Individualizing Treatment in Type 2 Diabetes

MODERATOR

Peter L. Salgo, MD

Professor of Medicine and Anesthesiology Columbia University College of Physicians and Surgeons
Associate Director of Surgical Intensive Care

New York-Presbyterian Hospital New York, New York

PANELISTS

Vivian Fonseca, MD

Professor of Medicine and Pharmacology Tullis-Tulane Alumni Chair in Diabetes Chief for the Section of Endocrinology Tulane University Health Sciences Center New Orleans, Louisiana

Robert R. Henry, MD

Professor of Medicine
Director, Center for Metabolic Research University of California, San Diego
San Diego, California

Julio Rosenstock, MD

Director, Dallas Diabetes Research Center
Clinical Professor of Medicine University of Texas Southwestern Medical Center at Dallas

Dallas, Texas

Carol H. Wysham, MD

Clinical Professor of Medicine University of Washington Endocrinologist
Rockwood Center for Diabetes and Endocrinology

Spokane, Washington

Sulfonylureas have been a mainstay of treatment for patients with type 2 diabetes for more than 50 years,1 and are still widely used now to manage this chronic illness. However, patients with diabetes often have comorbidities that necessitate a more individual approach to treatment than a decades-old standard of care. There are now more than 10 classes of medications available from which physicians can choose to create a treatment regimen that targets an individual patient’s diabetes, making the management of this illness the latest form of personalized medicine.

MD Magazine® Peer Exchange® recently hosted an esteemed panel led by moderator Peter Salgo, MD, of Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital in which the topic of discussion was taking the personalized approach in type 2 diabetes management. As the panel opened, the physicians quickly came to agreement that the goal was no longer to simply “get the sugar down and keep it down.” Now, it depends on what “down” means.

“TOO DOWN”

“‘Too down’ is bad for you, so you need to choose the right thing for the right person, depending on whether they’ve just been diagnosed or had it [diabetes] a long time,” said Vivian Fonseca, MD. “You’ve really got to personalize it, and we have tremendous choices today. The science is strong. We need the art of medicine to choose the right medicine for the right person.”

Julio Rosenstock, MD, agreed, saying, “One of the good things that, now, practitioners have is the ability to measure [hemoglobin] A1C, which is much easier to help diagnose diabetes. If, routinely, people are going to measure A1C—let’s say, every 6 months or every year—and it’s about 6.5%, then that makes the diagnosis ‘diabetes.’ The point is to be more aggressive and intervene at the beginning when the diagnosis is made so we can get whatever target we’re going to have. If the patient is somebody who has cardiovascular disease, has comorbidities, has some medical issues, then we’re not going to be that aggressive in getting the A1C down below 7%.”

The panelists discussed how personalizing treatment for patients with diabetes comes down to personalizing their goals for their A1C levels, taking into consideration other factors such as their risk factors for cardiovascular disease; the possible side effects of treatment, such as hypoglycemia; other health factors, such as their age and remaining expected life expectancy; and whether there are any other existing complications to take into account.

“Some of us are not far away from 78 years old, so let’s look at it in terms of life expectancy. You could have a very fit, healthy 78-year-old, who tolerates 1 or 2 medications very well without any side effects and is looking forward to living to 100 years old,” Fonseca pointed out. “You need to personalize the goals as well. The goal that we choose on A1C is to prevent complications. If you’ve got no complications, then a goal of 6% or 6.5% is appropriate. If you already have all of the complications that are irreversible, and you’re at risk for side effects, then a higher goal—maybe closer to 7.5% to 8%—would be better.

“If I have a 78-year-old person with diabetes and some cardiovascular disease, I would be satisfied with an A1C between 7% and 7.5%.” Rosenstock replied.

“That is exactly the point that I think needs to get out there,” Carol Wysham, MD, concurred. “If I have a 78-year-old patient with an A1C of 6.5% and they want to take metformin at that point, and if they want to test their blood sugars at that point, that’s very appropriate. But I’m going to counsel them. They’ll get education. We’ll monitor them. To try to get a 78-year-old down below 6% is not giving them any benefit.”

TARGETED SCREENING

During the next topic of the exchange, the panelists focused on screening guidelines and the rising prevalence of prediabetes, which is an A1C level between 5.7% and 6.4%.2 According to the latest data from the CDC,3 from 2014, 29.1 million Americans have diabetes, which means their A1C level would test at or above 6.5% on 2 consecutive blood tests; however, 1 in 4 of these people haven’t had this test and are unaware of the danger they are in. The question posed to the panel, regardless of the approach to personalized medicine, given the rising numbers of prediabetes and diabetes, should the entire US population be screened? Should everyone have a periodic A1C test?

“I think the American Diabetes Association has pretty good guidelines,” Wysham said. “You look at the patient’s family history, their age, their ethnicity, and if they don’t have any high-risk characteristics, they should be screened starting at the age of 45.”

“Targeted screening—not everybody, but people who are at risk. You can identify risk based on simple clinical things,” Fonseca said.

“But that is a little controversial,” Rosenstock countered. “Even the American Diabetes Association doesn’t have a specific policy in terms of massive screening. Now, with the advent of the A1C, where people check lipids, why don’t you check an A1C level?”

In terms of preventing people with prediabetes from developing diabetes, management of that risk factor alone is important, yet it doesn’t mean that everyone in the warning area will go on to tip into the danger area.

“Well, prediabetes is a risk factor, but of people who develop prediabetes, only about 30% to 40% are going to go on to get diabetes,” Robert Henry, MD, said. “We can’t go treating 100% of the population for 40%...What we need to do is do a better job of defining who is going to get it.” ■

REFERENCES

1. Sola D, Rossi L, Schianca GPC, et al. Sulfonylureas and their use in clinical practice. Arch Med Sci. 2015;11(4):840-848. doi: 10.5114/aoms.2015.53304.


2. American Diabetes Association website. http://www.diabetes.org/are-you-at-risk/ prediabetes/?loc=atrisk-slabnav. Accessed May 1, 2017.


3. CDC website. https://www.cdc.gov/features/diabetesfactsheet/. Accessed May 1, 2017.