TRENDS IN THE MANAGEMENT OF TYPE 2
DIABETES
Trends in the Management of Type 2 Diabetes. What's happening now and
what's coming up next? You are listening to ReachMD XM157, The Channel For
Medical Professionals. Welcome to focus on pharmacy. I am your host Dr.
Charles Turck, PharmD.
Dr. Su Cornell, PharmD, a Certified Diabetes Educator and
Assistant Director Of Experiential Education at Western University Chicago
College of Pharmacy, a fellow of the American Pharmacist Association, Dr.
Cornell is also an assistant professor of pharmacy practice at Midwestern.
DR. CHARLES TURCK:
Dr. Cornell welcome to the program.
DR. SU CORNELL:
Thank you Charles, it's pleasure to be here today.
DR. CHARLES TURCK:
We will be discussing current trends in the diabetes
management, and I wanted to start off by asking about those trends. What
exactly are we seeing in the type 2 diabetes population?
DR. SU CORNELL:
Well, unfortunately, we are seeing a huge epidemic in this
disease and mainly in type 2. What's happened over the years is as the world
has evolved and people have evolved, we have seen an increase in food, we have
seen a decrease in activity. We have multiple cultures coming to the United
States and you know worldwide and it's actually estimated that worldwide every
10 seconds someone dies from diabetes and again worldwide in that same 10
seconds, 2 people actually develop the disease. So, it is a global epidemic
and more close to home we find that actually here in the United States every 21
seconds someone is developing diabetes and we see type 2 as being the main type
of diabetes that most people are developing. You know, years ago, and I am
sure you remember back from the girl pharmacy school days as I do we were
thought that type 2 diabetes was something you got later in life. You know, at
that time, it was at all people over 40 get it or over 50, of course, now
those numbers seem young to me, but what my finding is age is not an indicator
anymore that type 2 can occur at any time as well as type 1 can occur at any
time. So, really age does not define the disease and worsening a trend of
children in adolescence that are developing type 2 diabetes. As a matter of
fact I have a patient who is in my practice, who was diagnosed with type 2
diabetes at the age of 13, so we are seeing more and more again children in
adolescence that are developing this devastating disease which comes, as you
know, with multiple, multiple complications.
DR. CHARLES TURCK:
What are the current treatment goals of therapy, both
nonpharmacologic and pharmacologic for patients with diabetes?
DR. SU CORNELL:
The good news is we have had a huge plethora of medications
that have come to market to try to treat this condition. The other good news
is it is something that can be treated with some simple, very simple lifestyle
modifications and what we try to do as a diabetes educator as I always put to
my patients, my job as a diabetes educator is to give them all of my knowledge,
so they can live everyday with diabetes without me, and you know, if you think
about it, the person who has diabetes they live with the day in and day out, so
they have to always manage it, and knowing how to manage it is the best way
they can control it opposed to letting it control them. So, what we encourage
the patients to do is learn as much as they can about diabetes and that’s where
actually 80% of managing the disease comes from non-pharmacological treatment
strategies, so you know, healthy eating, notice I didn't say diet because we
don’t say diet because diet is a usually short term thing, healthy eating is
just a behavior you want to develop for life. Exercise or activity just
increasing activity, managing their weight, losing a few pounds can actually
make a huge difference in their blood sugar, their blood pressure, and their
lipids, so in a simple lifestyle modifications can actually make a big
difference and of course, as a pharmacist you are very well aware of all of the
new drugs that have come to market and the new ones that are, you know,
knocking on the door and in the pipeline. What we have learned over past
decades about diabetes, specifically type 2, is it’s a multiple organ disease.
Again, years ago, back when were in school we were first learning about it. I
was told the pancreas was the problem. Well, now we know the pancreas is one
of five organs that is actually the problem in this very serious disease. If
the liver doesn’t work right, the tissue doesn’t absorb sugar correctly. We
have the stomach or the GI tract that doesn’t utilize or move the food through
appropriately and of course even the brain. So, we have multiple organs that
we now are even more discovering more every day that are defective with this
disease, and so when we come to treating it we need to use treatments that fix
all of the broken organs opposed to picking 1 medication that fixes 1 organ and
my knowledge when I talked to another healthcare professionals or patients. Let's
say, for example, if you had a car and your car you bring it into shop because
your transmission went out, your brakes went out and your fuel line was faulty
and you brought it in, but they only fixed your transmission, the car still
wouldn’t work right and that’s the same thing with diabetes. We have multiple
organs that are broke and if we choose 1 particular medication to fix 1
particular organ that is great, but we are not fixing the other organs that are
broke. Now, in addition to that, you know, for every medication that's out
there, it pretty much mimics a lifestyle behavior, so for example, I mean, lot
of folks are familiar with pioglitazone and rosiglitazone. The glitazone class
of drugs and don’t you think more than exercise and a pill. Metformin, which
is first line therapy for treatment of type 2 diabetes is nothing more than
eating breakfast, so for every drug that’s out there, it is adjunct to
lifestyle because its complementing those behavior changes with those lifestyle
changes that we are encouraging folks to actually make to improve their health.
DR. CHARLES TURCK:
So, you have outlined the rationale for combination therapy
certainly. When a patient is newly diagnosed, what exactly do we start them
on?
DR. SU CORNELL:
Interesting that you bring that out because every June, the
American Diabetes Association hosts their annual scientific sessions and you
know this is where the latest, greatest trends are actually introduced and you
know folks are educated on them and this years Banting award winner was Dr.
Ralph DeFronzo and as I always thought that Dr. DeFronzo is one of the
godfathers of diabetes and he is in Saint Antonio Texas and he does lot of the
research on type 2 diabetes, and interesting in his lecture, he actually stated
that he sees down the road upon diagnosis of type 2, triple therapy from the
get-go. His recommendations were metformin, a glitizone, and one of the
incretin hormones, specifically he went with an incretin mimetic, but you know,
he did generalize it to say incretin hormones, so he is actually identifying 3
pharmacological agents from the get-go again with the rationale of there is
multiple body parts that are broke, so you are going into fix those multiple
body parts.
If you are just joining us, you are listening to Focus on
Pharmacy on ReachMD XM157. I am your host, Dr. Charles Truck. Our guest is
Dr. Su Cornell, PharmD, a certified Diabetes Educator and Assistant Director Of
Experiential Education at Mid Western University Chicago College of Pharmacy.
We are discussing best practices in the management of type 2 diabetes.
Specifically, starting the patients out potentially with triple drug therapy at
diagnosis and that may be becoming a trend.
DR. CHARLES TURCK:
Dr. Cornell you mentioned incretin mimetics as one of the
different components of that triple drug therapy. Are increased mimetics
currently recommended in treatment guidelines?
DR. SU CORNELL:
In the treatment guidelines, the ADA algorithm that was
actually introduced and published in the latter half of 2006, they are actually
not on that algorithm, but interestingly the reason or the rationale behind it
is when the consensus group met to come up with kind of road map for lack of a
better term or the algorithm and the treatment of diabetes of type 2 diabetes
in particular. They had set some clear guidelines because again with the
plethora of drugs out there where do they go with this and one of the things
that they had discussed was, you know, whether you agree with us or not, they
discussed not utilizing drugs or placing them in the algorithm if they had not
been on the market for at least 6 years within the United States. So, with
that being said many of the newer agents that were very familiar with and were
actually in favor of using, they are actually not in that algorithm. However,
in the revision of this algorithm, I do expect to see them definitely showing a
presence, and the rationale behind that as well is because some of the newer
agents have a better side effect profile should we say, then some of the older
agents. You know one of the big concerns with diabetes and medication is
weight gain. Many of the agents that are actually listed on the 2006
algorithm, one of the adverse effects is weight gain and here you have a
person, you know, with diabetes you are trying them to lose weight, but the
drug is causing him to gain weight. They are kind of going well, which I do
here. The newer agents are either weight neutral or encouraged some weight
loss and that’s where the newer agents may actually show a better or favorable
effect as first line therapies down the road. Not to mention that one of the
things coming up now too again we talked about the multiorgan dysfunction with
diabetes, but diabetes is a progressive disease and what happens as we know
from the ADOPT trial, which looked at sulfanuria, metformin, and the glitizones
and they were kind of looking over 5 years in monotherapy, how do these drugs
work and how do they last and in all cases, over 5 years of time the disease
progressed and the patient actually lost control of the A1c, and actually the
A1c increased. You know, with of course the glitizones being most favorable at
keeping the A1c to a lower end. However, what we were looking at, as the
monotherapy alone just wouldn’t control that A1c. So, you know, with that
being said the ultimate goal is how do we preserve or prevent the progression
of diabetes and with that we are looking at how do we save the beta cell
because the destruction of beta cell is what progresses the disease. If the
beta cells are not producing insulin, then that’s where the disease progresses
and that’s where most patients will end up using insulin. What's really
interesting and you probably heard about the study that was done in China with
a group of patients that were immediately newly diagnosed was type 2 diabetes.
They were actually put an insulin pump for 2 weeks and then taken off and after
2 years 40% of those people still did not have diabetes, so their diabetes went
into a remission and stayed in that remission for 2 years to-date. So resting
the beta cell or saving the beta cell at an early intervention can actually go
a long way.
DR. CHARLES TURCK:
So, when the patient is newly diagnosed it is not
necessarily even too late.
DR. SU CORNELL:
Correct.
DR. CHARLES TURCK:
And then you had also mentioned sulfanuria. Are those dying
breed?
DR. SU CORNELL:
You know, sulfanuria were the first drug, oral agent, that
came into market and you know that was a nice alternative for folks from
insulin who were not fond of injecting themselves several times a week or you
know once or twice a day back in the 70s and 80s. So, when sulfanuria came to
market, they definitely had a place, but as we have learned more about the
disease
INCOMPLETE DICTATION
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