Prescriber Treatment Considerations in Diabetes

Troy Trygstad, PharmD, MBA, PhD: What do you think are the most important factors, from a patient perspective, that you need to address in your clinical practices when addressing a patient’s diabetes needs? You have a new patient in your practice. You’ve done your assessment. What are the 2 or 3 most important things to address? Maybe not all of them are therapy related? Dhiren, do you want to go first?

Dhiren Patel, PharmD: For me, it would be determining what’s nice to know versus what they need to know. You’re talking to someone who just got this diagnosis. You’re going to establish a relationship rapport with this patient because it’s a lifelong disease. You don’t want to give them 15 handouts, and overwhelm them, whether it’s the medication list that they’re going to get or the readout of adverse events they’re going to get from their pharmacy, and all of the stuff that you’ve layered on top of that. So, I would say, tell them what they need to know now. Tell them that it’s going to be alright. 'We’re going to work together and we’re going to get things under control.' I tell my students, residents, and fellows that it’s never been a better time to have diabetes, if you’re dealt that hand. This is because of the innovation that you see, that we’ve talked about, and what’s in the pipeline, right? We have drugs that we can give for early, quick control, with all of these additional pleotropic effects, and benefits. But, again, it’s a relationship. The patient’s got to do their end—the lifestyle piece, and taking of the medications—and then you can help customize that regimen.

Troy Trygstad, PharmD, MBA, PhD: Yes. What you’re saying is: level set, simplify, address 1 or 2 things to start with, and that this is an ongoing relationship. This is lifestyle. This is….

Dhiren Patel, PharmD: We can work together, right? There are some things you could help with, on the immunization piece, and all of the other things, that don’t have to be done today. You can work with your entire team, and use everyone for their strengths.

Troy Trygstad, PharmD, MBA, PhD: And for you, Dr. Morales? So, you’ve got this new patient. We’re hearing 'level set,' because the first item might be the human response to, 'You have diabetes.' Now what?

Javier Morales, MD, FACP, FACE: I think it’s important to ascertain where you are, where you have to go, and how much baggage you are carrying. In patients who have diabetes, if you look at the most common presentation for diabetes, a lot of them actually present at tertiary institutions. They get admitted with heart failure or maybe a myocardial event. Then, 'Oh, by the way, you have diabetes.' It’s astounding. The second thing, in the outpatient setting, is the use of that hemoglobin A1C. Even though we’re using it more to screen for diabetes, you could still have diabetes if your hemoglobin A1C is less than 6.5. So, you have to look for other factors that could be a clue toward diabetes, whether it’s high triglycerides, low HDL, blood pressure elevation, increased waist circumference, or the typical metabolic syndrome patient. Maybe you should be doing 2-hour postprandials on these patients? That being said, if you do have that diagnosis of diabetes, how urgently do we need to have that blood glucose controlled? Obviously, we want to try to normalize the blood glucose as quickly as possible, without creating a dangerous situation like hypoglycemia. We’re now able to do that, with these agents that we currently have available.

Dhiren Patel, PharmD: Absolutely.

Javier Morales, MD, FACP, FACE: They’re all efficacious, and they’re all reasonably safe. Not only are they reasonably safe, but they’re beneficial in terms of cardiovascular outcomes.

Troy Trygstad, PharmD, MBA, PhD: When you’re making this assessment with the new SGLT2 therapies, how might that change your initial assessment? Who are the good or core candidates for this therapy?

Javier Morales, MD, FACP, FACE: I don’t think that there really is a wrong individual for an SGLT2 inhibitor, aside from those who may have renal insufficiency. If you do have significant reduction, then the drug is going to be less efficacious. If your renal function is unrestrictive, then all comers should use it. The question now becomes, what should be the first pharmacotherapeutic agent to initiate? Without question, metformin has a lot to offer. It’s got a proven track record. Unfortunately, it’s really not going to curtail the natural history of type 2 diabetes, which is progressive beta cell failure. As we saw in some landmark trials, like ADOPT, that A1C will go up as time goes on. Now, the question is, what’s going to be the next best agent to intensify therapy? Or should you use combination therapy from the beginning? This is something that I often consider in clinical practice, particularly in patients in whom I discover diabetes with a much higher hemoglobin A1C. So, I don’t really think there is a restriction in terms of the SGLT2 inhibitor. All comers, even in late-stage diabetes, can benefit from it.