Selecting Therapy to Meet Individual Needs

Dennis P. Scanlon, PhD: Welcome to The American Journal of Managed Care^® Peer Exchange^TM, “Finding Value in Today’s New Insulin Therapies.” My name is Dr Dennis Scanlon. I’m a professor of health policy and administration, and director for the Center for Healthcare Policy and Research in the College of Health and Human Development at the Pennsylvania State University.

The use of insulin continues to improve the care of those with both type 1 and type 2 diabetes, nearly 100 years after its discovery. While the current treatments represent a marked improvement over the insulins of the past, the rising cost of insulin has led to access challenges.

In today’s discussion, the panel of experts will examine current issues and evidence about the newest insulins and combination therapies. We are joined today by: Dr Zachary Bloomgarden, clinical professor in the division of endocrinology of the Department of Medicine at the Icahn School of Medicine, at Mount Sinai in New York; Dr Robert Gabbay, senior vice president and chief medical officer of Joslin Diabetes Center in Boston, and associate professor at Harvard Medical School; Mary Ann Hodorowicz, a Chicago-based dietitian, certified diabetes educator, consultant to physicians and health systems, and certified endocrinology coder; and finally, Dr Kenneth Snow, medical director for Aetna. Thank you so much for joining us.

I’d like to start today by talking about the treatment of diabetes—type 2 diabetes, generally. The standard of care calls for starting with metformin and adding additional therapy if necessary, but, of course, there’s been quite a bit of evolution over the treatment landscape in the past few years. Dr Bloomgarden, maybe you could start us off by talking about how that treatment landscape has evolved, and some of the considerations, as a clinician, that you need to factor in?

Zachary Bloomgarden, MD: The treatment of diabetes has become much more complicated as we’ve gone from 1 or 2 classes of medicines to now more than 10. We really have a plethora of choices. We consider starting with metformin to be appropriate, but really, what we want to do is individualize—recognizing that different people will have different benefits, but also different adverse effects of specific treatments. Some people will not tolerate metformin because of gastrointestinal side effects. Even though the considerations of renal disease in metformin have changed quite a bit recently, still, many people do have advanced renal disease and should not be treated with metformin. And we have all sorts of other agents that can be used in aiming to safely and effectively control the blood sugar in our patients.

Dennis P. Scanlon, PhD: What are some of those other clinical factors that are important when you consider these different treatments, and whether to add secondary therapy even beyond?

Robert Gabbay, MD, PhD, FACP: They’re really based on the different aspects of the various medications that have now become available. There are drugs that are likely to lead to weight gain, which is generally undesirable, but, on the other hand, there are a series of drugs now that lead to weight loss, and that’s certainly an advantage. So, weight is a key factor. Potential side effect profile, depending on the individual and what their comorbidities are, could be another key choice. For some patients, cost and coverage obviously drives some of that choice as well. And there are oral medications and, also, injectable medicines. The GLP-1 (glucagon-like peptide-1) agonists are another category that has advantages, but that requires injections. It’s really the opportunity to individualize treatment based on all of those different factors.

Mary Ann Hodorowicz, RDN, MBA, CDE: I think another key factor is to individualize certain classes of medication, and, correct me if I’m wrong, work better on pre-meal blood glucose. Other classes work better on post-meal blood glucose. And so, depending on where the patient is having a particular issue, pre- or post-, or both, has to be taken into account when they’re started on an oral or a noninsulin injectable.

Zachary Bloomgarden, MD: In general, the postprandial blood sugar is the greater contributor as the A1C level, the average glycemic exposure, gets lower. The preprandial becomes more and more important in people in worse glycemic control. And what we haven’t mentioned yet, but which is really our overriding concern in adjusting treatment, is that we are aiming for excellent glycemic control in as many of our patients as possible, recognizing that we want to avoid hypoglycemia, weight gain, gastrointestinal side effects, all of these issues which plague us. And we want to avoid undue expense while recognizing that some of the less expensive medicines with more side effects may ultimately be much less desirable.

Mary Ann Hodorowicz, RDN, MBA, CDE: I have to say this. As a diabetes educator, I’ve had multiple patients where their job practice setting prevented them from using certain medications. Eighteen-wheeler truck drivers who drive long hauls for 12, 14 hours a day, firemen, policemen, disposal garbage trucks. And they just don’t have the environment to use some of these medications that are injectable or require mixing or refrigeration. So, lifestyle and health numeracy, health literacy, method of dosing, all go into play.

Dennis P. Scanlon, PhD: We have to factor that in as well.