Friday, July 29, 2016
Individualized Diabetes Care: Not a 'Daunting Task'
Hello. My name is Chris Sorli. I am an endocrinologist and chair of the endocrinology department at Billings Clinic in Billings, Montana. It is a real pleasure to talk with you briefly today about a symposium that took place at the 76th sessions of the American Diabetes Association Scientific Meetings in New Orleans. The session's title was, "This Is How You Do It: Medication Options, Sequence, and Combinations for Optimal Management of Type 2 Diabetes." The symposium involved a number of speakers looking at how we add medications together to treat to appropriate treatment goals. We really wanted to focus on how our treatment paradigms are changing for the treatment of type 2 diabetes and incorporating our understanding of the disease and our new treatment modalities.
Patient-Centric Treatment Targets
We are evolving in terms of how we are treating type 2 diabetes. Protocol-driven strategies from just a decade ago have given way to patient-centric and individualized treatments and treatment targets for people with type 2 diabetes. When I say "individualized targets," I am really talking about picking the right target for the patient, with the caveat that you achieve those targets safely.
It sounds like a daunting task, but through our understanding of some of the pathophysiology, duration, and treatment of diabetes on a long-term basis, we actually have very good guidelines based on outcome data to suggest how you should individualize targets. Specifically, the American Diabetes Association has put forward a very nice graphical representation of individual physiologic and patient-centered aspects that one should incorporate.
This is not something that takes a long time. When I sit with a patient, it literally takes about 30 seconds to discuss some of their disease characteristics: their risk for hypoglycemia, how long they have had the disease, whether they have other important comorbidities that I should assess, their risk of weight gain, their motivation status.
The key is, not everybody's A1c goal is 7%. There are patients who very appropriately should have an A1c goal of 6.5% and others who should have an A1c goal of 8%. It is really up to us to spend that 30 seconds to identify that treatment goal. I recommend putting it in the patient's chart so that other healthcare providers and other people who see the patient will have a perspective and a rationale for why you are approaching treatment the way you do.
When we say to achieve individualized goals safely, we're looking for clinically tangible targets that we can hold on to: hypoglycemia and weight gain. For every patient you see, you should be thinking about what their risk for hypoglycemia is, and how much it should affect their choice of treatments. For other patients, what is the risk of weight gain? We consider weight gain to be an inconvenience, but it's really more than that. Weight gain in a patient at risk with lots of insulin resistance is more than just a few extra pounds. It can actually be affecting the overall morbidity and mortality of the patient.
In that setting, the symposium focused on some of the newer agents we have to treat type 2 diabetes: glucagon-like peptide 1 (GLP-1) receptor agonists, sodium-dependent glucose cotransporter 2 (SGLT2) inhibitors, and dipeptidyl peptidase 4 (DPP-4) inhibitors. We had a very nice discussion and excellent data presentation about our understanding of where those agents fit in the treatment paradigm.
For the patient very early in the disease with lots of insulin resistance, my treatment strategy is very different than for a patient who has had the disease for 30 years, has a high risk for hypoglycemia, and has lost most of their endogenous insulin supply. For that second patient, I am really still doing damage control. My glycemic targets should be less aggressive. I should be picking medications that minimize hypoglycemia, and I should be titrating insulin and other things to goals that are less aggressive. That is appropriate for that patient. This is really how we've approached diabetes for many years: treat to failure. We use one agent until it fails.
Treat-to-Prevent, Not Treat-to-Fail
I want to interact with the first patient earlier in the disease process that person who has only had diabetes for a few years and has lots of insulin and lots of insulin resistance. We are starting to see data from clinical trials suggesting that treatment should not be treat-to-failure, but potentially treat to modify the disease and talk about preventive medicine.
A consensus of the speakers at the symposium was that this is a complex disease, and that we are learning about the complexity. But successful treatment strategies that are ultimately going to lead to disease modification and prevention will likely need combination therapy with complementary mechanisms of action to address much of the pathophysiology that we know exists within type 2 patients.
Bottom line: It's very important to individualize treatment goals, and for many patients it is very appropriate to have A1c targets lower than 7% or 6.5% if you want to do disease modification and prevention. It's also very appropriate to have less aggressive targets in the patient population at highest risk.
Establish those goals, document those goals, and figure out strategies which are now available to achieve those goals safely because that can be done. That is really what patient-centric pathophysiologic-based therapy is.
Obviously, the more data we accumulate to confirm the combinations of these newer agents—their overall efficacy—and what patient populations we should use them in most appropriately still needs to be acquired. But it is not too early to begin thinking and using our clinical experience to help benefit long-term patient care at this time.
That is a summary of the take-home points from the symposium today. I hope it is somewhat helpful, and we look forward to discussing things with you in the future.
Christopher H. Sorli, MD