A New Strategy for Diabetes Care? Insights from the ADA Conference

I arrived at the convention hall about noon today. The American Diabetes Association (ADA) meeting like none other is vibrant, teeming with enthusiasm and interest. Even at the registration desk there is a cacophony of foreign languages and unfamiliar garb. I’m always struck by how many of the younger people present seem to be from Europe and Asia. Perhaps this speaks to the fact that we are training fewer endocrinologists and primary care physicians here in the United States.

I arrived in time to hear Dr John Buse (University of North Carolina Medical School) speak on incretin therapies. This class of treatment is clearly catching on. The fact that incretins (DPP-4 inhibitors and GLP-1 receptor agonists) work without causing hypoglycemia is certainly attractive and the added benefit of weight loss with the GLP-1 receptor agonists make these drugs equally valuable, alone or as add-on therapy to insulin.

The highlight of my Friday was a lecture by Dr Lawrence Phillips (Emory University School of Medicine) on early combination therapy. He reviewed “step therapy,” the sequential addition of treatment when the A1C is not controlled. He contrasted that with what he calls “pattern care” where one works on reducing fasting glucose and also controlling postprandial glucose levels to less than 130 mg/dL. This strategy will often lead to use of metformin alone or with bedtime glipizide (with or without a basal analog insulin like glargine or detemir to reduce fasting glucose) while adding a DPP-4 inhibitor or GLP-1 receptor agonist (with or without a TZD or rapid-acting analog insulin) at the largest meal of the day to control postprandial glucose. This strategy makes a lot of sense to me. You are actually fixing everything that is broken all at once. He showed very instructive anecdotal patient data demonstrating excellent control that is remarkably durable.

Maybe we should think about not just treating the whole patient but also the whole problem. I like his ideas.

For me tomorrow is the session titled “Diabetes Is Primary.” We expect about 200 primary care providers to attend and hear some of the best speakers ever on topics of diabetes care in the primary care setting.