The Curbsiders Podcast
Podcast Recap: Diabetes Updates with Dr. Marie McDonnell - New Tools for the New Rules
Podcast length - 1 hr., 1 min.
In The Curbsiders Internal Medicine Podcast, hosts Dr. Matthew Watto and Dr. Paul Williams interview the Director of the Brigham Diabetes Program at Brigham and Women's Hospital, Dr. Marie McDonnell (MM), to get her take on the latest diabetes treatments and trends. Using a simulated scenario, the hosts discuss treatment options for Ms. J., a 39-year-old female with a history of hypertension, dyslipidemia, new-onset diabetes, and class 3 obesity. Her A1c was 6.4% over the past two years but has recently surged to 9.6%. She's symptomatic, polyuric, and generally doesn't feel well. Here are a few key takeaways:
When initiating treatment, consider ordering blood tests, starting potent therapy, and requesting a timely follow-up.
After considering red flags, Dr. McDonnell explains her first step would be to check for antibodies, specifically for glutamic acid decarboxylase 65 (GAD65), the most prevalent islet cell antibody observed in autoimmune diabetes. At this stage, measuring C-peptide is an option but, according to Dr. McDonnell, it might not be necessary unless you see the patient's not responding to your next step. This next step, she explains, should be something potent, like a GLP-1 receptor agonist, although current guidelines also support metformin with behavioral and lifestyle changes, due to the patient's obesity.
MM: I would go over quick things that she might be doing that are getting in her way. So, juice drinking, soda drinking, milk drinking are the big ones. If she's suddenly going crazy with that stuff, maybe it's a really big factor. Otherwise, if there's nothing really clearly identifiable, for example, let me just add a steroid injection into a joint. Just make sure we're not missing those things. But if we don't have something super identifiable, yes, I would move her to a GLP-1 and I would explain to her that because her A1c is so high, we want to get her under control.
With newer drugs available, metformin is still a right answer, but more aggressive options can be considered for certain patients.
Now that the newer SGLT2 and the GLP-1s are around, the hosts clarified that metformin is still a right answer as a first-line therapy, especially if the patient isn't sick. But, in certain cases, GLP-1s can be reasonable since they can be as potent as insulin—and may attenuate cardiovascular risk.
MM: For example, if you did the ASCVD risk or the AHA 2018 cardiovascular risk score, if you do that and somebody's really more than 13% or more than 15% [at] risk of having an event in the next 10 years, you should be considering something that can impact that risk. So, that's another chip there that might help you move to a GLP-1 in the case of where you need potency, too. I would say metformin is never wrong, unless, of course, it's completely contraindicated.
For younger patients, consider aiming for an A1c target of less than 7.5.
Target A1c levels can be a controversial topic. The most recent ACP guideline recommends treating patients with type 2 diabetes to achieve an A1c between 7 and 8 percent, which the hosts agree is a safe zone, especially for those with heart disease, comorbidities, and for those older than 65. Dr. McDonnell agrees with this recommendation and offers additional guidance to consider when treating a younger population.
MM: A good number of people can achieve an A1c well below 6.5 on the GLP-1 receptor agonists or lifestyle plus metformin even. That's a good number of people ... There's now a new concept. The [National Diabetes Prevention Program] showed us that, because they followed people for 15 years. They showed us that the more time you spend in the normal A1c range, and then they looked at below 6, actually, the less likely you are to have a complication. That sounds like a no brainer. But the concept is try to spend some more time down in the normal range. Even after you get diagnosed with diabetes, try to get there. If you can get there, spend some time there.
So, her target, our young 39-year-old, is definitely less than 7. We can tell her once she gets to below 7.5 that she's in the safe zone, but when we want to have her really in a guaranteed long-term disease control space, we want her below 7 and even below 6.5.
Ask your patient about yeast infection before initiating treatment with SGLT2-i.
Patients suffering from chronic yeast infections may not make the connection to their diabetes, and initiating the SGLT2-i may exacerbate their infection, explains Dr. McDonnell.
MM: Now, the SGLT2 inhibitor is not ideal for somebody this hyperglycemic in my practice, especially for women but I'm going to say across the genders, because you do see more side effects related to the glucose, the glycosuria. Women will describe more yeast infections to the point where—I've seen some pretty serious, like, perineal tinea. You just don't want to go there. You can have a patient requiring antifungal treatment for months if you make the wrong move here. For men and women, you can have that issue.
Final thoughts: Recognize insulin deficiency, treat high blood glucose, set holistic goals for the next therapeutic, and try to lower their A1c.
As the hosts concluded the conversation, the clinicians aimed to give Ms. J’s case a happy ending. By starting her on a weekly GLP-1 agonist, which she tolerates well, they recommend titrating the dose monthly. The patient finds time for therapeutic lifestyle changes, consistently attends a diabetes education program, and thereby lowers her A1c to 7.4, at which point Dr. McDonnell explains her top three take home points.
MM: What I would say is insulin deficiency [is] pretty uncommon in type 2 diabetes. But when you see it and people are really miserable, losing weight and catabolic, recognize it and make sure that we don’t miss that, but otherwise, very high blood glucose is common in type 2 diabetes, and it takes work, and happily we have potent agents to do that. So, that’s number one.
The second thing is just make sure you do consider what goals you have for the patient in terms of selecting the next therapeutic. Potency is important, but also the agent to help with weight loss, organ protection, and glucose control, we're trying to do all those three things at the same time.
The last point is trying to get a lower A1c in a young person … below 7.5, [which] is important for [the] long term.
Any views, thoughts, and opinions expressed in this podcast recap are solely that of the host and guests and do not reflect the views, opinions, policies, or position of epocrates and athenahealth.
Source:
The Curbsiders Internal Medicine Podcast. (2023, Mar 27). #387: Diabetes Updates with Dr. Marie McDonnell: New Tools for the New Rules. https://audioboom.com/posts/8270369-387-diabetes-updates-with-dr-marie-mcdonnell-new-tools-for-the-new-rules