—we have to learn to do the wrong thing the right way. And this is where working with the person individualizing, what they need, and recognizing it's not a 1 size fits all.

PT Staff: What are some of the worst culprits of health inequities and how do they impact rising diagnoses of diabetes in the United States?

Susan Cornell, PharmD, CDCES, FAPhA, FADCES: Yeah, we have here we have the best medications, we have the best technology. But if we can't get it into the hands of the person with diabetes, it's useless. And I think that's the biggest thing is affordability. People want don't even know about half of these medications or devices. There's a lot of misinformation again, about lifestyle, and we have to get the right information to the people. So I think that is 1 of the biggest misconceptions out there, probably the biggest reason for the rise in diabetes. And it's projected continued rise is the obesity factor. And let's just talk about that for a second. So before COVID-19, 42% of the United States was obese. I'm going to say that again because it's really impactful. 42% of the United States is obese. I'm not talking overweight, I'm talking obese. We don't have post COVID-19 data. It'll be very interesting to see what those numbers are. Another interesting point is new data that just came out looks at people with type one diabetes. You know, historically, we always looked at people with type 1 being thin people with type 2 being overweight or obese. Now, it doesn't matter. Two-thirds of people with type one diabetes are overweight or obese. So that's 66% of people with type 1 have an obesity or overweight problem. So we're going to start to see not only lifestyle impact, but we're going to start to see medications common leaves are type 2, but have weight loss abilities, they're going to be used in type one. The other thing we're seeing is younger people are being diagnosed with obesity, we must recognize obesity as a disease, and we have to treat it. If we don't treat the obesity, we're not going to get control of the diabetes. So the diabetes, the obesity, the cardiovascular all goes hand in hand. And we really need to address all 3 of those, as well as kidney disease and liver disease. So all 5 of those at 1 time.

PT Staff: How do the guidelines suggest remediating/treating patients with diabetes?

Susan Cornell, PharmD, CDCES, FAPhA, FADCES: Well, and once again, lifestyle is still the cornerstone; medication helps. So we can expect medication to replace lifestyle. And [that’s] the reason we see people take medications, and then they stop and then go back to old habits. That's where the weight gain comes in. The guidelines actually focus on the patient, and what comorbid conditions this patient has. So when we look at the guidelines today, as I mentioned, again, Metformin is no longer first-line, we look at: Does the person have cardiovascular disease? Do they have kidney disease? Do they have heart failure? And in those cases, definitely GLP-1’s or SGLT2’s. However, we can look (and say) Okay. Maybe the person doesn't have cardiovascular risk—which I find impossible in anyone with diabetes, but side note—but then we have to look at obesity. And when we look at obesity, the GLP-1 antagonists really come to the forefront because many of them are also recognized with an obesity indication. So that's where we're going to see these newer drugs, double-dipping for lack of a better term, in not only helping lowering blood glucose but lowering weigh while simultaneously protecting the heart. And that's where we have a win-win. So again, I think the newer drugs are really going to take the forefront. We're going to anticipate a concern because they know finally these drugs are really being used, which they should have been all along. But we're finally starting to see they're getting their time in the spotlight. And now there's a shortage of many of these medications. So you know, that is something that has been worked on and hopefully it will be remedied in the very, very near future.