Dr. Neal Skolnick (5:32)

Thanks so much. That is really helpful hearing the emphasis on an individualized approach and hearing some of the details again.

Dr. Charles Schaefer (5:39)

Thank you.

Dr. Hermes Flores (5:40)

Thank you again.

Dr. Neal Skolnick (5:42)

Our Next speaker is Dr. Charles Schaefer, who is an assistant clinical professor of medicine in the Medical College of Georgia, Augusta, Georgia. And he just gave a wonderful talk on new therapies and basal insulins. Welcome, Dr. Schaefer.

Dr. Charles Schaefer (5:59)

Thank you very much, Neal. It's a pleasure to be here. It was fun talking to this group today about the new therapies and the new approaches to diabetic management. A lot has changed in the last year or so. We've had several significant turns in the area of diabetic management. We've had the introduction of one of the the first new classes of diabetes drugs that we've seen in a little while. And then finally, we are continuing to learn how important it is to rely on principles of early insulin use in a lot of our patients. So we dealt with those three topics during the lecture today. First of all, just the whole concept of using the new ADA guidelines that were released in April of last year. In my impression, this really has changed the whole pattern of diabetic Management in the old style. The clinician, with somewhat of a dictatorial wave of the finger, would state that, you must take this for your diabetes, or you must take that for your diabetes. And then all of that went away in April of last year. And over the last 12 months, we've really been trying to adapt to what these new guidelines mean for us in clinical practice. Now, instead of the clinician dictating what the individual should do, we actually are sitting down with the individual, opening up a dialogue, having a discussion, learning what that patient values, learning what they fear, learning something about their lifestyle, what they are able to do, given the work they do and given the money they have and the support system that's available to them in their community and at home. So I think that it's a new day for diabetic management. Now, instead of the dictatorial finger wagging, we have the patient and the clinicians sitting side by side, much like a pilot and a co pilot in an airplane. Now, one of the issues that arises in that metaphorical picture is that somebody's got to teach that co pilot patient how to fly an airplane. So I think in the last year we've had a great emphasis developing on educating the primary care community to be aware of new drugs, to be aware of diabetic staples when it comes to what we use to manage diabetes. And of course, we're going to have to develop some new talents to really get to communicate with our patients. This whole area of motivational interviewing, where the clinician sits down and really has a dialogue with the patient, is something that we need to be pulling out. And of course, the American Diabetes association wasn't the only group that was was active in giving new guidance. This year, the Clinical Endocrinology Group has released their new algorithm for the coming years. And in that particular paper, nothing really new or too surprising arose. But it was interesting that for the first time, the clinical endocrinologists are really looking at the importance of addressing some of the root causes of diabetes, such as obesity, and looking at how do we go about assessing this patient's degree of obesity, how do we go about assessing the needs that are going to be required to address and treat that condition. And we're including that now as a formal part of our diabetic treatment parameters. So I think an active year for clinicians in terms of how do we do diabetes differently. I think on the forefront of new medicines coming about, of course, we're continuing to get a deeper appreciation of the benefits of DPP4 inhibitors and GLP1 receptor agonists. Our incretin family of drugs. We have a new one that's just come on the scene, alligliptin, a DPP4 inhibitor. And we're probably poised in the next several months to a year to get a couple of new GLP1 receptor agonists. And I think as we bring these drugs into our armamentarium, we're beginning to learn that all incretins are not the same. Some incretins have largely a tonic or global or basal type of approach that lowers the blood sugar uniformly throughout the day. Others are highly prandial. They, that is they lower the blood sugar immediately following meals. So I think we're going to see a little bit of a shift in our incretin thinking as we divide these treatments into prandial and nonprandial and begin to look at how can these drugs help our other diabetic managements when it comes to addressing post meal needs and overall A1C reduction. So a bit of appreciation there. But the big news on the new drug scene was the appearance of the SGLT2 inhibitors. This sodium glucose linked transporter type 2 is a substance that's expressed only in the kidney. It's involved in removing glucose from the urine and actually redepositing the glucose into the blood of patients. And that's how we're able to to produce a urine output that's essentially free of sugar. The inhibitors to SGLT2, this new class of drug blocks that process and therefore there's incomplete reabsorption of glucose and hence we produce a glucose rich urine. And that has some really significant implications. One is it's an insulin independent way of reducing glucose in the bloodstream, which obviously has some impact on improving both fasting and postprandial blood sugars. In addition, you're wasting about 300 grams of sugar a day and that translates to calories and calories translates to weight. So it's been exciting to see that these products, currently there's one on the market, look like they're going to be generating a degree of weight loss, much like we're accustomed to seeing with the GLP1 receptor agonist. Now these drugs are going to require a little bit of a sophisticated clinician to use them. There are several different dose adjustments based on glomerular filtration rate and there's the possibility of both urinary tract infection and even more likely mycotic infections of the vulvovaginal or penile areas. So the clinician's going to have to be on his toes using these medications. But a great new addition, a class of drugs that inherently does not cause hypoglycemia, does not cause weight gain, and produces sort of that holy grail of diabetic therapy that is, let's lower the blood sugar and the weight at the same time. So very, very attractive there, I think, looking sort of through the binoculars and trying to peek over the hill at what's coming next. One thing of course is a new once a week DPP4 inhibitor. I don't think that particular medicine is going to add a lot of new properties, but it will raise a new question and that is to what extent will patients really value once Weekly Oral Dosing vs Daily Oral Dosing? And is that even a good thing for diabetic patients? Because diabetes is really a daily disease and perhaps we're sacrificing a little something when we don't face it head on every day when we go to the pill bottle. So it'll be very interesting to see how that sorts out for us. I think one other area that is looking very promising is the development of new sort of ultra long acting insulins. Degladec, of course, we've known about for more than several years. It's approved in, in Europe, it was not approved in America. But we continue to learn that this is an insulin that can be taken any time of the day with very little hypoglycemic or weight related issues. So I think we'll be getting more information back in the coming year or so about Deglodeq and probably a renewal of interest in approving that drug in America. Also, Lilly has a new long acting insulin, a pegylated Lispro, an insulin, interestingly, that's far more active at the level of the liver than in peripheral tissues. Now the reason that's important is normal human insulin goes to the liver first. Most of the insulin effect is experienced in the hepatic area. And so this drug is touted as being a bit more like endogenous insulin activity. It'll probably be a year or so before it's on the market. But a lot of phase three trials are ongoing now and the promise for an insulin that can be given pretty much anytime during the day and again without the risk of hypoglycemia and with the hope of perhaps even weight neutrality or weight loss, is very, very attractive. So to summarize what we talked about today, I think I can put it into one sentence, and that is that the optimal diabetic therapy will evolve from the clinician's expertise and the patient's desires. Hopefully today we've learned a little bit about how to go about learning about the patient's desires and we've expanded our knowledge a little bit as we'll do not only today but through the whole ADA conference to expand our expertise.

Dr. Neal Skolnick (16:11)

Thank you so much, Dr. Schaefer. That was a wonderful overview of your talk.

Dr. Charles Schaefer (16:16)

Thank you very much. Pleasure to be here.

Dr. Neal Skolnick (16:20)

That concludes part two of our three part series of highlights from the Diabetes Primary conference recorded during the American Diabetes Association Scientific Sessions in Chicago in June 2013. Please tune in for part three where we will cover the kidney and diabetes and distinguishing between type 1 and type 2 diabetes. If you would like to listen to and watch these lectures in full, just go see the webinar at www.propri Professional.diabetes.org primary. Again, that's www.Propri Professional. Diabetes.org primary. For the American Diabetes Association, I'm Dr. Neal Skolnick. Thank you for listening.