Type 2 Diabetes: Treating the Whole Patient

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The MD Magazine Peer Exchange "Improving Management of Type 2 Diabetes Mellitus" features a panel of physician experts discussing current best practices to treating and managing patients with T2DM that generally includes lifestyle modifications as well as medication. The mechanisms of action, patient selection criteria, and side effects for various oral medication classes are included in the discussion.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

The panelists are:

• Robert Busch, MD, director of clinical research in the Community Endocrine Group at Albany Medical Faculty Practice in Albany, NY
• Ralph DeFronzo, MD, professor of medicine and chief of the diabetes division at the University of Texas Health Science Center in San Antonio, TX
• Pamela Kushner, MD, clinical professor at UC Irvine Medical Center and director of Kushner Wellness at UC Irvine Medical Center in Los Alamitos, CA
• Jeffrey Miller, MD, professor of medicine and clinical director of the Division of Endocrinology and Diabetes at Jefferson Medical School in Philadelphia, PA

Peter L. Salgo, MD: Let me then morph a little bit here because weight, of course, is a critical factor here. And we’re looking at elements in diabetes control beyond glycemic control. It’s what you were talking about, right? Working with the whole patient, not just the blood sugar, not just the A1C. What are the factors you look at, and how do you bring the whole patient into this?

Pamela Kushner, MD: I’ll start with weight loss, because I thought you did a good job mentioning how that fits in, Jeff. And when I’m choosing a medication, why would I not choose a medication where that patient may have some weight loss, knowing that the Heart Association Guidelines says 10% weight loss is a big benefit, 5% also. So, if I can choose a medicine that has that, that’s a good choice. I try to avoid hypoglycemia, I take into account having a history of having managed an osteoporosis diagnostic center—and bone management is an important part for me. And I’ll remind the audience that when people have bariatric surgery, read the small print in terms of vitamin D supplementation and calcium.

Ralph DeFronzo, MD: Keep your vitamin D on board and your calcium.

Pamela Kushner, MD: That’s right. So, definitely bone management is an issue, renal management is an issue, and gastrointestinal issues. And then, definitely, also taking into consideration probably the most important issue, which is cardiovascular comorbidities, thinking about blood pressure management. Does the patient have congestive heart failure? Does that patient already have evidence of atherosclerosis? Trying to maximize medications that will help me manage as many things as possible.

Jeffrey Miller, MD: And one thing we haven’t mentioned obviously is smoking.

Peter L. Salgo, MD: There’s a perfect ground for intervention. But there again, I mean, you have an octet here. I don’t even know how many issues are involved with smoking, but that’s tough, right? We can get into that again later, but of all the patients in our cardiothoracic ICU who come in with vascular issues and heart disease, a huge number are diabetic. And don’t these two things almost play with each other? They’re synergistic. Having diabetics with cardiovascular issues is bad, but not worse than each individually.

Robert Busch, MD: But we can still be aggressive with non-hypoglycemia drugs with these patients. In the old days, we had drugs that caused hypoglycemia and set off an arrhythmia. Now, we have many drugs that don’t cause hypoglycemia that are used in combination to lose weight, as well, and lower the blood pressure. So, there are a lot of other side benefits of the drugs that we use.

Peter L. Salgo, MD: And that brings me to, I guess, the $64-billion question. At the end of the day, diabetes can be very, very complicated. And all internists I know think that they can manage diabetes. At what point do you need a specialist referral to start parsing all of this out?

Robert Busch, MD: That depends on where we are at. So, a good primary care physician could do the same job that we have. They know where the drugs work and everything else.

Peter L. Salgo, MD: Wait a minute, if she can do the job, who needs you?

Robert Busch, MD: Well, it depends on where you’re practicing. In my area, the state worker in Albany, they’re very well insured. They flood the primary care offices, and they refer patients if they’re on two oral agents and a basal insulin. They don’t use rapid acting insulin, they never use GLP with basal, and they use very little SGLT2. Whereas whenever we’re out teaching, we talk about our favorite regimen—a GLP-1, SGLT2, metformin. It’s three drugs, no hypoglycemia, weight loss—a no-brainer. They don’t have to do a lot of finger sticks either. So, we may all do that, but our primary care doctors where we are don’t do that. In other areas, I’m sure Pam and many of your colleagues do, do that.

Peter L. Salgo, MD: Let me put it to you. You’re family care, specialist. When do you refer?

Pamela Kushner, MD: I think Bob pointed out a very good critical time to refer. Recognize that when somebody comes in my office, they don’t just come in with their diabetes. They come in with every other part of their body, and I can’t say, “Don’t tell me that” because they have a list talking about each part. They’re doing a review of systems right in front of me. So, if I don’t feel comfortable with the 12 new classes of medications, then I would refer to a specialist.

If I have a very complex patient who’s complicated and I’m not getting through, and I feel maybe someone else would have another idea that they could throw into the mix, I refer them to an endocrinologist. And sometimes in many areas, there are not tools available in my private practice office that you have available in your office. You may have a full-time diabetic educator, but mine comes once a week. So, that may be a tool that I can access easier by going to your office.

Peter L. Salgo, MD: It’s a collegial kind of a decision, is that it?

Pamela Kushner, MD: It’s helping to make us plan. That’s a big reason to refer.

Jeffrey Miller, MD: I think you raised a very important issue. I always tell my patients I’m not a real doctor. I’m here to take care of your diabetes, and if you got a pain in the leg and you’ve got a pain in the belly, etc., etc., please go to your primary care doctor. So, the primary care doctor, as Dr. Kushner said, has a whole long list. I have, because time is limited in medicine, a shorter list so I can therefore concentrate on the issues specifically related to the diabetes. I think this is one of the big differentiators between a primary care doctor and a specialist.

Peter L. Salgo, MD: It’s always a fine line, and it’s always a give-and-take. Some primary care people feel very comfortable doing this; others say maybe this is out of my league, and you have to know yourself, too.

Pamela Kushner, MD: Well, I think that one of the ways that we can work together in medicine—which we need to do more and more, because we recognize the importance of communication—is as an endocrinologist. You can help empower your primary care clinicians by setting a plan. Saying “This is the plan that I would recommend that we follow” might help that primary care person gain more confidence and use that with their next patient.