Annual Diabetes Update Provides Insight Into Evolving Treatment Options

Pharmacy Times spoke to Susan Cornell, BS, PharmD, CDCES, FAPhA, FADCES, about her session she presented at the APhA 2022 Annual Meeting and Exposition, titled "Know the Facts: Annual Diabetes Update."

Susan Cornell: Well, things come to mind, I guess I'm going to put this into 2 categories. I'm going to put this into medications and therapy options, and then I'm also going to put it into management and monitoring. So I think probably, you know, going to the biggest change, and I think this is what everybody really wants to hear, or really want to know about is the guidelines and how we treat diabetes. From a medication standpoint. I've been projecting for probably more than 5 years now, that metformin would no longer be the only first line therapy or first line therapy at all. And I finally can say, yay, metformin is no longer our only option for first line therapy. It still can be used, don't get me wrong, but we have a plethora of other options now, looking at the 2 inhibitor class of drugs, and of course, our GLP-1 receptor agonist class of drugs. And it's very important, because what's happened over the past several decades, is we've moved from managing sugar to managing diabetes and its complications. So we have to look beyond just the sugar. What about the blood pressure? What about the heart? You know, cholesterol? What about the kidney? What about the liver? And when we look at some of the older therapies, such as metformin, metformin lowers sugar, but does it do anything to benefit the heart? We don't know, because back in 1995, when it came out, you know, the cardiovascular studies weren't being done? Does it do anything to help the kidneys? Does it do anything to help the liver, we don't know. And we're realizing that there's no such thing as a person with just diabetes, they automatically have cardiovascular disease, or are at high risk for developing it, kidney disease, etc, you know, non- alcoholic fatty livers is starting to pop up due to the obesity rates. So when we look at this, it's really about managing more than just sugar. And when we're thinking drug therapy, we have to look at drugs that manage more than just sugar. So that's some of the drug therapy sites, I'm very excited to see that there's more than metformin now as first line therapy, we have a menu of option. And then the other big thing that I think pharmacists really, really need to know is monitoring. How are we monitoring our patients, and historically, you know, everybody's done finger sticks at home, again, 30 years ago, coming out of pharmacy school, you know, that was the hot thing. Things have changed since then. And not to say finger sticks are going to go away. But they're going to be replaced, or at least hopefully, you know, taken over by continuous glucose monitoring. And I know here at APhA, there's quite a few sessions about continuous glucose monitoring. From my session talking about the guidelines, the Guidelines Act actually have in them now that they recommend starting to use continuous glucose monitoring, in addition to the A1C monitoring, in order to optimally manage people with diabetes. So this concept where we call time in range, meaning in a 24 hour period, how much time is that person with diabetes in a good range? What is that? And what is the what is that data? This is very important.

Cornell: So as continuous glucose monitoring continues to evolve, it's being purchased now in the community pharmacy. And again, ambulatory care pharmacists are dealing with this as well. It even recently now we see that hospitals are accepting continuous glucose monitoring. CGM is the future of monitoring diabetes. Because really, we can prevent complications. And there is talk that we could even prevent diabetes through the use of continuous glucose monitoring. So I think all pharmacists, no matter where they're working, will, you know, kind of be involved with all this.

Cornell: Great question. Because as pharmacists, we always want to go to the drugs. That's just the nature of our profession. However, really managing diabetes is really about lifestyle. Drugs are always added to lifestyle drugs never replace lifestyle, even though many of the drugs mimic a lifestyle, you know, so for example, metformin does the same thing that eating breakfast does. So in this case, drugs do mimic lifestyle, but lifestyle was the cornerstone. And so, I believe pharmacists needs to recognize that, you know, we're, we want to counsel on the drugs and side effects. Let's also counsel on lifestyle, you know, how's the patient doing in terms of healthy eating? Are they you know, eating fruits and vegetables? Or are they eating fast foods? What about exercise? And I don't like to use the word “exercise,” What about physical activity? You know, are they getting up and moving around? And how much sleep sleep is very important, you know, quality, a good night's sleep, 7 to 9 hours can actually make a difference. It can lower blood sugar, stress reduction, there's actually studies done that show yoga, lowers and A1C as much as some medications, like a DPP four inhibitor. So again, what strategies are people using to keep themselves mindful, and you know, I'm not under stress? So again, I'm looking at their lifestyle, and of course, you know, tobacco cessation, blood pressure checks, etc. So I think pharmacists looking at all of this can really counsel patients, even in 30 seconds, it can make a difference.

Cornell: Going into a lot of detail, we could be here for a couple of days. So cliff note version, very simply stated, is with the guidelines, if a person is at high risk of atherosclerotic cardiovascular disease, so ASCVD, really, we want to go with a GLP-1 receptor agonist. So the GLP-1s are very beneficial. And let me back up just a second. These are the long acting GLP-1 agonist analogs. So it is the analogs that have a benefit have shown a proven cardiovascular benefit, again, for ASCVD, you know, they reduced mace, the whole kit and caboodle there. However, if we're looking at heart failure, or if we're looking at kidney disease, now we're going towards the SGLT-2 inhibitor because the SGLT-2 inhibitors, many of them are approved not only for reducing the risk of heart failure, and reduced ejection fraction, but empagliflozin just got cleared for preserved ejection fraction. And this is in people with or without diabetes. So again, that heart failure component within SGLT-2 inhibitor, that's where you want to go. And then of course, kidney, you know, if you have chronic kidney disease, or if there's kidney issues, the SGLT-2 inhibitors are the preferred agent. So you kind of have to look at the 3 columns: atherosclerotic cardiovascular disease, heart failure, and then kidney disease.

Cornell: So one of the things that I hope to see for people with diabetes is a well-rounded team based care. You know, oftentimes, and this is more with T2D, but you do see a with T1D occasionally, it's not thought of as a problem disease, you know, it's not considered serious. Oh, you know, I have T2D, but it's not like I need insulin. And people don't take it seriously. You know, it's kind of almost in (I'm dating myself here, again,) the “Rodney Dangerfield”, where I don't get the respect. And people don't always respect T2D. So one of the things I think goes, if people can understand this is a serious disease, but it can be controlled, and you can put it into remission. But that takes a team effort. And so this is where again, pharmacists working side by side with prescribers, as well as nurses and dietitians, exercise physiologists, audiologists, dentists, etc. Together, we can help that person with diabetes go into remission, but it needs to be taken seriously. And to do that it requires the entire team to help that person. So you know, for the future, I really just hope for more of this team based care and people's understanding of the seriousness of the disease, but we can help them.