Peter Salgo, MD: Hello, and thank you for joining this American Journal of Managed Care® program titled “A Review of the New Classes for the Treatment of Type 2 Diabetes.” As diabetes is a progressive disease, it is a continued challenge for physicians to provide adequate control of patients’ diabetes. When new agents with novel mechanisms of action become available, they help reduce the burden in the management of diabetes. Today we’re going to review these novel agents in the treatment plan for glycemic control and discuss their role in patients with and without cardiovascular disease.
I’m Dr Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and I’m [an] associate director of surgical intensive care at NewYork-Presbyterian Hospital. I’m delighted to tell you that participating today on our panel are:
Dr Om Ganda, medical director of the Lipid Clinic and chair of the Clinical Oversight Committee at the Joslin Diabetes Center in Boston, Massachusetts.
Jim Kenney, founder and president of JTKENNEY, LLC. He’s here from Waltham, Massachusetts.
And Dr Helena Rodbard, past president of the American College of Endocrinology and past president of the American Association of Clinical Endocrinologists. She’s here from Rockville, Maryland.
I want to thank all of you for joining us, this is going to be great.
Why don’t we begin with something very basic. Let’s talk about pathophysiology, diabetes, and specifically type 2 diabetes. What are we dealing with?
Helena W. Rodbard, MD: Well, we’re really dealing with a progressive disease. It’s a disease that’s just exploding throughout the world. It’s basically characterized by hypo glucose levels, so that’s a very simplistic explanation.
Peter Salgo, MD: It sounds simple, but we’re going to start digging into this.
Helena W. Rodbard, MD: Very complex, and we are very fortunate that nowadays we have a plethora of new medications [and] better forms to diagnose and to treat our patients with type 2 diabetes. In this country alone we have over 30 million [individuals] with diagnosed diabetes, and about 80 million with prediabetes.
Peter Salgo, MD: We’re going to get into that too. But before we start, let’s just make the distinction. I know it sounds simple; it may not be. Distinguish between type 2 and type 1 diabetes.
Helena W. Rodbard, MD: Very different diseases. Ultimately both diseases, type 1 and type 2, are characterized by high blood glucose levels. However, people with type 2 diabetes start out with insulin resistance. But the pancreas [is] still producing insulin, and in fact may actually be overproducing insulin. [That’s] different from people with type 1, which is an autoimmune disease in which the beta cells of the pancreas have lost their ability to produce insulin. SRV cardiovascular complications
Peter Salgo, MD: You know, again, it sounds simple. But when I was in medical school, when pterodactyls flew through the air, that wasn’t so clear. Type 2 was called adult onset, type 1 was juvenile onset, and it was just an age thing. It’s 2 different diseases.
Helena W. Rodbard, MD: It is totally different. And in fact, a lot of people with type 2 diabetes I think [are] misdiagnosed and vice versa. People with type 1 diabetes, just because they are younger, they are being labeled. [There are] people with type 2 diabetes [who] are younger [and] are being mislabeled as having type 2 diabetes. So age is no longer the [criterion].
Peter Salgo, MD: Age is not the issue. So there are older people with type 1 [and] younger people with type 2. [They are] different diseases and you can get them at different ages.
Helena W. Rodbard, MD: Exactly right. Age is no longer a criteria.
Peter Salgo, MD: I told you this was complicated. All right, let’s talk about the microvascular and the macrovascular complications now of type 2 [diabetes], because I think everybody associates type 1 with all these horrendous changes. But type 2 is not off the hook.
Om P. Ganda, MD: No, not at all. You know the complications of diabetes are really what cause havoc in people with diabetes. So we have 2 major types of complications: microvascular, [which] includes retinopathy, nephropathy—now known as CKD, or chronic kidney disease; and neuropathy, both peripheral and autonomic. So these complications are not different from what we see in type 1 diabetes. They occur in all kinds of diabetes. They’re hyperglycemia and how long you had these complications.
Peter Salgo, MD: Let me ask a difficult [but] not impossible question. If these are 2 distinct diseases, each characterized by hyperglycemia, and yet they converge on their vascular complications, why?
Om P. Ganda, MD: Right. I think it’s the pathophysiology as we began to address. Long-term hyperglycemia over a period of years will cause certain changes that lead to not only microvascular changes but some other metabolic changes that lead to the microvascular complications. But let me just add that SRV [systemic right ventricle] cardiovascular complications are concerned—or macrovascular complications, as you said; again, there are 3 kinds—include coronary artery disease, strokes, and peripheral vascular disease. Now these are not unique to diabetes, unlike microvascular complications. They get aggravated in the presence of diabetes, not only hyperglycemia but other major risk factors. High cholesterol, particularly LDL [low-density lipoprotein] cholesterol, other lipids, and hypertension.
Peter Salgo, MD: So there are fellow travelers that are coming along. That’s a complicated disease.
Om P. Ganda, MD: It’s a very complicated disease.