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.
Individualizing Goals
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
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