In part 6, the conclusion of this Exclusive Interview, Aaron Vinik talks with Diabetes in Control Publisher Steve Freed during the AACE 2018 convention in Boston, MA about the possibility of using available medications to restore the body’s balance as well as his thoughts on a possible tool to help with the prescribing of medications.
Aaron Vinik MD, PhD, FCP, MACP, FACE is the Director of Research at Eastern Virginia Medical School in Norfolk, VA.
Transcript of this video segment:
Freed: So, can we restore balance with readily available medications because there are so many medications now.
Vinik: Oh, it’s a piece of cake. The cases I’ve put together for my little two sessions today were straightforward. I picked people that had parasympathetic excess and parasympathetic deficiency and sympathetic excess and sympathetic deficiency, and we’ll be showing them the clinical syndromes. Then we’ll say if you’ve got a parasympathetic excess, I can block it. I can take a drug that people take for their nerves and block it. Piece of cake. One pill at night. If you’ve got the opposite, it’s a parasympathetic deficiency, I have tons of drugs, I have a little patch that I can stick on and turn on your parasympathetic nervous system. If sympathetic blockers, they’re a dime a dozen, beta blockers of all variety are available to me. If you are deficient, I have every form of agonist possible. It’s like a delicacy that’s available with all these condiments that I could add to and then rebalance you very easily.
Freed: I don’t want to take any more of your time, I know you are a busy guy and you have things happening but there is one thing that I would like to just briefly mention to you and get your opinion on. I am working with a physician, you may even be aware of this, and a computer guy, and they basically put together a software program where you take the patients’ information such as blood pressure and A1C, put it into a program and it goes through 5 million possible combinations. Then, it spits out 6 possible combinations that you might consider, and it rates them and tells you how much the A1C should drop according to the studies. You put their insurance in and it will also tell you which drugs are going to cost the most so you can ask the patient if he or she is willing to spend 20 dollars more a month to help with your neuropathy or whatever the case may be. It also puts the drug coupons in there too to help lower the cost. What do you think of that particular idea?
Vinik: I must tell you where I think the problem is. The problem right now is, who is supposed to be using that? The patient or the physician?
Freed: No this is the physician and it’s not meant to put like in the Bible, “This is what you need to do.” It gives you 6 possible combinations and the physician has to decide which one he or she thinks is going to be the best one for that individual patient. That’s why they don’t even need FDA approval.
Vinik: I’ll give you my closing remark. The catastrophe that is occurring with healthcare, not only in this country but globally, is that decision is not being made by the physician. The physician is no longer Dr. So and So, he or she is a healthcare provider, an HCP. He or she is a unit of service. Ninety percent or more of the decision-making he or she makes is made by the third-party payer. So that is what your problem is. So, you can have the best tool in the world and you can’t lead the horse to water, it won’t drink.
Freed: There’s 5 million possible combinations, how do you determine the one –
Vinik: – that’s going to work and that the physician can apply? It’s the same question you asked me earlier when you asked why aren’t people on cycloset doing this? Why aren’t they using it? Why aren’t they reading this? It’s because they take on a mindset that they’ve lived with for years, donkey’s years. That’s why I started off by talking about glucose centricity. So, I think glucose centricity has to go away. And until we change the way healthcare, I mean Donald Trump told you he’s going to change it right, and he’s going to get them out of the equation. But, if you today are on insulin and say for example, you are taking 40 units a day and so you are taking about 1200 units a month, a pharmacist gives you maybe 1,150 units. So, you’re 50 units short and you’re a kid with type 1 diabetes and you end up in ketoacidosis – do you believe that’s happening today?
Freed: Oh, of course.
Vinik: Every day. And then you go and have a fight with them. And that means you spend hours as a physician saying, “Why the hell did you do that?” And they say, “Well it’s specific, we are held at the point of a gun.”
I am not decrying this [software]. I think it’s fantastic. What I do, it’s just the opposite, that’s why I told you about the QUAL questionnaire. It boils down to six questions. Six. That’s all. And I can predict your mortality.
Freed: Endocrinologists have it a little bit easier because they have a much better understanding and they are more focused on diabetes. When you go to the family practitioner, I think it’s just overwhelming all the possible combinations.
Vinik: They don’t even want to try it.
Freed: They stay with what they know – sulfonylureas, it’s cheap, metformin, it’s expensive.
Vinik: That’s exactly right. We had all the primary care doctors, very nice, and they came to say, “We just want to hear what is happening, that doesn’t mean we’re going to do that.”
Freed: It’s just mindboggling that we keep coming out with these new drugs that have unbelievable benefits in so many different ways, and yet, it’s not being used properly.
Vinik: Oh yes, but we still haven’t had the experience that we need. One that is going to have, ultimately, and you must not forget that when we started looking at risk calculation for heart attacks and strokes and death, we only account for 24 percent of the total risk. So, 76 percent of the time we’re ignorant. Now we get these new drugs that we apply them to the same endpoint.