Transcript
A (0:03)
Hello, I'm Dr. Neal Skolnick and I'd like to welcome you to this special edition of Diabetes Corps. Update on this special series of podcasts. We will be interviewing faculty who presented during the American Diabetes Association's Scientific Sessions Diabetes Primary Conference on June 6, 2015. In part one of this series, we heard Dr. Andrew Reinhart discussing and updating us on the standards of Care, and Dr. John Buesse discussing new medications for diabetes. In today's podcast, which is part two of this series, we will hear Dr. Charles Schaefer discussing what to do after basal insulin is no longer sufficient, and Dr. Jim Chamberlain discussing data on the importance of and the management of hypoglycemia. Next month, in part three of this series, we'll hear Dr. Jay Shubra discussing atypical diabetes, Dr. Henry Rodriguez discussing diabetes in adolescents, and Dr. Eric Johnson discussing continuous glucose monitoring and insulin pump therapy for primary care. Please visit www.professional.diabetes.org CE to access the full webcasts of these lect. Our next speaker is Charles Schaefer, who.
B (1:33)
Is in practice in Augusta, Georgia. Charles is an internist who focuses almost exclusively on type 2 diabetes who just spoke on the topic of when basal Insulin doesn't work.
A (1:47)
Welcome, Dr. Schaefer.
C (1:49)
Thank you, Neil. It's a pleasure to be with you this morning.
B (1:51)
Could you give us some overview of your talk and some of the high points for our listeners?
C (1:57)
Sure. It's an interesting topic, I think. What to do when Basal Insulin Doesn't Fully Work we're so accustomed to starting basal insulin sort of as the last thing. When all of the orals don't work, then we think about starting basal insulin. And we, we work and work and work toward trying to get that morning sugar down to our established target. And yet, interestingly, when you look at the large spectrum of people taking basal insulin, only 42% of them ever get to a target A1C. So in fact, basal insulin doesn't work more than it does. And the question that's begged by that circumstance is what do you do next? So obviously there are several answers. One is, well, you can add mealtime insulin. That's what we've been taught. There are a variety of ways to do that. Fortunately, I think some of the exciting news over recent years is that we've learned, particularly in our type 2 patients, that you don't have to go to the full monty. You don't have to go to three injections of mealtime insulin a day to get the effect you're looking for. In fact, there's several studies that show that a single injection of basal insulin at the largest meal of the day may in fact get you that a 1C reduction that you're looking for. So that's one way to go about improving upon what we can traditionally accomplish with basal insulin alone. Unfortunately, even in that circumstance, only slightly more than 50% of people receive the kind of A1C coverage that we would like to get to restore them back to their target levels of glycemic control. So in the last several years, a group of new options have popped up that are very compelling, very interesting. Adding the DPP4 inhibitors to basal insulin have been shown to be effective not only in reducing a 1C by around a half a percentage point or maybe slightly more, but we're able now to do that without the problem we have with mealtime insulin, which is no hypoglycemia, no and no weight gain. So again, a simpler way to go about achieving the same outcome. In addition, we've seen some studies done and there's a lot of work in a future type way going on looking at the possibility of using Rapid Acting GLP1 substances to try to get us better mealtime control. John Buse has done some excellent work with exenatide twice daily and shows substantial A1C reductions of around seven to eight tenths of a percentage point. And again, not only no weight gain, he actually showed weight loss in that setting, an ability to reduce basal insulin, total dosing, and also no introduction of increased hypoglycemia. So another sort of novel way to go about approaching mealtime control. And similar studies have been done with liraglutide that show similar results. A third way that's come up recently has been the introduction of SGLT2 inhibitors to basal insulin. And again, we see substantial A1C drops of 7 to 8/10 of a percentage point, weight reduction, no hypoglycemia, in fact a little bit of improved blood pressure control, which isn't a bad thing because 75% of our type 2 patients are going to come to us with hypertension anyway. So this looks like a very substantial option to add to basal insulin. That's not getting our patients to go. Now, let me add a quick caveat. On May 15, the FDA said, oh, by the way, we're now seeing some random cases of diabetic ketoacidosis in patients taking SGLT2 inhibitors. So this may suggest that something is going on at some elementary level that's affecting glucose metabolism. I think we just need to throw out a warning that these drugs should be used. With that in the back of our mind, these cases of DKA were not just in type 1 patients. In fact, we believe that most of these 20 reported cases occurred in patients with type 2, many of whom were on insulin therapy. So that needs to be used with a reasonable measure of caution. And then just in the what's new arena, we have inhaled insulin technosphere, insulin which can be inhaled either as 4, 8 or 12 units at the time of meals. The advantage of this insulin is almost an immediate uptake in the system, almost an immediate onset of action. And I think in the end the real benefit is you puff this rather than injecting it. So for patients who may be needle phobic, this is an exciting alternative to taking shots. And in fact we're seeing that there's at all stages, both immediately after you take it within the first couple of hours and from the 2 to 5 hour mark of reduction in hypoglycemia. So the good news is lots of stuff to do when basal insulin isn't enough. I would throw out a little challenge to the, to the primary care community here and that is, I'm not sure we always know when basal insulin isn't enough. We've been taught that you fix fasting first and by gosh, we often go about that with a zeal that's remarkable. We're going to get that fasting sugar less than 130 despite all odds. And in fact if you look at treat to target trials that targeted fasting sugars of less than 100, generally they got to about 127. So even under the best of circumstances we, we don't fix fasting first. And in fact if you look at what happens with basal insulin, progressive use produces less and less benefit in reducing the morning sugar. So I think one thing we've learned, and in fact our group, including you of course, Neil, are presenting a poster today in the ADA poster sessions that have shown that once you reach a basal insulin use of about 4, 10 to 5, 10 of a unit per kilo, you're very unlikely in a population basis way to further reduce fasting insulin. And it is time to turn to one of these alternatives we've just talked about.