Put the Patient First in Managing Hyperglycemia

Anne L. Peters, MD


December 08, 2022

This transcript has been edited for clarity.

The American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) consensus report on the management of hyperglycemia in people with type 2 diabetes was recently released. I'm not going to review the whole report today, but I encourage you to read it. Today, I'm going to talk about what it means for my patients who are treated in an underresourced setting in East Los Angeles.

First, it's important to note that this report's title still says "management of hyperglycemia." We know now we have many drugs that were created to treat type 2 diabetes that do much more than treat hyperglycemia, including the glucagon-like peptide 1 (GLP-1) receptor agonists and the sodium-glucose cotransporter 2 (SGLT2) inhibitors.

When you're writing these algorithms, it becomes very hard because different people with different risk factors need different agents. It's a real problem, because those agents are more expensive than the generic agents we've had around for a long time. There are many underresourced settings where those drugs aren't on the formulary and we can't afford them yet, or we can only afford them for a smaller subset.

When we look at the glucose-lowering medication category on the overall figure for managing hyperglycemia, it's very non-proscriptive. It says to look at the patient and try to choose the best agent for glucose lowering. I can't argue with that, but I can say it doesn't really help my providers who work in a setting where they can't necessarily choose among all the agents.

What I think is really important is as follows. Throughout the guidelines, they talk about putting the person with diabetes at the center of care. I couldn't agree more, because that person may or may not be someone like me. These are people who may live in very different settings. They may have many issues involved with the social determinants of health. They may have food insecurity. They may live in a place where they can't exercise. They may have worries about losing their job, becoming homeless, or dealing with sick family members.

There are many things that exist in our patients' lives that we need to understand. I think part one is understanding your patient. If you start discussing using a drug like a GLP-1 receptor agonist that's completely unaffordable, it's actually not doing your patient any service. I think we can do good for our patients, even with very limited resources.

When you look at Figure 4 in the guidelines, it's called a holistic person-centered approach. In the very middle, there is a person, and around that person are blue boxes that represent all these social determinants of health and concerns that we really need to think about when treating a patient with type 2 diabetes. Around that is a circle that goes into whether a person has preexisting cardiovascular disease and/or chronic kidney disease (CKD) or heart failure.

Then, in my world, there is a very small portion talking about the standard treatment we have for patients. That standard treatment is composed of generic medications that really help.

When we have a patient with type 2 diabetes, starting a statin is an easy first step in terms of lowering cardiovascular disease risk. Many patients are not started on statins who need to be on statins. Step one should be to start a statin.

Step two is to measure blood pressure. Again, this is a low-cost way to treat our patients. There are many good generic drugs for lowering blood pressure. By giving a statin and treating blood pressure, we can actually prevent cardiac and renal disease. I think we need to remember that those first basic steps are as important as anything else we can do later. Frankly, later means that someone already has complications.

In terms of glucose lowering, metformin works. It's been well tested. We've had it since 1957, and we're very used to it. It doesn't cause hypoglycemia or weight gain. It's not going to cause weight loss, which is a goal in our patients, but it does help control glucose.

As for next steps, you can use a sulfonylurea agent. In the GRADE study, they worked. It may not be as good as a GLP-1 receptor agonist, but the differences weren't huge. Yes, sulfonylurea agents can cause hypoglycemia and some weight gain, so I tend to use them at a lower dose. I also educate the patient as to potential side effects, but I can get many patients down to a reasonable A1c.

More important than anything is not to let therapeutic inertia sink in. That's a problem in all our patients. You need to really be on top of the patient, look at their A1c, add a new therapy when they're just a little bit above their target, and get them down below their target with each new step.

Now, if that doesn't work, I can add in pioglitazone because it's generic, although I don't tend to use higher doses because I'm concerned about some of its side effects. I can add in neutral protamine Hagedorn (NPH) insulin if I need to get someone down, at least in terms of just having them on bedtime insulin.

Again, you need to educate the patient, discuss the risk for hypoglycemia and targets, and work with the patient to achieve these goals and to continue to keep them at these goals, because you really want to be sure patients are followed over time.

That gets me to the concern about access. One of the problems I see over and over again is the patient who lost access to healthcare, who then falls off their medications, and who ends up coming back years later with terrible complications. I think finding ways in communities to promote and help people with access to healthcare is really important.

It is also important to educate patients that they need to really work to find access insofar as they're capable, because they need to be on those medications we just mentioned. I do think we need to work with health plans and with whatever your safety net providers are to see if it's possible to get some of these newer drugs on the formulary.

In LA County, we've been able to get SGLT2 inhibitors and GLP-1 receptor agonists on the formulary for people who have high-risk characteristics. I'm very proud of that, because now I know I can use the drugs that I need to simply get patients under control and add to their therapy newer agents once complications develop.

I want to say that I really commend the work the committee did looking at all the options and looking at the best scientific data we have for treating patients. Don't ever forget that it is your patient who matters most. Our patients may need a social worker, someone just to listen to them, or all sorts of help dealing with the social determinants of health, which impact how they live. If you don't do that, you're never going to get them even on the basic treatments that we now have available.

Work with your patients. Remember who they are. I am optimistic that I can make a big difference in terms of managing their diabetes and cardiovascular risk, and help them avoid developing the complications of diabetes and to hopefully live a longer and healthier life.

Thank you.

Anne L. Peters, MD, is a professor of medicine at the University of Southern California (USC) Keck School of Medicine and director of the USC clinical diabetes programs. She has published more than 200 articles, reviews, and abstracts, and three books, on diabetes, and has been an investigator for more than 40 research studies. She has spoken internationally at over 400 programs and serves on many committees of several professional organizations.

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