Management of Type 2 Diabetes Management-Medication

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DALE Initiative Podcast Transcripts! …

DALE Initiative Podcast Transcripts!

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  • 1. PODCAST TRANSCRIPT MANAGEMENT OF T2DM –MEDICATIONJoel Zonszein, MD, CDE, FACE, FACP: When we treat patients with type 2 diabetes, we treatall cardiovascular risk factors. We call it the A, B, C;A for Hemoglobin A1c, B for blood pressure,and C for cholesterol. Smoking cessation and lifestyle changes are important, even smallchanges for a healthier lifestyle with better diet, more exercise, are helpful. So treating diabetesis very complexWe have to check blood pressure, cholesterol, A1c, and microalbumin and we have to monitorthe weight. We have to be sure that the medications we use do not make something worsewhile treating something else;for instance we do not want to use medications that will causemore weight gain when the patient already is obese. We want to use antidiabeticmedicationsthat can have a favorableeffect on cholesterol in addition to the cholesterol medications. So,when we decide what medication to use in managing diabetes, we have to decide what will bethe best medication.I think in the last three or four years, we are having a lot ofcontroversy on how to best treatpatients with type 2 diabetes, mainly on how lowthe hemoglobin A1c needs to be. Therecommendations that we have at the American Diabetes Association is to lower the A1c to lessthan 7%; we know that patients who live with an A1c above 7% develop chronic complications.The patients need to know that they cannot live with an A1c higher than 7% because slowly,slowly they will continue to get more and more complications of both small and large vesseldisease. The American Association of Clinical Endocrinology and the European Association ofDiabetes recommend a hemoglobin A1c of 6.5%. In my books, I think that theserecommendations are generalized standards. We have to tailor the goal of the A1c and theblood pressure and the cholesterol to any given patient. So an A1c of 6.5% may be a little bithigh for some of my patients who are very young and very healthy and an A1c of 8% may be alittle bit too low for a patient who is elderly andis in the nursing home, etc.To individualize therapy is important in achieving the goal, but even more important isindividualization of medications for different patients. This is very critical because some patientsrespond very nicely to some medications and some patients do not respond. This is notprovided in the algorithms by the American Diabetes Association or by the AmericanAssociation of Clinical Endocrinology. They are really using a “one fits all approach” I reallyDeveloped in collaboration with the Center for Continuing Medical Education at Albert Einstein College of Medicine and Montefiore, and the American Academy of Nurse Practitioners, through a strategic educational facilitation by Medikly, LLC. Supported by an unrestricted educational grant from Lilly USA, LLC.
  • 2. think that there is a big difference in how to treat patients, andantidiabetic therapy needs to beindividualized.Metformin is a common drug in treating diabetes, a drug that does not cause significanthypoglycemia, and or weight gain, and is generic thus not expensive. We use metformin oftenin combination with other medications, but the truth is that we do not have any good data onhow to better use these medications and to what type of patients. I mentioned before that I usecombination therapy very, very early. I do not wait for the patient to be living with an A1c of 7 or8 or 9% for one or two years before I give combination therapy. I give combination therapyveryearly, but we do not havelong term outcome data using combination therapy. Unfortunately,the information we have has been provided by the drug companies in shorter term studies, sixmonths or a year, to find the efficacy of the drugs often in combination with metformin, but wedo not have long-term data and certainly not cardiovascular outcomes. The only long term drugtrial is the ADOPT trial comparing metformin, glyburide,and rosiglitazone during five years, tofind out efficacy as well as their side effects. So, obviously we need the same thing withcombination therapy, and finally after many years of me complaining, the NIH is finallysponsoring a study (the GRADE trial) using metformin with insulin, metformin with TZD,metformin with sulfonylurea, etc., as combination therapy long term.This study will be starting very, very soon, but we need more information on what are the bestmedications to what type of patients and what type of combination therapy to use. We do nothave that information and therefore physicians, when they look at the algorithms recommended,do not pay too much attention because they treat patients according to their needs and we donot always use the cheapest medications. Some patients may require insulin very early, somepatients who have been treated with insulin may do better with oral agents; insulin does notwork that well in patients who have dyslipidemia and are very insulin resistant. On the otherhand we know that when we give more and more pills, and there is no response, the patient isinsulin deficient. These patients needs to start a more aggressive therapy with insulin, oftenbasal-bolusregimen if they have very little beta cell function.We have to look at the patient very carefully and make an assessment on what would be thebest medication choice. Then, we have to sit down with the patient and share the differentoptions of what and why we are doing, and what goals we have. To formulate a treatment onlyfor blood sugar is complicated, but we also need to treat the LDL or the non-HDL cholesterol, tobring the blood pressure down.At the end of the day, I think what is important for the primary care physician is to know thattreatment needs to be individualized foreach patient, their age and comorbidities; sometimesyou havebecome more aggressive treating blood pressure or cholesterol than glycemic goals. IDeveloped in collaboration with the Center for Continuing Medical Education at Albert Einstein College of Medicine and Montefiore, and the American Academy of Nurse Practitioners, through a strategic educational facilitation by Medikly, LLC. Supported by an unrestricted educational grant from Lilly USA, LLC.
  • 3. certainly become very aggressive in blood sugar therapy very early in the disease when we donot have any complications, treating concomitantly the other cardiovascular risk factors.Developed in collaboration with the Center for Continuing Medical Education at Albert Einstein College of Medicine and Montefiore, and the American Academy of Nurse Practitioners, through a strategic educational facilitation by Medikly, LLC. Supported by an unrestricted educational grant from Lilly USA, LLC.