Optimal Management of Diabetes: Expert Nurse Practitioner Perspectives - Episode 7
Davida Kruger, MSN, APN-BC, BC-ADM: Here’s our challenge: You and I are steeped in the whole world of endocrinology. We live and breathe diabetes. I say that I know diabetes, hypertension, hyperlipidemia, and a little bit of thyroid. On some days, I don’t even know my kids’ names, but ask me anything about diabetes, and I gotcha. The truth is that I don’t see the patient who’s newly diagnosed with type 2 diabetes. I don’t see the patient who’s just on metformin. If you send me a patient who is on just metformin, I’d ask, “Why did you do that?”
The real question is that I always thought that a GLP1 receptor agonist was going to be a primary care drug. Fifteen or 18 years later, we’re still asking why it’s not a primary care drug. I know that part of it is because it’s an injectable agent, but the primary care physicians, nurse practitioners, and PAs [physician assistants] do great with basal insulin, so it’s not just that it’s a needle. It’s no longer because it’s the PAs, because most of the PAs are gone. Does it have adverse effects? Yes, it does. It has some adverse effects, but so does insulin. What are we going to do? Even though it’s supported by the guidelines [American Diabetes Association Standards of Medical Care in Diabetes], we know that the guidelines say that after metformin, give a GLP1 receptor agonist. How do we get it into the hands of the primary care world? What do you think are the educational gaps or the issues we’re dealing with?
Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: You are asking some tough questions because, as you said, these drugs have been around for a while. The only thing I can think of is timing. When metformin came to market in 1996, it still took a long time for a lot of clinicians to incorporate that because of the predecessor to metformin causing all those liver problems, and people were dying. With the lactic acidosis as well, they were hesitant to adopt it even though it had been used for decades in the UK [United Kingdom].
It’s timing. It’s 1 of the newer kids on the block even though it’s not new anymore. If primary care providers would realize that when you start a basal insulin, you’d better also be talking to the patient about hypoglycemia, its signs and symptoms, and blood glucose monitoring. The amount of work for us and for the patient, as well as the burden of disease, are exponential. It goes up so high.
With a GLP1 receptor agonist, it’s about whether it’s the injectable agent or the oral agent. We’ve got injectables that are once a week—not even once a day but once a week—and they don’t have to take it at a particular time. Even if they forget a day, there’s so much forgiveness with these long-acting GLP1 receptor agonists. Some of them give you a full 3 days, some are a full 5 days of grace period for getting back on track with no worry about hypoglycemia and no need to monitor blood sugars intensely. It’s the best-kept secret because if more primary care providers were using GLP1 receptor agonists, I wouldn’t get as many referrals. I don’t know.
Davida Kruger, MSN, APN-BC, BC-ADM: Except for when I look at these patients and say, “I’m happy to see you.” The truth is, they can be managed at a primary care level.
Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: Absolutely, and for longer without intensifying treatment if you can get them on these medications sooner.
Davida Kruger, MSN, APN-BC, BC-ADM: Exactly. Are there insights that we could share with primary care providers that might help increase their understanding? I listen to you and all this pathophysiology, and I then think that people want the down and dirty a lot. I love the brilliance and how it works, but I then think that, when I’m explaining it, I’ll sometimes just say, “It’s once a week. It doesn’t cause hypoglycemia. It has weight reduction instead of weight gain, and if you go low, go slow, you decrease the risk of nausea.” We talk about foods and have them see a dietitian. They don’t have to do blood glucose monitoring. Almost every GLP1 receptor agonist will get your patient to at least 1% or 2% lowering of the A1C [glycated hemoglobin].
Even if you look at some of those amazing data, if you have someone who has an A1C of 9.4%—and I was looking at that data today—that A1C could come down to as much as 1.8%, so that person is going to get to an A1C of less than 7%. If I have someone who’s got an A1C of 8.4%, they can still come down to an A1C of less than 7%. It’s almost as if you give the patient a once-a-week drug, a once-a-day drug, or whatever this is, even some of the twice-a-day drugs, and then they have an incredible amount of A1C lowering with weight reduction and cardiovascular benefit. What can we tell the primary care providers to say when you’re concerned about cardiovascular disease and diabetes? What are you looking for in A1C, blood pressure, and those kinds of things?
Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: It may be that they’re a little hesitant because of the information with the pancreatitis and the medullary thyroid carcinoma. These are the questions, and these are the things I get when I speak to primary care provider and try to find out why we are not using these medications. There is still a lot of misunderstanding and misinformation out there. It doesn’t help that the black box warning still exists on those boxes. Clinicians may not understand that medullary thyroid carcinoma is an extremely rare cancer, and we have not seen a direct correlation. For the pancreatitis, you’re prescribing DPP4 inhibitors, and if there really is a risk for pancreatitis, your patients shouldn’t be on DPP4 inhibitors either.
It’s a whole ball of wax of education, but show them the simplicity and efficacy and that it doesn’t burden their staff. They don’t have to worry about how this patient is doing with titrating up the dose of insulin and whether they are having low blood sugars or those kinds of things. This is a no-brainer. It’s so effective without the burden of work for the staff or the patient.
Davida Kruger, MSN, APN-BC, BC-ADM: Yes. The other thing is that it’s a rare patient who truly has needle phobia.
Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: Yes, true.
Davida Kruger, MSN, APN-BC, BC-ADM: In my career, I can probably count on 1 hand someone who truly has a needle phobia.
Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: You’ve had to get psychologists involved in those cases if these are patients who are truly needle phobic.
Davida Kruger, MSN, APN-BC, BC-ADM: Yes. If you think about the GLP1 receptor agonists that you can give once a week and how tiny and small the needles are, we usually have the patient take their first injection in the office. There are some who say that they don’t even see the needle. Every patient will say the same thing to me: “I didn’t realize it was going to be that comfortable. Why didn’t you have me do this sooner?” It goes on and on. We have to get past that, and I don’t think the needle is the issue.
Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: No.
Davida Kruger, MSN, APN-BC, BC-ADM: If it was, then we wouldn’t be using insulin in primary care. It’s getting them more comfortable, as you said, with understanding adverse effects. It’s not as if they don’t use other medications.
Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: That are more dangerous.
Davida Kruger, MSN, APN-BC, BC-ADM: Exactly. We need to focus on A1C lowering, more blood glucoses time and range, the weight reduction, the satiety, and the huge ones are the cardiovascular benefit and the lack of hypoglycemia. Those are the things that, if we can impart that and share that, then more people would understand. If you look at the data, I saw a study that had 10,000 patients. It was a record review with 10,000 patients who could qualify for a GLP1 receptor agonist, and only about 2% of them were actually on a GLP1 receptor agonist. I thought, “That’s horrible. That’s just horrible. We should be able to do better than that.”
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Transcript Edited for Clarity