Emerging therapies and technologies in type 2 diabetes that aim to improve patient care and empower self-management.
Troy Trygstad, PharmD, MBA, PhD: So it sounds to me like protocols were all the rage in the 1990s and the turn of the century, and now we’re getting back to patient-centered care, a holistic approach, and patient-specific care plans. And then we have the Internet, with devices that provide feedback, really dashboarding in a very automated way with the patient. How has that changed your practice? Are you starting to get, “Here’s my glycemia EKG [electrocardiogram]”? What does that look like, and how has it changed your practice?
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: I’m a fan of it. I’m all about the connected devices and try to use them. It’s access to the data, right? I don’t have to have a receiver. It’s on my iPhone. I have a mobile app, and I have something checking my blood sugar pretty much around the clock. And maybe it’s going to help me eat a little bit better. I know what I should eat and what I shouldn’t eat. I want to go through that journey the same way the patients are. It’s not going to be for everyone, but I think it makes a big difference.
All the major diabetes manufacturers have connected pens that are in the pipeline or that are coming out. So I’m going to be able to know that the patient took that shot of the insulin or the GLP-1 [glucagon-like peptide-1] agonist. If it was daily, they missed 4 out of 7. So maybe that’s where my counseling point should be, and not, “Go up from this dose to the next dose” because you didn’t see a response in your blood sugars. So I think all the connected information is going to help. But there are 2 schools of thought on it, and not everyone is going to be happy with more data, because more data doesn’t necessarily mean you get paid to look at the data.
I have a lot of clinicians who would probably not publicly say this, but may say, “I don’t know if I necessarily want real-time blood sugar data on all my patients. What am I going to do? It’s going to be like air traffic control. I’m going to have to [continually] be monitoring who gets a load. Do I have to respond to that right away?”
And so there’s got to be some balance of it, where there are some type of algorithms and some sophistication that’s built in. Out of your panel, the 5 that had a low overnight are the ones that rise to the top, and the 15 that are going do great…
Troy Trygstad, PharmD, MBA, PhD: What if you had a 20% loss or a 20% bonus based on the ability to have 90% of your patients below A1C [glycated hemoglobin]?
Susan Cornell, PharmD, CDE, FAPhA, FAADE: Then you’re getting paid for it.
Troy Trygstad, PharmD, MBA, PhD: You would think about it differently.
Susan Cornell, PharmD, CDE, FAPhA, FAADE: But I think it also goes back to where we start with this. It’s diabetes self-management, where the patient needs to take an active role. And I think that’s the bigger picture of what we’re missing here. How do we empower our patient to best manage their case?
Troy Trygstad, PharmD, MBA, PhD: So I’m hearing this certified diabetes educator saying, “We need to teach people how to fish.”
Susan Cornell, PharmD, CDE, FAPhA, FAADE: Yes. Not feed them the fish, but teach them how to fish, so they can fish for life. Exactly.
Troy Trygstad, PharmD, MBA, PhD: So for the whole panel, what’s the most exciting innovation coming down the pipeline in diabetes care?
Susan Cornell, PharmD, CDE, FAPhA, FAADE: I’m very excited about the SGLT2 [sodium-glucose cotransporter 2], SGLT1 [sodium-glucose cotransporter 1] dual inhibitor. I know right now it’s currently being looked at in the treatment of type 1 diabetes. Type 2 diabetes is always in the spotlight, and type 1 diabetes is kind of behind the curtain all the time. So we can’t forget about those patients. And as we start to grow, and I mean that intentionally because we’re growing as a country—ie, our waist size—type 1 diabetes is growing as well. We’re starting to see a huge insulin resistance problem, or metabolic syndrome in our type 1 diabetes patients. So adding to the armamentarium of drugs available to treat type 1 diabetes is going to be very helpful down the road.
Troy Trygstad, PharmD, MBA, PhD: Yeah, it’s interesting, because we’re finding out a lot about hormones generally both in reproductive endocrinology, in this space, and a lot of other spaces; and environmental factors, potentially. Jess, what is the most interesting innovation coming down the pipeline with diabetes?
Jessica L. Kerr, PharmD: It’s constantly evolving, so I can’t really pick 1 thing. Drug therapy is interesting. I do get excited a little bit more with the technology and capabilities that maybe we can utilize for our drug therapies but also through the pumps and then the CGMs [continuous glucose monitors]. So it wouldn’t necessarily be specific to a drug for me, but I think having that connectivity with the providers could be beneficial for us.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: For me, I would have to say the oral delivery of peptides, which we haven’t been able to do. We talked a lot about injection barriers and GLP, so currently all the ones that we have involve a subcutaneous injection. At some point this year we’ll see GLP on the market, where they can take it as a pill. This will be given as an oral drug. So I think that’s a big deal if you think about where we’ve been able to think about delivery of peptides and proteins. To be able to overcome that piece of it will be a big deal, and we’ll see a GLP that can be delivered orally. I think that will be a big game changer.
Troy Trygstad, PharmD, MBA, PhD: So give me a yes or no answer. Within 5 years we’ll have gene therapy that cures or partially cures diabetes—yes or no?
Susan Cornell, PharmD, CDE, FAPhA, FAADE: Partially.
Troy Trygstad, PharmD, MBA, PhD: Yes.
Jessica L. Kerr, PharmD: I guess it’s a 'yes' then.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Yes.
Troy Trygstad, PharmD, MBA, PhD: Well, that’s a big deal. So all of you are instructors, faculty, teachers of young, aspiring minds. What is the most important piece of advice that you’d give to an aspiring pharmacist specialist in the area of diabetes? Dhiren?
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Listen to your patient, and let them talk more than you do.
Troy Trygstad, PharmD, MBA, PhD: Jess?
Jessica L. Kerr, PharmD: Know what they need out of their own disease state.
Susan Cornell, PharmD, CDE, FAPhA, FAADE: Stay current. Diabetes changes faster than I change clothes.
Troy Trygstad, PharmD, MBA, PhD: Excellent. Well, this has been extremely informative in a number of ways. Before we end the discussion, I’d like to open the floor and ask each of you to provide some final thoughts. What is your advice on GLP-1 agonists, Dhiren?
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Get to know the drug class. Get a few under your belt, whether it’s from a counseling standpoint or a prescribing standpoint. And then once you start seeing the results on a few of them from your patients, I think it’s just going to become a lot more…
Troy Trygstad, PharmD, MBA, PhD: So get your feet wet. Get your sea legs, and you’ll get comfortable?
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: That’s right.
Jessica L. Kerr, PharmD: Yeah. I think really keeping up-to-date with some of the emerging studies that are going to probably finish in 2020, and seeing where, in subpopulations with diabetes, we can really utilize them.
Troy Trygstad, PharmD, MBA, PhD: Susan, close us out.
Susan Cornell, PharmD, CDE, FAPhA, FAADE: Help your patients to help themselves.
Troy Trygstad, PharmD, MBA, PhD: Well, thank you for your contributions to this discussion. It was a great panel and a great discussion. On behalf of the panel, we thank you for joining us. We hope you found this Peer Exchange® discussion to be useful and informative. We’ll see you next time.