Optimizing Care for Patients With Diabetes

Troy Trygstad, PharmD, MBA, PhD: What is the most exciting trial, and what are some of the new therapies, on the horizon, that keep you glued to your computer screen?

Dhiren Patel, PharmD: We talked a lot about type 2 diabetes. The focus was on that patient population, which affects almost 95% of the folks that we’re dealing with. But, I think when we’re talking about type 1 diabetes, we need to consider this class that we just talked about—these SGLT2 inhibitors. SGLT2 inhibitors actually show a lot of promise in type 1 diabetes, and there have been a couple of dedicated trials that have looked at that. One of the companies has submitted for a filing in Europe. So, we’re looking to see a couple of submissions this year, specifically for type 1 diabetes. We don’t have any oral medications for that community. I think that’s going to be a big win, to be able to now have some other additional innovation and tools that the type 1 diabetes community can also benefit from.

Javier Morales, MD, FACP, FACE: When it comes to the type 1 diabetic community, I think that the more recent publications did show significant benefit in patients with type 1 diabetes. One thing that we do need to consider, though, is the safety of the SGLT2 inhibitor class in patients who might be insulinopenic. These are the patients who are going to be at greater risk for developing ketoacidosis. So, when we are looking at using this class of drugs in patients with type 1 diabetes, it’s important to recognize that these patients don’t make any insulin. The goal is actually to reduce the insulin needs but not eliminate it, and to take into consideration that patients with type 1 diabetes are also gaining weight. So, it’s also going to be beneficial in terms of containing some of the weight gain with intensification. Nonetheless, these recent publications certainly showed promise, again, as adjunctive therapy to insulin.

Dhiren Patel, PharmD: Yes, and I think that language will probably be very bold, and centered when the FDA does approve these drugs. Again, to be clear, none of them have that indication right now. Regarding the ketoacidosis—that’s something that we can counsel on, and prevent. We just need to be a little bit mindful of that patient who you think is not going to be using their insulin—they’re not going to be adherent, or there are pump failures, or alcohol. There are some high-risk areas where we know we can counsel, and prevent some of that. I’m sure we’ll see some language, front and center, when that comes.

Troy Trygstad, PharmD, MBA, PhD: Tripp, I’m going to put you on the hot seat. When I think about exciting horizons and exciting developments, I keep hearing about 2000 drugs in the pipeline, or 2000 gene therapies in the pipeline. Do you have any general thoughts? We’ve got all of these gene therapies in the pipeline. We’ve got exciting SGLT2 inhibitors, and new therapies coming with diabetes. Even if we end up with a perfect gene therapy, or perfect drugs, are we still going to end up with problems?

Tripp Logan, PharmD: I’m going to spin that, a little bit, because you’re actually asking a question on what I wanted to say. We just circled the wagon, so to speak, with all of our pharmacists, and students in the last month, about our approach, going forward. A lot of it has to do with that very thing. For the patients that we see, their therapies are often not maximized. Their regimens are not optimized. From a retail pharmacist’s standpoint, this sounds counterproductive. But our mission over the next year, or 18 months, is to try to take some of these really, really complex patients, and optimize their regimens, and actually get them off some of these medications. You see this carry over from year to year to year on a lot of them. Pharmacogenomics is one way that we can do that, and we’re putting that in our program. Weight loss is something that we’re going to consider. The Diabetes Prevention Program will allow us to bill for some of that, which covers some of the cost. So, we’re putting our package together right now. This is something that the pharmacists who are on staff at our organization really believe in, even to the point of functional medicine. There are nutrient components, too, that we don’t always think about when we’re taking care of these patients. You look at access to high-quality food. In a place like where I live, it’s almost impossible to find affordable high-quality food. So, we need to just focus on education, on how you can do that, and how it’s not so scary. We’ve got some wonderful testimonials, and case studies where this has been done in our practice by our pharmacists. You change people’s lives, just by redirecting them on how they access food. So, that’s what I’m excited about. I’m excited that all of these options are out there. Somebody’s on 10 medications. Do they really need to be on 10? Or, do they really need to be on those 7 or 8 that are most important? We can help with lifestyle modification. In the community, we’ve got enough touch points where we can keep reinforcing that over, and over, and over. Plus, there are more, and more tools available for us to do this, as well, whether it be through the use of mobile apps, or just by picking up the phone, or by bringing people into the pharmacy for educational opportunities, and giveaways—whatever you do to get them in there. There are a lot of ways to touch these patients who we really are trying to impact.

Troy Trygstad, PharmD, MBA, PhD: Well, that’s an excellent closing thought. Do you have any final thoughts, Dhiren, before we leave?

Dhiren Patel, PharmD: No. It takes a village to take care of folks with diabetes. And so, you need to take advantage of all of your resources, and all of the folks who can provide the touch points. If we could have solved diabetes just with endocrinologists, we wouldn’t be in this situation; or if we could just do it with primary care doctors. And so, it requires all folks, all the way down from the community health worker to that specialist, because there are just so many things that are involved with it.

Troy Trygstad, PharmD, MBA, PhD: So, we have a newly minted resident who is fresh out of residency. What would you, as a seasoned clinical practitioner, in closing, provide to them, with respect to diabetes? Where are we going? What do they need to be thinking about as they set out for the next 30 years?

Javier Morales, MD, FACP, FACE: I think that they need to be welcoming of change—paradigm shifts, avoiding inertia, because that’s also another problem that we really didn’t touch upon, and appropriate intensification. It’s also important to convey, to this young resident, or new clinician, that collaborative efforts, not just pharmacologically through the use of combination therapies and so forth, but also on a personal level, with the use of multiple specialties, are really needed, in order to get our patients to their ascribed targets and goals. And also, keep reading. Learn about these new products that are out there, that are going to be beneficial, and ultimately lead to a good outcome.

Troy Trygstad, PharmD, MBA, PhD: Well, this was a wonderful discussion. Thanks for your contributions. On behalf of our panel, we thank you for joining us, and we hope you found this Peer Exchange® discussion to be useful and informative. We’ll see you next time.