Paradigms in Insulin Use for Type 2 Diabetes - Episode 1

Treatment Approach for Patients With Type 2 Diabetes

Jennifer Brigitte Green, MD, reviews her treatment approach for managing patients with type 2 diabetes and shares insight on how to identify patients that are uncontrolled with oral antidiabetic agents.

Jennifer Brigitte Green, MD: My approach to the treatment of people with type 2 diabetes relies fairly heavily upon the ADA [American Diabetes Association] standards of care, which are revised annually. Those care guidelines have become fairly sophisticated, and it is recommended that we make medication choices based upon, first, our individual patients’ personal level of risk for cardiovascular and kidney events or complications. Then, if a patient is not at particularly high risk for those complications or does not have cardiovascular or kidney disease yet, the guidelines recommend that we focus our medication choices on whether we have certain priorities for the care. And those would include issues such as reducing the risk of hypoglycemia, minimizing weight gain or promoting weight loss, or devising a treatment regimen that is low cost or accessible to the patient.

Of course, those are overlapping concerns, so we usually don’t just have 1 that applies to each individual. But that’s how I tend to think about my approach to care of the individual patient. Then, of course, we’re still worried about and want to make sure that our patients have individually appropriate glycemic control. That’s a separate but related issue, and we need to make sure that all of those goals of care are addressed simultaneously.

I think some of the major issues or major difficulties in the management of type 2 diabetes is simply the fact that a) Many people if they have diabetes for a number of years are going to need a number of medications to control their blood sugar adequately, and b) They often have many other related conditions, such as obesity, hypertension, hyperlipidemia, or even unrelated medical conditions that all need to be treated separately. The medication burden for the individual patient can become very significant. Thus, I like to look for opportunities to choose a pharmacotherapy or intervention that can address multiple of those issues at the same time. I also like to look for opportunities to make substitutions of potentially more effective medications for drugs that patients are already taking, again to minimize their medication or regimen burden and perhaps their cost as well.

If we’re talking about identifying patients who are not well controlled on oral agents, usually you would define that as having glycemic control that’s inadequate to meet their individual goals or individual targets. Usually, that’s pretty easy to identify based upon their hemoglobin A1c [glycated hemoglobin] being above the desired range. We’re also seeing, of course, many people use continuous glucose monitors or glucose sensors at home, and so we can easily identify the range in which their blood sugars fall. We can identify whether they’re having significant fluctuations in blood sugars at certain times of day. Thus, those are pretty good clues and can help us fairly readily identify when someone using oral glucose-lowering medications is not adequately controlled. There can be some rare circumstances in which a person’s hemoglobin A1c isn’t reliable, but that’s fairly uncommon. We do have other testing modalities such as measurement of fructosamine in those cases that can provide some insight into overall blood glucose control as well.

There are many goals of therapy in the management of type 2 diabetes, and there are really too many to list during this conversation. But I think personally, designing a regimen that both achieves the individually appropriate degree of glycemic control for the person I’m caring for but also addresses their excess risk of cardiovascular and kidney complications is really my goal. I want to do that using the regimen that is acceptable as well as accessible to the person who will be using it. To be honest, most of the people who are referred to endocrinologists are not meeting one or perhaps all of those goals, so there is an opportunity almost always to make meaningful changes.

Another goal of therapy is to make sure that the glycemic goal is reached, or we can get as close to that as possible with a minimum risk of hypoglycemia if at all possible. It’s sort of hard to describe or measure specifically, but my goal is for things not to happen. I want to keep people out of the hospital. I want to keep them from experiencing adverse cardiovascular or kidney outcomes. Thus, it’s really a matter of not letting bad things happen, which can be difficult to measure but is critically important.

Transcript Edited for Clarity