Type 2 Diabetes: Improving Care in the Community

MARCH 24, 2017
MD Magazine Staff

Peter Salgo, MD: We’ve had a tremendous discussion. This is, from the point of view of somebody who doesn’t treat diabetes as an outpatient physician, exciting stuff. Before we leave, I want to ask each of you to give one last thought about diabetes, about these agents, to share with our audience?

Vivian Fonseca, MD: I’m excited to have a toolbox with so many tools in it, that allows me to choose the right one for the right person along the lines that we’ve discussed today.

Robert Henry, MD: My suggestion is to not be afraid to treat. Treat not only to glucose targets, but the blood pressure and lipid targets as well. We’ve gotten such a wealth of wonderful medications that can be targeted to that patient’s specific problems. So, personalized medicines have come, and I would just encourage physicians to be aggressive about going after people with diabetes, and again, helping that patient to comply with their disorder.

Peter Salgo, MD: Dr Rosenstock?

Julio Rosenstock, MD: I fully agree with the personalized medicine. But, I think more importantly, we need to focus on personalized targets. To define, very clearly with the patient, what the personalized target is. And for whatever the target is, I’m going to choose the right tools to get to that target. I’m going to ask the patient—respect the patient’s wishes, for sure. But, in the end, I’m going to give you the “Rosenstock treatment” for the future, in looking at the crystal ball once we have evidence about it. I think that 90% of people with type 2 diabetes will be well treated with 1 pill/1 shot, and I would start everybody with metformin and an SGLT2 (sodium-glucose co-transporter-2). And when that is not enough, I will use an injectable that is a combination of basal insulin and GLP-1 (glucagon-like peptide 1). You start with metformin and an SGLT2 (1 pill), because you have a fixed combination that you can give in 1 tablet and then 1 shot. I cannot think of any reason to use insulin alone when we know that gives you weight gain and it gives you hypoglycemia. And I cannot think of any reason why to use a GLP-1 that gives you a lot of gastrointestinal side effects. With that, it doesn’t. So, 1 pill/1 shot will treat 90% of people with type 2 diabetes.

Peter Salgo, MD: I know you’ve been sitting here expectedly. This is your shot. You get the last, last word. Dr Wysham?

Carol Wysham, MD: I agree with Julio’s last comment. I also want to express the importance of primary providers out there getting familiar with these new drugs. They are very effective. Patients really appreciate the impact that they have on their blood sugars, but also on their weight. And that’s very motivating for them to continue their weight-loss efforts. I take care of lots of patients who come in from other primary providers, and when I talk to them, they say, “I don’t know enough about those drugs, I don’t feel comfortable using them.” I feel like they could expand their abilities. Patients would be so much more satisfied.

Peter Salgo, MD: I want to thank you for a tremendous discussion. From my personal perspective, I see diabetics coming in as outpatients all the time to the operating room. We have diabetics in the intensive care unit. It’s a complicated disease, but it’s not so complicated that you can’t figure it out with the help of people like these 4 that we had on our panel today. Again, I want to thank you for joining us, all 4 of you. Thank you, of course, for joining us as well. I’m Dr Peter Salgo. We’ll see you next time.

Transcript edited for clarity.

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