John Anderson, MD: In 2017, diabetes care has become much more complex. In 1989, when I started practice, there was glipizide, glyburide, NPH insulin, and regular insulin. Now we have this whole host of medications that treat those ominous octet deficits, those things that make up type 2 diabetes. We have a lot of options, and you have to individualize treatment for each patient. So, there is no one-size-fits-all, and you have to look at, how long has this patient had diabetes? How severe is their diabetes? How many comorbidities do they have? Is this someone who’s young and healthy, who’s going to live a long time? Is this someone who’s older and fragile and for whom safety may be your primary concern?
And then, you have to look at the hemoglobin A1C. How much glycemic lowering do you need from a medication? Do you need just a little bit to tweak their improvement, or do you deed something more potent that has more robust efficacy? You have to look at kidney function and you have to look at side effect profiles that patients may or may not be able to tolerate. You have to look at the complexity. Is this something this patient is going to acquire, like insulin? Does monitoring of glucose adjustments based upon carbohydrate content and exercise, something that’s a little more complex, require a little more numeracy?
And then, you have to look at the other nonglycemic benefits. Does this patient really need the benefit of weight loss? Does this patient need the benefit of systolic blood pressure reduction? And, of course, cost always plays a role. What’s available on the formulary? Is this a patient with Medicare Part D for whom the doughnut hole may be a problem? So, all of those things go into a fairly complex decision-making process.
One wants to also consider hypoglycemia. There are subsegments of the population, particularly those who’ve had significant cardiovascular disease, for whom hypoglycemia may be really riskier than for a younger, healthier person. In that case, you’d probably want to stay away from medications that have a real potential for hypoglycemia, or risk, or possibility at all—minimize that risk. You have patients who may need weight reduction, and that may need to be as big a primary concern as efficacy and A1C reduction.
We also have at least 1 new medication in the SGLT2 class that is indicated for cardiovascular risk reduction regardless of hemoglobin A1C in patients with cardiovascular disease. So, as I think about my patients with type 2 diabetes, I’m starting to think about, does this patient have cardiovascular disease? Does this patient not have cardiovascular disease? That may also now be a consideration. And we’re seeing that newer agents have these CV outcomes trials, where that is going to be a consideration.
We know, and have known for a long time, that both type 1 and type 2 diabetes carry a microvascular risk: that is, the small blood vessels of nephropathy in the kidneys; neuropathy, nerve endings in the feet; and retinopathy, which is eye disease in the small blood vessels. But we also have learned more about the link between type 2 diabetes and macrovascular risk—peripheral vascular disease, cardiovascular disease, and cerebral vascular disease.
We’ve come a long way, but patients with type 2 diabetes still have a 2- to 4-fold increased risk of cardiovascular disease, including heart attack and stroke. If you look at the last 20 years in the United States, we’ve probably reduced the risk for patients with type 2 diabetes about 67%, or two-thirds reduction, in risk for heart disease. We’ve reduced stroke risk by about 50%. So, we really have done a good job.
However, if you look at age-matched controls versus people with type 2 diabetes, there’s still a huge gap in terms of what we can do for improvement, and that’s what we call the real residual risk with type 2 diabetes. We still have a lot more that we can do, even despite statin therapy, ACE inhibitors, and antiplatelet agents, like aspirin, that we know about. We have many more tools, and we’re doing a better job about meeting those “standards of care” in those patients. Even despite that, there’s a lot of residual risk, and there are a lot of patients who are still suffering from cardiovascular disease needlessly because we can do more for it.