Initiate Insulin, Titrate, and Switch

Too many patients who should be on insulin to control their type 2 diabetes aren't receiving therapy, delegates heard here at ENDO 2017.

People are suffering and needlessly gaining weight, said Carol Wysham, MD, from the Rockwood Center for Diabetes and Endocrinology in Spokane, Washington. "Patients may view the need for insulin as a failure, and doctors inadvertently feed that notion by trying to delay therapy for as long as possible, but this isn't a good idea," she said. "Insulin shouldn't be seen as evil."

Experts also weighed in on the costs and benefits of new versus old drugs at the meeting.

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New Options

Once basal insulin goals are met with aggressive titration, as needed, it is important to move on to something else, Dr Wysham told Medscape Medical News after her talk on initiating insulin, polypharmacy, and new therapies.

Medications can make it harder to lose weight, she pointed out. "Patients blame themselves, and that's really unfortunate because this doesn't have to happen with the modern options available."

Dr Wysham said she has seen dramatic improvements when she switches her patients from basal insulins to newer alternatives. "This has afforded not only improved glucose goals, but weight loss and less or no hypoglycemia."

Daniel Drucker, MD, from the University of Toronto, also spoke at the meeting about the benefits of newer drugs, which include lowering HbA_1c and reducing the need to monitor blood glucose levels. Certain drugs can also reduce the risk for nephropathy, stroke, and cardiovascular death, he noted.

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Costs and Benefits of New and Old Drugs

Medication costs have gone up faster for diabetes than for any other disease, including cancer, David Nathan, MD, from Massachusetts General Hospital in Boston, reported here at ENDO 2017.

During the 70 years after the introduction of insulin, only two other types of drugs were used to treat type 2 diabetes: sulfonylureas and biguanides (such as metformin). In the subsequent 20 years, four times as many classes of drugs became available, along with numerous combination products. But the benefits, Dr Nathan argued, are not worth the cost, especially considering the adverse effects associated with newer options.

But Dr Wysham told Medscape Medical News she disagrees. Many physicians mistakenly believe that established therapies are more effective at reducing HbA_1c, "but these older options tend to be tested on patients with high HbA_1c levels — of 9% to 10%. Modern studies evaluate lower HbA_1c levels — in the 8% range — so the reductions are very similar, if not stronger, with the newer medications," she explained.

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Carol Wysham, MD, from the Rockwood Center for Diabetes and Endocrinology in Spokane, Washington

Revolutionizing Diabetes Care

Diabetes drugs have come a long way in the 30 years Dr Wysham has practiced medicine. During her career, the first human insulin became available and "home glucose monitoring changed everything," she enthused. Although she never intended to treat diabetes for a living, Dr Wysham became mesmerized by classic general endocrinology, was drawn into the specialty, and has never looked back. "I've witnessed miraculous change," she reflected, as patients with risk factors once considered untreatable transition to appropriate glucose control. "And we continue to see improvements and advances."

Image courtesy of Carol Wysham, MD

For more information

Type 2 Diabetes Mellitus Practice Essentials

News coverage of ENDO 2017: The Endocrine Society Annual Meeting

Medscape Diabetes & Endocrinology

Endocrine Society

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