Treating Type 2 Diabetes: Looking Ahead - Episode 7
The benefits of using new therapies, such as SGLT2 inhibitors and GLP-1 receptor agonists, to treat type 2 diabetes.
Davida Kruger, NP: One of the things that the standards do say, which is totally different than anything we’ve had in years is that we don’t care what the A1C [hemoglobin A1C] is. If your patient is at cardiovascular disease risk, start the medication after metformin. The beauty of the SGLT2 [sodium-glucose transport protein 2] inhibitors and the GLP-1 [glucagon-like peptide-1] is they work when the blood sugars are elevated, especially at the GLP-1s. They have this magic component that I still don’t understand. That when the blood sugars are elevated, they work; when the blood sugar is normalized, they turn themselves off. Neither of these medications, since they only work when blood sugars are elevated, cause hypoglycemia in of themselves. The things that patients hate the most, hypoglycemia and weight gain. And the beauty of these medications is they also provide weight reduction. You’re going to see somewhere between 5 to 8 pound weight reduction with your SGLT2 inhibitors and upwards to 14 pounds with your GLP-1 receptor agonist. With no hypoglycemia unless you have another medication, such as a sulfonylurea, which on these patients you should not be using. Or insulin, we can talk a little bit about that. But in of themselves and weight reduction. And not only are you giving cardiovascular benefit, you’re giving A1C lowering if needed, but there’s so many remarkable things to start these medications. We don’t care if the A1C is 7.2, if they have a cardiovascular risk, you’re going to give them a GLP-1, or if they have heart failure, think about an SGLT2 inhibitor. And of course, if they have kidney disease, you’re going to give them an SGLT2 inhibitor as well. They have some remarkable benefits. And that’s the other reason why. And the A1C lowering, again, depending on the doses, depends on where you start with A1C. If you have an A1C of 9% or 10%, many of these drugs will bring the A1C down to 7%. If not, you can then back load it with insulin or something else if you’re not going to get that patient treatment goal. But they have everything possible for our patients.
Margo B. Minissian, PhD, ACNP: They do. Their pleiotropic is really—at the end of the day. And I love the highlight of the weight reduction. That’s probably helped to drive, number 1, when you lose 5 to 10 pounds, that’s usually a half a pill to a full blood pressure pill reduction in what they’re having to potentially take. That’s powerful. That weight loss is significant. And we also know that it helps to reduce their overall inflammatory load.
Davida Kruger, NP: Exactly. And all of these things are just phenomenal in what we can offer people with diabetes. Insulin is not the bad guy for our patients, because many of the patients are still going to need insulin. But we do urge providers to use the newer insulins. Some of the longer acting insulins—stay away from the NPH [Neutral protamine Hagedorn] if you can—but use some of the longer acting insulins that do last 24 to 36 hours. They have less peak, less hypoglycemia. And if you are adding an SGLT2 inhibitor or a GLP-1 to insulin, or you bring insulin on, you want to be careful of low blood sugar. If I have a patient who I have on basal insulin and I’m going to add an SGLT2 inhibitor, what I typically do is lower the insulin when I start by at least 20%, look at blood sugars before I titrate the GLP-1 or the SGLT2 inhibitor. And if I can continue to lower the insulin—sometimes if the patient’s only been on 20 units of basal insulin—I can get them off insulin, which I think in of itself is pretty great.
Margo B. Minissian, PhD, ACNP: That’s exactly right. In preparation of our discussion today, I love PubMed, you can hop in there and just get yourself updated so quickly. As well as on UpToDate, which is also so helpful. But there was a recent paper that came out in Metabolism: Clinical and Experimental. That just came out at the end of October. That was a very comprehensive, systematic review on basal weekly insulin, and how it’s the wave of the future starting it early. And it’s all about adherence. For those of us that are spearheading all this chronic disease management, it’s more of the same language. Which is get started early, teach the adherence piece and why it’s so important. And oftentimes we can avoid a lot of this and organ damage that we oftentimes will see if these things aren’t started early enough.
Davida Kruger, NP: The takeaway message here is being as aggressive as we can with people who have type 2 diabetes [T2DM] and there is a reason to use the new therapies. Make sure they’re on statins, check their blood pressure. And then when you move into the diabetes medications utilize the newer medications. And the truth is every insurance company, Medicare, Medicaid, any commercial will provide both SGLT2 inhibitors and GLP-1. We need to urge people to use them instead of siphon areas. I understand there are places for siphons areas when there’s an insurance issue or cost issue, but mostly they cause hypoglycemia and weight gain, and they’re just nasty. And if we can avoid them, that would be really good.
Transcript edited for clarity.