Multidisciplinary Team Approach in Type 2 Diabetes
APRIL 19, 2017
MD Magazine Staff
Robert A. Gabbay, MD, PhD: Type 2 diabetes is a complex disease, and it really requires a team effort in order to manage it. It’s more than just blood glucose control, which is clearly very important, but the other cardiometabolic risk factors necessitate other specialists to be brought in as needed. Cardiologists play a key role in terms of cardiovascular disease, which is the leading cause of death for people with diabetes. Kidney specialists can manage complications related to renal disease. Also involved are ophthalmologists, diabetes educators, as well as dietitians. A team effort is really required to be able to manage the disease. And most importantly, it’s the role of the primary care physician who brings that whole team together under the medical home.
Scott Solomon, MD: We, as cardiologists, take care of a lot of patients who have diabetes and other metabolic diseases. In fact, if you have diabetes, you have about twice the risk of an adverse outcome if you have heart failure or if you’re following a myocardial infarction. And so, we need to engage other clinicians, endocrinologists, and primary care physicians in the care of these patients. I don’t generally prescribe antidiabetic medications myself, for example, but I like to know what’s happening to my patients who are taking antidiabetic medications, including insulin. I like to work with the clinicians that are also treating them, such as endocrinologists, diabetologists, and nutritionists even, or other care providers (not just physicians), who are involved in managing these patients who have metabolic risk.
I have a lot of patients who are obese. Obesity is obviously an incredible risk factor in patients with heart disease, in general. Many of my patients will say, “I’ve tried to lose weight and I don’t know how.” So, we refer them to nutrition. But I think it’s incredibly important that cardiologists have the resources, too, around them, such as the other clinicians who can help them take care of these patients in a holistic way.
Patients with diabetes and patients, even, who have prediabetes, who are predisposed to diabetes, are at markedly increased risk for cardiovascular disease. This includes myocardial infarction and it includes heart failure. In fact, we see a lot of patients who develop the syndrome of heart failure with preserved ejection fraction who have diabetes. They may have a little renal disease. It’s impossible to take care of their heart alone. And so, we really have to think about the entire patient.
Managing their glucose, again, is not something that I do as a cardiologist, but if I knew that a patient of mine had glucoses that were out of control, I would want to treat them differently. These patients almost always had elevated cholesterol, so they need to be on good lipid management. Generally, that involves the use of statins. If their low-density lipoprotein doesn’t go low enough, we can use drugs like ezetimibe, as well. And, of course, there’s excitement these days with the PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors for patients who either have very severe hypercholesterolemia or are truly statin intolerant. And then, we can consider other options.
Transcript edited for clarity.