COMMENTARY

What I Want for Christmas (Next Year)

Diabetes Expert Highlights Wishes for the Coming Year

Anne L. Peters, MD

Disclosures

December 23, 2015

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Usually around this time of year, I do a video that's basically a review of all that's happened in the prior year. But this year, I decided to do something a bit different. Instead of reviewing 2015, I'm going to talk about what I'd like to see happen in 2016. So, this is my wish list. It's not a set of predictions per se, but it covers what I'd like to see happen in diabetes care in the next year, and what I hope you all can help me accomplish.

SGLT-2 Inhibitors: Validation of Benefits and Wider Adoption

First off, I will say that one remarkable study, the EMPA-REG trial, changed how I look at the treatment of type 2 diabetes. As a reminder, EMPA-REG was the cardiovascular outcomes trial that looked at empagliflozin compared with placebo and showed a big difference, both in terms of cardiovascular mortality, overall mortality, and hospitalization for congestive heart failure. This was truly the first study that showed a diabetes drug can reduce macrovascular complications.

What I'd like is to see EMPA-REG more translated into our practice in the year going forward, and there are a variety of ways in which I'd like to see this happen.

First, in my dream world, I'd like to see that the effect is true—that this cardiovascular benefit was true for all of the sodium/glucose cotransporter 2 (SGLT-2) inhibitors, for canagliflozin and dapagliflozin as well. Now, we're not going to get those cardiovascular outcomes trial results until 2017 and 2019, but I hope next year we see a lot of activity in terms of understanding the benefit of SGLT-2 inhibitors in terms of macrovascular disease modification. And I'm really hoping that we see an improvement in their use, meaning that more clinicians are choosing to use SGLT-2 inhibitors—and, for the moment in particular, empagliflozin—in these high-risk patients with diabetes and known cardiovascular disease.

That brings me to the concept of guidelines for the treatment of type 2 diabetes. I've been working on these guidelines for a number of years, and one of my frustrations is that we can't make them simple, because we know that in different circumstances we have different formularies. Also, patients have different individual needs.

We have a variety of choices that we make when we treat an individual patient. Everybody agrees that metformin is the single best starting drug for treating type 2 diabetes, but when you go to the second-line step, what do you choose? Again, on the basis of EMPA-REG, I certainly hope that more and more of us choose to use empagliflozin, an SGLT-2 inhibitor, as our second step when we're treating patients who have known cardiovascular disease.

It disturbs me to think that it is an equally acceptable second step to use a sulfonylurea agent in these high-risk patients, because we know that sulfonylurea agents can increase the risk for hypoglycemia, and that hypoglycemia—severe hypoglycemia—increases the risk for mortality in these patients with type 2 diabetes. Now, I'm not opposed to sulfonylurea agents per se, but they have enough side effects, and we have more really effective agents—in particular the SGLT-2 class, but the others as well—that are beneficial and perhaps have more than just a benefit in terms of glycemia.

Better Patient Access to Drugs and Devices

This brings me to the notion of using insulin in the treatment of diabetes. I use insulin often in the treatment of my patients, whether it's for patients with type 1 or type 2 diabetes, and I use lots of insulin analogues. In the past couple of years, we've seen a marked increase in the insulin analogues that are available for treating our patients, and I think that's great. But a real problem is that insulin seems to cost more and more, and in many cases, it becomes cost-prohibitive for our patients. So even though I enjoy having access to these analogues, for patients who can't afford them, I would hope that 2016 shows us the way to having lower cost-effective analogues, perhaps in terms of biosimilar insulins.

Another pet peeve that I would love to see changed, though I doubt will ever change, is how many prior authorizations we have to do in order to get patients medications that they need. I understand about controlling costs; I really do. I want to control costs, but I also want to make it easier for our patients to have access to some of the treatments that I think would be beneficial.

I also want to see it become easier to get devices for my patients, and this particularly includes continuous glucose monitoring. I don't think I should need to prove that patients are having episodes of severe hypoglycemia in order to get them a tool that could help them not have severe hypoglycemia. For my type 1 patients in particular, the piece of mind that comes from continuous glucose monitoring is pretty amazing, and peace of mind with a disease that's as difficult to treat as type 1 diabetes is really worth a lot.

I also use continuous glucose monitoring frequently in my patients with type 2 diabetes. I don't use it all the time, but intermittently in order to look and see what's happening with their glycemic profile. It helps guide me in terms of advancing insulin therapy; it helps guide me in terms of starting a next step. I use it episodically very frequently, and I would love to see that covered.

Finally, I would love to see us make headway in terms of coverage for continuous glucose monitoring in older patients. Medicare and other plans, such as Medi-Cal, have been reluctant to cover these continuous monitors in older and poorer patients; I firmly believe that these patients deserve this technology, and we deserve to be able to use it in our patients.

Clarification on Individualized Hypertension Targets

In 2016, I would love to finally understand blood pressure targets for my patients. I know that the reason they keep changing is because there are new data coming in from large trials—most recently the SPRINT trial, which was in individuals without diabetes. But I think there are data from both ACCORD and ACCORDION that may actually tip us more in terms of tightening the blood pressure targets in our patients, rather than making them looser, which is what we've done recently.

So, I would really like for somebody in 2016 to help me understand the data and to help me individualize blood pressure targets in my patients, just like I individualize blood glucose targets. I don't find it hard to think about the glucose target for any given patient, but I often have difficulty in determining really what is the best blood pressure target for my patient, because I believe that appropriate control of hypertension can lead to a significant improvement in macrovascular outcomes.

A New Drug Combo

In 2016, I'm really hoping that IDegLira is approved. The combination of insulin and a glucagon-like peptide 1 (GLP-1) receptor agonist is phenomenal. You see really great improvements in A1cs, and I would like to be able to use this in my patients in the upcoming year.

Improved Diabetes Management for All

My final wish is in the realm of public health. In 2015, we had some pretty good news: Rates of obesity are leveling off, and the increase in diabetes rate is also leveling off, and I think that's great. The problem is that's not true in everyone.

In my Beverly Hills practice, where patients are more educated, wealthier, and more often Caucasian, those are the patients who are seeing a lot of this benefit. In the area that I work the other part of the time—in East Los Angeles, where my patients are poor or less well-educated, and are Latino or African American—these rates aren't changing nearly as much.

So in 2016, I'd love to see a broader public health effort to really help these communities where need is greatest. I'd like to see better payment and reimbursement for such tools as the Diabetes Prevention Program (DPP). I'd like to see it reimbursed in the Medicare population. I'd like to really see improvements in terms of diabetes and obesity prevention, where it counts the most.

In summary, I'd like to see us more able to apply some of the benefits and tricks we've learned in our higher socioeconomic populations, and apply them across the socioeconomic spectrum so that all patients from all walks of life have the same access to these preventive health measures.

Have a happy 2016, and I hope both you and your patients stay healthy and well.

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