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Managing Costs in Diabetes Means Intervening Early to Avoid Complications Later, Experts Say

Mary Caffrey
The Los Angeles gathering of the Institute for Value-Based Medicine focused on the need to intervene early in the course of diabetes, so that patients can avoid long-term complications. Over the past decade, cardiovascular outcomes trials for glucose-lowering therapies have revealed unexpected benefits, offering new opportunities for cardiologists. 
To show why diabetes has become a public health crisis, Peter Butler, MD, the renowned endocrinologist from the University of California at Los Angeles, tells the story with pictures: the food portions are bigger. The stretches spent in front of screens last longer. The distances we commute are farther. Too much eating and sitting do not add up to good health, he explained, creating a $327 billion tab for diabetes just in the United States.1

What’s worse, Butler said, “we’ve exported our lifestyle,” making diabetes, driven by rising obesity rates, a growing global threat. In 2018, the journal Diabetes estimated there are 500 million cases of type 2 diabetes (T2D) worldwide, and rates are comparable between wealthy and poor countries.2

“Clearly, we have to take care of people and manage it,” he said.

To understand the challenges that health systems face—and what must be done do to meet them—Butler, the division chief of Endocrinology and director of the Larry Hillblom Islet Research Center at UCLA, hosted the April 17, 2019, session of the Institute for Value-Based Medicine (IVBM), “Diabetes Management: Advances in Treatment and Management to Reduce Cost and Improve Outcomes.” The session, presented by The American Journal of Managed Care®, explored how investing in better interventions—from newer therapies to improved monitoring to more attention to the whole person—not only leads to better health, but also saves money in the long run.

An all-star lineup joined Butler at the Loews Santa Monica Hotel: Anne Peters, MD, professor of medicine at the Keck School of Medicine at the University of Southern California and director of the USC Clinical Diabetes Programs; Karol E. Watson, MD, PhD, FACC, director of the UCLA Barbra Streisand Women’s Heart Health Program, co-director of the UCLA Program in Preventive Cardiology, and director of the UCLA Cardiology Fellowship; and Sachin H. Jain, MD, MBA, president and chief executive officer for CareMore Health.

Getting Empagliflozin on Formulary: A Case for Cost-Effectiveness
Peters is not a typical diabetes expert. Besides being involved in cutting-edge research in both drug and device development, she splits her time between patients on both the west side of Los Angeles County, where most patients have health coverage, and the east side, where she said, “there are some of the saddest stories you’ve ever seen.”

Her service on the county’s Department of Health Services formulary committee has offered a front-row seat for debates about price and value. “One of the things I know the most about is cost,” Peters said—she’s had to make the case that certain therapies that may have higher acquisition costs ultimately save money by preventing complications that occur when diabetes is not well-controlled.

She is not a fan of insulin or sulfonylureas, but recognizes that for now both will stay on formulary in T2D. But Peters succeeded in getting empagliflozin on the Los Angeles County formulary 2 years before the EMPA-REG OUTCOME trial was reported.3  She told the IVBM attendees how she convinced the committee that the sodium glucose co-transporter 2 (SGLT2) inhibitor was keeping patients out of the hospital for heart failure—a result that has been borne out across the class in multiple studies.4-6

With empagliflozin, she said, “You get an immediate benefit.” And for low-income patients especially, that makes a difference. “Heart failure is so hard for these patients. It’s heart-breaking. They don’t have the home environments where they can deal with sodium and everything else that would really make their lives better.”

But overall, avoidable complications persist in diabetes. Peters said only 14.3% of adults with diabetes reach all of their targets—not just glycated hemoglobin (A1C), but also blood pressure and cholesterol,7 and there are serious knowledge gaps among primary care physicians. “I’ve asked some of my best internist friends, ‘What do you do after metformin?’ And most of them look at me blankly. That is not a good start. We’ve made the algorithm too complicated.”

Diabetes causes suffering, Peters said, from blindness, to kidney failure, to amputations, to tooth loss. “There’s an increased risk of depression and a whole host of other things,” she said. “Diabetes is not your friend, but my feeling is, if you take care of it well, none of this stuff has to happen. It’s the taking care of it well that matters, and that means access to healthcare, which I think is the most important part of all of this.”

As patients get T2D at younger ages,8 it’s essential to achieve and maintain glycemic control. “A 45-year-old who gets diabetes is someone who is going to live long enough to get complications,” she said, and this is what costs the health system money. Obese patients, in particular, incur high costs from joint replacements and sleep apnea, “but more than that, their lived experience is miserable.”

Even when patients get outstanding care, they remain at high risk for heart attacks. “Every time I hear a patient of mine has had sudden death, I race back to their chart to make sure I didn’t miss something,” Peters said. “One of the reasons I’m so passionate about this is that most of my patients are really well risk-modified and they still die.

“I know we’re all going to die,” Peters said. “But I’d prefer it not be in your 50s and 60s.”

Which New Therapy Makes Sense in Type 2 Diabetes
Metformin remains the first therapy patients take when they are diagnosed with T2D. Now that SGLT2 inhibitors have been shown to have cardiovascular benefits, Peters said, there’s an argument to be made that SGLT2 inhibitors should be foundational for T2D patients with cardiovascular disease. The question becomes: which of the newer T2D therapies should come next? First Peters, and then Watson, reviewed evidence from a key set of studies—the cardiovascular outcomes trials, or CVOTs—that have fundamentally changed treatment of T2D and brought cardiologists into the mix in the treatment of this condition.

As Watson later explained, in 2008 the FDA required CVOTs to show that new glucose-lowering therapies at least did not cause harm—meaning they did not cause heart attacks, strokes, or other events—to patients with T2D.9 Watson shared during her talk how the 2015 announcement of the EMPA-REG OUTCOME results3—that the SGLT2 inhibitor had reduced hospitalization for heart failure 35% and all-cause mortality 32%—hit like a thunderclap, and set off the wave of rethinking among both endocrinologists and cardiologists that culminated with the American College of Cardiologists’ 2018 Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease.10

CVOTs for 2 classes of therapy—SGLT2 inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists—have shown results with cardiovascular benefits. Peters reviewed the results and the criteria physicians should consider in deciding which class makes sense for a patient:
  • Patients at risk of heart failure would likely benefit from an SGLT2 inhibitor.
  • There are established cut points for estimated glomerular filtration rate (EGFR) to consider when prescribing an SGLT2 inhibitor, and patients with amputation risk should avoid canagliflozin, given the results of CANVAS.4
  • If patients have a compelling need to minimize hypoglycemia and they need to lose weight, a GLP-1 receptor agonist is a good choice.

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