Adjusting the Diabetes Treatment Paradigm

APRIL 24, 2018


Troy Trygstad, PharmD, MBA, PhD; Tripp Logan, PharmD; Dhiren Patel, PharmD; and Javier Morales, MD, FACP, FACE, discuss treatment barriers in diabetes and remark on the potential benefits of early initiation of newer therapies.

Troy Trygstad, PharmD, MBA, PhD: Tripp, you’re on the front lines.

Tripp Logan, PharmD: Right.

Troy Trygstad, PharmD, MBA, PhD: You’re dealing with this every day, everything from pathophysiology to copayments to "I got snowed in" to “I’m going on vacation” to “I’m not sure what all of this medicine is about or what it’s for.” This idea, or the promise of the future, and being able to address multiple disease states simultaneously, while simplifying therapy, potentially what might that mean for patients, such as the everyday patient who is walking into your pharmacy?

Tripp Logan, PharmD: Listening to this conversation, what I’m encouraged by is that not many years ago, we were worried about cardiovascular risk with new diabetes medications on the market. It made some of our prescribing partners a little gun shy, with these new options, and made practicing pharmacists consider, “Am I doing the right thing? This is something new. Should we wait until more data are out there?” That’s different from where we are right now, where we are talking about treating multiple chronic conditions with the same prescription. Also, and you all can speak to this, it seems like the reason that these studies started was to make sure there wasn’t cardiovascular risk. But what we found was that there’s actually benefit. The patients that we see are not limited to just diabetes. I don’t know that I have 2 patients with just diabetes. So, we need to be looking at this holistically. It’s impressive that it took a wrong to make this right. Now, we’re going down a good path.

Troy Trygstad, PharmD, MBA, PhD: Absolutely. So, heart failure hospitalizations, systolic blood pressure, weight loss, and renal—positive effects in all of those domains seem very promising to me. As a person with a family member with diabetes, that seems very appealing. What affect does that have on your practice?

Dhiren Patel, PharmD: I’ll share a personal story. My father had type 2 diabetes. When I read about this, before any of these additional trials or indications came out, that was enough for me to put my own father on an SGLT2 inhibitor. In all of the previous classes that we’ve talked about, there’s not one class in which we can go through the list like this. If it’s your TZDs or your SUs, there’s weight gain or fluid retention or hypoglycemia concerns. Here, we’re looking at a drug that’s actually pulling in the same direction, and we’re counseling all of our patients on it. There is the lifestyle piece. It’s not going against their measures, right? That’s just a personal story, where the data were so profound to me that I ended up implementing it in my father. But it goes beyond that. It’s helping that patient with all of the other things that you’re telling them to do. You’re not putting them on a drug that’s going to have a countermeasure.

Troy Trygstad, PharmD, MBA, PhD: This dates me a little bit, but I remember that my very first assignment, when I was on a rotation in a primary care clinic, was, “We’re interested in prescribing this class of drugs, but we’re concerned about the cardiovascular risk that is associated with it. Can you go look all of this up and present it to us?” That was then, and this is now. And so, you could almost flip that. If you had a pharmacy student in your practice, and you wanted him or her to go look something up on the SGLT2 category, what would you have them look up?

Javier Morales, MD, FACP, FACE: All of these data are just completely compelling. But aside from reviewing all of this data, by listening to everybody’s testimonials, and points of view, maybe the paradigm really needs to change in terms of prescribing habits? Yes, metformin is here to stay; it’s never going to go away. When we look at the next line that’s usually implemented after metformin, most of the time it’s actually a drug that may not offer these benefits that we’re discussing today. So, I think it’s probably more important to implement these therapies sooner, rather than later, to help further avert some of the risk.

Dhiren Patel, PharmD: I would definitely agree. I have a quick trivia question for the panel: Out of all of the diabetes medications that are dispensed more recently, can anyone guess what percentage is the SGLT2 inhibitors?

Tripp Logan, PharmD: I looked at our data before I came, just to see, and it’s a very small percentage.

Dhiren Patel, PharmD: Yes, you’re right. It’s 4%. So, despite us knowing this information, it’s what you said. Clinicians are a couple of iterations behind. We need to get them up to speed in order to close this gap.

Troy Trygstad, PharmD, MBA, PhD: Yes. It speaks to progression of disease though, as well, right? You have a lot of established patients with diabetes.

Tripp Logan, PharmD: Who also have cardiovascular disease and heart failure, right?

Troy Trygstad, PharmD, MBA, PhD: Right. They’ve gotten established disease with an established stable therapy. But maybe they haven’t been re-evaluated for what is next in line? When you’re thinking about it from a population level, there are already a lot of patients on existing therapies that are established. What do we do with them, from a practice perspective?

Tripp Logan, PharmD: If it ain’t broke, don’t fix it.

Dhiren Patel, PharmD: Cost certainly comes up, right? The most commonly prescribed medications are your SUs and insulin, in many cases. But again, it’s been around and it works. It’s something that the patient can afford. No matter how good the data are and what the package insert says, if the patient can’t afford it, and they can’t take it, then it doesn’t matter, right? But I make a very conscious effort to look at patients who are coming in. Do they have this established cardiovascular disease? We’ve looked at our data, and we’ve looked at adherence data and persistence data. We segmented medications that had a high hypoglycemia risk, such as SUs, and then we looked at medications that had a low hypoglycemia profile, along with weight gain or weight loss potential. Anyone want to guess as to which group did better?

Dhiren Patel, PharmD: The ones who are losing weight, and are not going to get low blood sugars, right? From a patient’s standpoint, those are things that are really important. And so, again, that also kind of translates into persistence and adherence data. Again, it’s helping that patient, as well.

Javier Morales, MD, FACP, FACE: It’s encouraging. It’s definitely encouraging.

Dhiren Patel, PharmD: Yes.

Troy Trygstad, PharmD, MBA, PhD: Tripp, you said, “If it ain’t broke, don’t fix it.” If the prevailing thought is that diabetes seems to be managed pretty well, but a whole host of these patients have cardiovascular issues that are either documented or are a potential, maybe part of the issue is, we don’t know it’s broke—if we’re starting to think about the newer therapies as covering more than one pathophysiological defect. Right?

Tripp Logan, PharmD: Right, and that’s my concern. You’ve got a lot of patients who would benefit from this, that would be willing and able to take this therapy and be adherent to it. But it’s never been introduced to them. It’s never been explained, in most areas. I’m envious of the prescribers who can help initiate therapy. But in the community space, it’s not always that easy. If the option is to add a new agent on or maybe take something off, what’s the cost of that? Is the out-of-pocket cost going to be higher? Then you’re working within that patient–pharmacist and patient–prescriber relationship, and we need to make sure that we’re making a great decision, as well, at the right time.


Troy Trygstad, PharmD, MBA, PhD; Tripp Logan, PharmD; Dhiren Patel, PharmD; and Javier Morales, MD, FACP, FACE, discuss treatment barriers in diabetes and remark on the potential benefits of early initiation of newer therapies.

Troy Trygstad, PharmD, MBA, PhD: Tripp, you’re on the front lines.

Tripp Logan, PharmD: Right.

Troy Trygstad, PharmD, MBA, PhD: You’re dealing with this every day, everything from pathophysiology to copayments to "I got snowed in" to “I’m going on vacation” to “I’m not sure what all of this medicine is about or what it’s for.” This idea, or the promise of the future, and being able to address multiple disease states simultaneously, while simplifying therapy, potentially what might that mean for patients, such as the everyday patient who is walking into your pharmacy?

Tripp Logan, PharmD: Listening to this conversation, what I’m encouraged by is that not many years ago, we were worried about cardiovascular risk with new diabetes medications on the market. It made some of our prescribing partners a little gun shy, with these new options, and made practicing pharmacists consider, “Am I doing the right thing? This is something new. Should we wait until more data are out there?” That’s different from where we are right now, where we are talking about treating multiple chronic conditions with the same prescription. Also, and you all can speak to this, it seems like the reason that these studies started was to make sure there wasn’t cardiovascular risk. But what we found was that there’s actually benefit. The patients that we see are not limited to just diabetes. I don’t know that I have 2 patients with just diabetes. So, we need to be looking at this holistically. It’s impressive that it took a wrong to make this right. Now, we’re going down a good path.

Troy Trygstad, PharmD, MBA, PhD: Absolutely. So, heart failure hospitalizations, systolic blood pressure, weight loss, and renal—positive effects in all of those domains seem very promising to me. As a person with a family member with diabetes, that seems very appealing. What affect does that have on your practice?

Dhiren Patel, PharmD: I’ll share a personal story. My father had type 2 diabetes. When I read about this, before any of these additional trials or indications came out, that was enough for me to put my own father on an SGLT2 inhibitor. In all of the previous classes that we’ve talked about, there’s not one class in which we can go through the list like this. If it’s your TZDs or your SUs, there’s weight gain or fluid retention or hypoglycemia concerns. Here, we’re looking at a drug that’s actually pulling in the same direction, and we’re counseling all of our patients on it. There is the lifestyle piece. It’s not going against their measures, right? That’s just a personal story, where the data were so profound to me that I ended up implementing it in my father. But it goes beyond that. It’s helping that patient with all of the other things that you’re telling them to do. You’re not putting them on a drug that’s going to have a countermeasure.

Troy Trygstad, PharmD, MBA, PhD: This dates me a little bit, but I remember that my very first assignment, when I was on a rotation in a primary care clinic, was, “We’re interested in prescribing this class of drugs, but we’re concerned about the cardiovascular risk that is associated with it. Can you go look all of this up and present it to us?” That was then, and this is now. And so, you could almost flip that. If you had a pharmacy student in your practice, and you wanted him or her to go look something up on the SGLT2 category, what would you have them look up?

Javier Morales, MD, FACP, FACE: All of these data are just completely compelling. But aside from reviewing all of this data, by listening to everybody’s testimonials, and points of view, maybe the paradigm really needs to change in terms of prescribing habits? Yes, metformin is here to stay; it’s never going to go away. When we look at the next line that’s usually implemented after metformin, most of the time it’s actually a drug that may not offer these benefits that we’re discussing today. So, I think it’s probably more important to implement these therapies sooner, rather than later, to help further avert some of the risk.

Dhiren Patel, PharmD: I would definitely agree. I have a quick trivia question for the panel: Out of all of the diabetes medications that are dispensed more recently, can anyone guess what percentage is the SGLT2 inhibitors?

Tripp Logan, PharmD: I looked at our data before I came, just to see, and it’s a very small percentage.

Dhiren Patel, PharmD: Yes, you’re right. It’s 4%. So, despite us knowing this information, it’s what you said. Clinicians are a couple of iterations behind. We need to get them up to speed in order to close this gap.

Troy Trygstad, PharmD, MBA, PhD: Yes. It speaks to progression of disease though, as well, right? You have a lot of established patients with diabetes.

Tripp Logan, PharmD: Who also have cardiovascular disease and heart failure, right?

Troy Trygstad, PharmD, MBA, PhD: Right. They’ve gotten established disease with an established stable therapy. But maybe they haven’t been re-evaluated for what is next in line? When you’re thinking about it from a population level, there are already a lot of patients on existing therapies that are established. What do we do with them, from a practice perspective?

Tripp Logan, PharmD: If it ain’t broke, don’t fix it.

Dhiren Patel, PharmD: Cost certainly comes up, right? The most commonly prescribed medications are your SUs and insulin, in many cases. But again, it’s been around and it works. It’s something that the patient can afford. No matter how good the data are and what the package insert says, if the patient can’t afford it, and they can’t take it, then it doesn’t matter, right? But I make a very conscious effort to look at patients who are coming in. Do they have this established cardiovascular disease? We’ve looked at our data, and we’ve looked at adherence data and persistence data. We segmented medications that had a high hypoglycemia risk, such as SUs, and then we looked at medications that had a low hypoglycemia profile, along with weight gain or weight loss potential. Anyone want to guess as to which group did better?

Dhiren Patel, PharmD: The ones who are losing weight, and are not going to get low blood sugars, right? From a patient’s standpoint, those are things that are really important. And so, again, that also kind of translates into persistence and adherence data. Again, it’s helping that patient, as well.

Javier Morales, MD, FACP, FACE: It’s encouraging. It’s definitely encouraging.

Dhiren Patel, PharmD: Yes.

Troy Trygstad, PharmD, MBA, PhD: Tripp, you said, “If it ain’t broke, don’t fix it.” If the prevailing thought is that diabetes seems to be managed pretty well, but a whole host of these patients have cardiovascular issues that are either documented or are a potential, maybe part of the issue is, we don’t know it’s broke—if we’re starting to think about the newer therapies as covering more than one pathophysiological defect. Right?

Tripp Logan, PharmD: Right, and that’s my concern. You’ve got a lot of patients who would benefit from this, that would be willing and able to take this therapy and be adherent to it. But it’s never been introduced to them. It’s never been explained, in most areas. I’m envious of the prescribers who can help initiate therapy. But in the community space, it’s not always that easy. If the option is to add a new agent on or maybe take something off, what’s the cost of that? Is the out-of-pocket cost going to be higher? Then you’re working within that patient–pharmacist and patient–prescriber relationship, and we need to make sure that we’re making a great decision, as well, at the right time.
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