Juggling Multiple Factors When Selecting Therapy

Dennis P. Scanlon, PhD: With all of these medication improvements, from a patient education perspective, what are the key challenges?

Mary Ann Hodorowicz, RDN, MBA, CDE: Just as a back drop, the American Association of Diabetes Educators (AADE) has an evidence-based curriculum called the AADE7 Self-Care Behaviors, which are the 7 evidence-based key behaviors to ultimately control blood glucose and reduce the complications which drives cost up.

One of those behaviors is medication. So, when you have these very novel, I call them “designer medications,” and the combinations and the unique dosing devices that sometimes have to be mixed, and you have to pull this lever and, “do this and this,” with the pen—it takes more time. And so, you have to subtract that time from the eating intervention, the exercise intervention, the psychosocial coping, and the monitoring. It presents a challenge.

But the bigger challenge is in providers actually referring patients to us to get all of this education. When providers try to do the medication education in the 10- or 15-minute appointment, it is very difficult for the patient because of literacy and numeracy issues. And the provider is trying to squeeze in that education on these designer drugs. It’s not a good situation.

Robert Gabbay, MD, PhD, FACP: I think diabetes educators are terribly underutilized, and it’s really a shame. We have the luxury, at Joslin, where, really, all of our patients see diabetes educators. And we firmly believe that that’s a big part of why our outcomes are as good as they are.

Mary Ann Hodorowicz, RDN, MBA, CDE: Do you feel me hugging you right now?

Robert Gabbay, MD, PhD, FACP: No, really. I think it’s a big issue. And it’s more than just reimbursement, because even in places where there is reimbursement, they’re still underutilized. And so, I think many providers may not realize the benefit. Also, I think patients probably don’t like the term “education.” “You graduated college or high school and you’re done.” “I don’t want to do any more education.” Coping skills, helping you to live better with diabetes—those kinds of things are probably nicer ways of framing it.

Dennis P. Scanlon, PhD: And we certainly don’t want to lose the behavior modification and all the complexities of how to take your medications, right?

This has been a great discussion. We could go on longer, as we did on our prior panel. Thank you all for joining me. What I’d like to do is give each of you some final opportunities to share a few thoughts. Dr Bloomgarden, I’ll start with you.

Zachary Bloomgarden, MD: I really appreciate the opportunity to be here, and I think we’ve gone over one of the really crucial areas of treating the person with diabetes, sort of at the further end (not the most advanced end of disease but treating people who really need a lot of medications such as these 2 injected medicines that we discussed—insulin and GLP-1s [glucagon-like peptide-1s]). These are people who cannot be treated in an easy, inexpensive, simple fashion that doesn’t require a lot of help, which one might call education or one might choose to use another term if the individual doesn’t want to say, “I already was educated.”

But every healthcare provider who tries to treat people with diabetes feels that this is a human being who’s struggling with this disease, who’s struggling with the lifestyle changes, who has so many choices of diet, food availability, a lack of desire to exercise regularly, and the need for these expensive medicines. So, I just want to emphasize that we really can help people by using these newer treatments. And, of course, the managed care companies have helped us to make it available. Even though we grumble a lot, without the insurance companies supporting patients’ use of this, we could never do it, so it’s a challenge.

Dennis P. Scanlon, PhD: Dr Gabbay?

Robert Gabbay, MD, PhD, FACP: Given all the choices that we now have in terms of managing diabetes, we can really individualize care much more effectively based on what the needs of that patient are. And we talked about a number of factors to consider—hypoglycemia, weight gain, and other comorbidities. I think the big studies that are done mix lots of groups of patients together. To really tease out the benefit of some of these newer agents, is a need for, probably, subgroup analyses, or studies that are designed to look at different subgroups. That said, it’s terrible that it’s going to become unaffordable for patients with diabetes. And I think, as a society, we need to do something about that. The first step is to be more transparent about what goes in to determining that large rise in price that’s occurred over the last several years. And that said, I think there’s so much improvement that can be made in diabetes care, and we have so many more tools to be able to do it now.

Dennis P. Scanlon, PhD: Ms. Hodorowicz.

Mary Ann Hodorowicz, RDN, MBA, CDE: I’m going to use the analogy of the “AAAs.” Insulin has to be (in all its forms, in all its devices to inject it), for the patient, affordable, accessible (per the payer and the mail order pharmacies), and appropriate (individualized for patients’ unique lifestyle needs, metabolic needs, complication needs). Affordable, accessible, and appropriate.

Dennis P. Scanlon, PhD: And Dr Snow?

Kenneth Snow, MD, MBA: We need to make sure that it’s being utilized as frequently as it needs to be. For type 1, in a way, it’s easy because it’s absolutely essential for life. But, for so many folks with type 2 (who clearly have a need to move beyond the therapy they’re on to achieve the level of control that they should be), insulin is still, almost 100 years later, a wonderful drug, and needs to be available for those folks so that they can achieve that control and stay healthy.

Dennis P. Scanlon, PhD: Agreed. Thank you, all, for joining in this discussion. On behalf of our panel, we thank you for joining us for this AJMC^® Peer Exchange^TM.