Evaluating the Diabetes-Cardiology Interface - Episode 2

T2DM Management: Endocrinologist or Local Physician?

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Paul Thompson, MD: Let’s talk a bit about the socioeconomic disparities, prevalence, and outcomes of diabetes. Certain ethnic groups are more vulnerable than others. Do you want to address that for us, Bob?

Robert Busch, MD: Almost all ethnic groups besides Caucasians are more vulnerable to diabetes. Asian Indians come to the United States and eat a Western diet, and they come prepackaged with insulin resistance, but they’re not obese. Their BMI [body mass index] doesn’t have to be 30 kg/m2 or 35 kg/m2 to get diabetes. They can be at 25 kg/m2 or 27 kg/m2 and have diabetes. As you know, they are at particularly high risk for coronary artery disease, even though they don’t have the look of a typical metabolic syndrome patient.

Paul Thompson, MD: That is a great point, and there are a lot of doctors out there who are of Indian origin. Remember that in your Indian patients. They can present with diabetes or prediabetes, and they don’t look like the typical Caucasian person with diabetes. They’re typically not obese, but they have prediabetes. That’s a great point. Talk to me a bit about when you think folks should be sent to an endocrinologist. I’m going to give you my bias. My bias is that all of us should be good enough to take care of most diabetes until it gets quite advanced. But you’re an endocrinologist, and I know you have to get the kids through college, so tell me when you think people should be referred to an endocrinologist.

Robert Busch, MD: I agree 100% with you. When I give any talk, I say, “This is diabetes. Do it yourself. No endocrinologist included. You don’t need us.” They have the same standard of care and the same drugs, and it usually takes 3 months to get into the local endocrinologist. As an endocrinologist, I’d rather be seeing thyroid disease and pheochromocytomas. My chief used to call it wax museum endocrinology. You go in the waiting room and say, “You’re hyperthyroid. You’re hypothyroid. You’re acromegalic. You’re cushingoid.” Diabetes pays the rent, and that’s what we end up doing.

Most endocrinologists didn’t go into endocrinology years ago because of diabetes. We had no drugs. Now we have a tantalizing array of drugs, and it’s fun to juggle them the right way. We play cardiologists. Just as you’re a cardiologist using diabetes drugs, we treat lipid disorders. We use PCSK9 inhibitors. We use Vascepa [icosapent ethyl]. We use the other drugs beyond statin therapy. We have statins in the drinking water, so our fields overlap. It’s not that I do the sugar and you do the lipids and blood pressure. We do both.

Paul Thompson, MD: You hit on some important points. One of the most important points you made is that it’s hard to get in to see the endocrinologist. One of my friends pointed out that only about 80 to 90 endocrinologists graduate out of training programs per year, so there is a shortage. Primary care doctors and cardiologists need to be able to manage diabetes. That’s why it’s important to listen.

The other thing is that the drugs we now have made it simple. They’ve made it easier to treat. 

We talked a bit about when primary care physicians and cardiologists should refer. It seems you’re saying that primary care doctors and primary care cardiologists need to be at least running through this gamut of potential drugs before sending patients to an endocrinologist. What’s your take-home message about going to an endocrinologist?

Robert Busch, MD: You’re definitely right. Also, if you’re treating a patient with diabetes and they have any kind of ASCVD [atherosclerotic cardiovascular disease] background, stop. You must give a drug that has cardiac benefit—either an SGLT2 inhibitor, a GLP1 receptor agonist, or both. Because you mentioned the weight loss, they have weight loss by different mechanisms. With the GLP1 agonists, you eat less. With the others, you’re urinating out calories, so the weight loss is additive. They also have combined efficacy for A1C [glycated hemoglobin], but additive efficacy for weight loss. These are the drugs that our cardiology and primary care colleagues use all the time. If they refer to an endocrinologist, the patient is going to come back with a GLP1 receptor agonist—probably a weekly GLP1 agonist—an SGLT2 inhibitor, and metformin tapered down. Goodbye, insulin. Goodbye, sulfonylurea. Goodbye, DPP4 inhibitors. That’s how they’ll come back to you, even if they come in on metformin, sulfonylurea, DPP4, and basal insulin.

Transcript Edited for Clarity