Type 2 Diabetes: Considerations for Initial Treatment

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Counseling patients on lifestyle and diet modifications is something that is very near and dear to me. As with any chronic condition, I think when patients can implement lifestyle changes, that’s probably the best starting point and something that should be sustained. I like to term it as “behavior change” because a lot of folks will, when we talk about diet modifications, automatically assume that they’re going to go on a diet, and there are some things that they can’t eat, and, by definition, that might be something that’s temporary. And so, what I try to talk to them about is regarding lifestyle and behavior changes. Patients will always ask, “What’s the best diet that I can go on to help with this?” I tell them, “There is no best diet. It’s whatever is going to work for you.”

The biggest thing that I tell patients is to make very, very, very small changes. Do not do anything drastic. If you decide that you’re going to cut out X, Y, and Z foods, the minute that happens is when you’re probably going to start craving it, and then you’re probably going to start eating more of it. Do whatever you can that’s very small and measured, and set goals that are what we call “smart goals.” Those are specific, measurable, attainable, realistic, and time bound, so that even when making those changes, you have a framework to help you get to those goals.

Javier Morales, MD: Lifestyle modification is actually very important when it comes to managing type 2 diabetes. It’s the cornerstone of type 2 diabetes. In fact, those patients who were more intensively managed with lifestyle management had a reduction in their hemoglobin A1C of about 0.6%. However, lifestyle modification is not always the answer, because type 2 diabetes is a disorder of progressive beta-cell failure. If no medical contraindication exists, then the appropriate initial pharmacotherapeutic agent to start would be metformin.

However, we’ve learned from several large-scale trials—1 of them was the United Kingdom Prospective Diabetes Study, another was a multinational 5-year trial called the ADOPT study—that even management with metformin is short-lived, as it probably offers not much with respect to the preservation of beta-cell function. As such, if you’re on metformin and after 3 months your hemoglobin A1C is not at your proscribed target, then intensification may need to be exercised.

Metformin is the cornerstone of therapy from a pharmacologic standpoint for the management of type 2 diabetes. It is advocated that hemoglobin A1C be checked every 3 months, and the appropriate intensification needs to be exercised if your hemoglobin A1C is not at the target level that you wish your patient to be at. According to the American Diabetes Association, the A1C target is a value of less than 7%. The American Association of Clinical Endocrinologists recommends a value of less than or equal to 6.5%.

Which agent to add to intensify therapy will need to be decided on an individual basis. Not everyone is created equally; therefore, not every diabetic patient should be treated equally. In fact, hemoglobin A1C targets can vary depending on which comorbidities you have. If you’re sick—maybe you have cancer, maybe you have heart disease or prior stroke, or maybe your life expectancy is limited—then perhaps a more relaxed hemoglobin A1C target would be more appropriate. However, if you’re younger and you have minimal comorbidities, a tighter glycemic target seems to be the more appropriate way to practice medicine.

When we look at which agents are available to intensify the management of type 2 diabetes, some agents actually increase the risk of gaining weight with intensification. Some medications may actually increase the risk of having a low blood sugar reaction or a hypoglycemic event. However, there are other agents that could be utilized that may impart a weight benefit, and a low risk of hypoglycemia. Furthermore, it’s come to light that cardiovascular risk needs to be taken into consideration, and that may also influence your decision process for which agent to appropriately implement—that add-on therapy to metformin.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: When talking to patients when medication or therapy is being advanced—if the patient is on 1 medication, another medication might be added to that regimen—it’s important to tell them why the second medication is being added and, in certain cases, why multiple medication might be required to treat the same condition. What I see a lot, and what I hear about a lot, is that we started a medication for diabetes, and then the patient automatically just assumes that the first medication they were on is no longer working or is something that they don’t need to take, and they’ll automatically stop taking it. Sometimes, I’ll tell patients with diabetes and high blood pressure, “This medication works in this manner, and this medication works in this manner. Between the both of them, we’re going to have them team up, and work on different areas of your body in lowering your blood pressure or in lowering your blood sugar.” It’s really important for them to realize that for some medications, the desire is to be taken in combination, because there’s benefit when those 2 medications are taken together versus just 1 medication alone.