Treatment Approaches for Type 2 Diabetes

Jennifer B. Green, MD: There’s recently been a tremendous evolution in guidelines for the care of diabetes. One of the areas of greatest emphasis within the last 5 years has been the goal of individualization or personalization of the care that we deliver. And it’s not just treatment targets per se. It’s not just what your hemoglobin A1C [glycated hemoglobin] target is, but more of a comprehensive and global approach. Would you mind sharing with us the factors or key considerations that you have in mind when you’re customizing or reassessing the care plan for a patient with type 2 diabetes?

Dennis Bruemmer, MD, PhD: Absolutely. It’s very important for us physicians to define a treatment plan for a patient with diabetes that works for the patient. There’s no use in prescribing medications if a patient doesn’t want to use an injectable, if costs are prohibitive, or if formulary restrictions are present in insurance coverage. We certainly need to modify therapy according to the patient needs. Mostly from the glycemic target trials, we have begun to learn very well that we need to individualize care for patients with respect to hemoglobin A1C testing. When we talk about the former view of A1C-centric care for patients with diabetes, those trials we were trying to obtain a hemoglobin A1C level of 6.5%, which is closer to normal. From those trials, we learned that there are risk factors that actually increase mortality in patients under intensive care therapy protocols.

When I discuss this with patients or colleagues, it’s first important to note that when we discuss goals of care, and particularly the hemoglobin A1C goal, it’s important to recognize that 30% of patients with diabetes in the United States actually have a hemoglobin A1C of above 9%, and 10% of patients with diabetes in the United States don’t get hemoglobin A1C testing at all. That’s already 40% of patients who are not close to the clinical trial data.

Whether it’s the American Association of Clinical Endocrinology pushing an A1C goal of 6.5%, or the ADA [American Diabetes Association] 7%, in practicality and daily care of patients, this discussion becomes obsolete because we’re dealing with patients who come in with myocardial infarction [MI]. They’ve never been diagnosed. Seventy percent of patients coming in with an MI today actually have diabetes or prediabetes, and half of them don’t even know it. If I have a 20-year-old patient with type 1 diabetes, it will matter whether the hemoglobin A1C is 6.5%, 7%, or 7.5%. That will likely make a difference because the exposure time to hyperglycemia is very different from when we have an 80-year-old gentleman who comes in with newly diagnosed diabetes and their hemoglobin A1C is 7.2%. I’m certainly not going to try insulin on a patient like that. So individualizing care is absolutely key.

At the same time, this makes care so challenging and difficult, because we, as physicians, like algorithms that are easy and transplantable to other care systems, to midlevel providers, etc, to provide broad access of care. But at the same time, diabetes falls into a specific category of management that requires substantial individualization, particularly looking at comorbidities, like if the patient has severe coronary disease and had CABG [coronary artery bypass graft] just now, or heart failure, or CKD [chronic kidney disease], requiring different treatment steps and algorithms than a younger patient with prediabetes, for example. Individualized care is very important.

Jennifer B. Green, MD: I agree. A couple of good examples that I often see would be the importance of reassessing the care regimen on a regular basis. Many people live with diabetes for decades, and what may have been an appropriate regimen for someone when they were first diagnosed may not be a good fit for that individual 25 years later. For example, I tend to see a lot of older individuals who are treating their diabetes with an intensive insulin regimen because that’s what they have always been on. In part, it’s because they could handle it when they were 20 years younger, and it was the best available treatment in the past, and their care has not caught up with what we presently have to offer in the way of antihyperglycemic therapies.

What I spend a lot of time doing, and I hope I’m doing successfully, is looking for opportunities to simplify and make care easier for my patients, particularly as they age and become a bit less able to handle a complex regimen, and may be depending on others for the delivery or administration, or even reminders for them to take their medications on a regular basis. It’s helpful to look for opportunities to choose medications that are given less often, perhaps even weekly.

I also agree with you about being realistic about glycemic targets. It can make everybody feel bad if we decide that everybody needs an A1C below 7% or 6.5%. It’s frustrating for both patients and diabetes care providers alike to have that line drawn in the sand. If I’m seeing patients who’ve traditionally had an A1C of about 10%, we need to choose even psychologically manageable goals, like, “My goal for you is to get your A1C down below 9%.” That’s something that may be far more realistically achievable and will be clinically important with respect to how the patient probably feels and what their impact on risk of complications or progression of complications will be. But remember to be realistic and make sure that we’re setting goals in care that are stepwise and realistically achievable. I completely agree with that.

Thank you, Dr Bruemmer. And I’d like to thank everyone for watching this HCPLive® Peers & Perspectives. If you enjoyed the content, please subscribe to the e-newsletters to receive upcoming Peers & Perspectives and other great content right in your inbox. Thank you very much.

Transcript edited for clarity.