Transcript

Lee Tetreault:

Hello and welcome to Frequently Asked Questions from Cases in Diabetes: Insulin Management. We're joined today by Dr. Abramson. Doctor, before we begin, can you provide a few key pointers for our audience from today's session?

Dr. Abrahamson:  

Sure, I'd be happy to. I think some of the key points are, firstly, not to be afraid to use insulin when it's needed in people with type 2 diabetes. There is a problem of clinical inertia that exists amongst many practitioners, and they are reluctant to start patients on insulin, or patients are reluctant to start insulin because of a fear of the medication. Well, if it's started properly and appropriately, there really needs to be no fear about using insulin. And we need to remember that type 2 diabetes is a progressive disease, which is characterized by progressive loss of beta-cell function. So ultimately many people will need insulin to maintain good glycemic control.

The next point is the fact that the insulins, together with other injectables like GLP-1 receptor agonists, can be used together and are not only more effective in many ways, but also safer to use together in that they cause less hypoglycemia when used together than, say, just using basal insulin on its own and are associated with less weight gain than just basal insulin on its own. And then finally, I think the audience needs to remember that there are drugs that have shown to have cardiovascular benefit outside of glucose-lowering and in people with established cardiovascular disease, or atherosclerotic cardiovascular disease, these drugs should be considered, in particular the GLP-1 receptor agonists and the SGLT2 inhibitors.

Lee Tetreault:

Thank you, Doctor. Let's now get into some of these frequently asked questions. First, injections pose barriers to advancing treatment. What is the status of oral GLP-1 RA therapies?

Dr. Abrahamson:  

So as you know, most all of the GLP-1 receptor agonists today are injectables. Some have to be given twice daily, some once daily, and some can be given weekly, but there is one oral GLP-1 receptor agonist that is in phase three clinical trials, it's an oral form of semaglutide. It's shown efficacy as good as the injectable almost and can be used in combination with other oral medications. So we hope that this will advance and will be approved in due course by the FDA, but they're in phase three clinical trials now with the product.

Lee Tetreault:

Should we use medications to prevent type 2 DM?

Dr. Abrahamson:  

This is a question that is frequently asked, and I always remind people of the Diabetes Prevention Program, which was a large multi-center study done in the United States many years ago, comparing the impact of lifestyle modification, in other words diet and exercise, versus metformin in people who had impaired glucose tolerance or pre-diabetes, looking at the rate of progression to diabetes. And in people who were randomized to the last arm modification arm of the study, they managed to lose about 7% of body weight, they walked or did some form of moderate intensity exercise for 150 minutes a week, and they reduced their risk for developing diabetes by 58%. Metformin, which is probably the safest of all the anti-diabetic drugs used to prevent diabetes or studied in the prevention of diabetes, only reduce the risk by 30%, and the most effective age group are people under the age of 60. So I always say to people, work on last arm modification, that's the key.

Lee Tetreault:

What about CGM in type 2 DM?

Dr. Abrahamson:  

Yeah, continuous glucose monitoring has really come of age, and there are a number of either what we call flash glucose monitoring systems or continuous glucose monitoring systems available, some of which don't require even finger stick calibration. The most beneficial group of people clearly are people with type 1 diabetes, but people with type 2 diabetes who are on multiple shots of insulin and are already testing sugars four times a day can actually get CGM if they're on Medicare. Interestingly enough, most commercial insurers are still not yet covering the cost of the CGM. So if patients are willing to pay out-of-pocket for it, if the insurance company won't cover the cost, I encourage them to use it. And even those who are not necessarily on multiple shots of insulin but who are on multiple medications, and need to know their blood sugars quite frequently, and are reluctant to test with finger sticks, if they're willing to pay out-of-pocket, I encourage them to use these newer forms of glucose monitoring.

Lee Tetreault:

What are your recommendations regarding self-titration of basal insulin?

Dr. Abrahamson:  

That's another good question. Interestingly enough, there have been studies that have actually compared what we call auto titration or self-titration against a program where patients had to call into their doctor's office or nurse practitioner's office for advice about titration of their basal insulin after starting basal insulin. And those who did auto titration actually did better than those who were... Had to rely on calling into a doctor's office. So in practice, if I give people a simple algorithm to follow, for example, adjust your dose of insulin by two units every 2-3 days until you reach your target glucose, which is usually around 80-130 milligrams per deciliter, but which could be defined by the physician for the patient or with the patient, and I find patients can adhere to this regimen. And to be on the safe side I sometimes say when you get to a certain insulin dosage and you're a little reluctant to keep titrating up, then you can give me a call. But auto titration works very well.

Lee Tetreault:

And lastly, Doctor, to what extent does cost and effectiveness influence decisions about second agent?

Dr. Abrahamson:  

Cost is always a question that comes up in these meetings, and quite rightly so, because there are many drugs today available to treat type 2 diabetes; the newer drugs are more expensive. And if people have an issue with cost, then we generally recommend using the generic products. But if insurance companies are covering the cost of some of the newer drugs, in particular people who have established atherosclerotic cardiovascular disease, I would strongly encourage people to add on to metformin GLP-1 receptor agonists and SGLT2 inhibitors. In fact, the American Association of Clinical Endocrinologists guideline for the treatment of type 2 diabetes says, from a hierarchical point of view of efficacy, the drugs to add on to metformin are GLP-1 receptor agonists and SGLT2 inhibitors, even in the absence of cardiovascular disease because of the efficacy and their safety profile. But that being said, not everybody can afford these drugs, and in those cases we need to resort to using the generic products more frequently.

Lee Tetreault:

This is great information, Doctor, thank you so much for your time today.

Dr. Abrahamson:  

Thank you for the invitation to be here.