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Dr. Steven Edelman Part 2, Diabetes Medications

Dr. Steven Edelman talks with Diabetes in Control Publisher Steve Freed during the ADA 77th Scientific Session in San Diego about determining the best drug for the diabetes patient.

Dr. Steven Edelman, Founder, Director, and Chairman of the Board of the nonprofit organization Taking Control of Your Diabetes, is a Professor of Medicine in the Division of Endocrinology, Diabetes and Metabolism at the University of California, San Diego and the Veterans Affairs Healthcare System of San Diego. He is also a 10-time winner of the San Diego Magazine Top Doctors in San Diego Award.

Transcript of this video segment:

Steve Freed: When it comes to PCPs, you have to go back 50 years and we had one oral drug, it may not be the best drug today, but we had one oral drug. You go see the doctor, you had type 2 diabetes, he’d put you on a sulfonylurea, it was a no brainer. It took us all the way up to 1995 before we had two drugs, that was Metformin, and from 95 until today, there’s probably over a million possible combinations, if you use triple therapy and add the insulin to it. Now, how does the PCP, figure out what is the best drug for their patient? Is it just trial-and-error, you try this combination, you try that combination. How does know what to prescribe?

Dr. Edelman:  Well, let me just add on to your first comment is that: since 2005, we’ve had over 40 new diabetes medications approved by the FDA. Not different classes but combinations. When you look at the NHANES database, the number of people in America with an A1C less than 7 hasn’t changed in 10 years, despite all of these new medications. GLP-1s, DPP-4s, SGLT-2 inhibitors. The answer to why that is such a shocking statistic. If you don’t take medications, they’re not going to work. I don’t want to throw people with type 2 under the bus. There’s a lot of issues with people: fear, and things like that. So, how is a primary care doctor able to do it? It’s almost impossible. Then you take 15 minutes and he has to spend 7 or 8 of those minutes doing perfunctory things like checking off the review systems, making sure the correct level, making sure you’ve reviewed the drugs. Nothing has to do with why that patient is doing poorly. No time to develop any relationship and it’s a complete disaster. They’re so busy, they don’t even use the 0-pay copay cards that people can get with some of these newer medications. That’s why I run “Taking Control of Your Diabetes”. Exactly because I want patients to learn about how to manage their own diabetes, learn about all the new strategies, medications, and injectable.  And if they don’t have and they think it will help them, go to their caregiver. The caregiver, they’re there to help people. And if a patient says, “Hey, doctor, I think I learned about this new medication, I think it might help me. I learned about it at a conference. What do you think? Could I try it?” And 85% of the time, based on our market research, they say yes.

Steve Freed:  When it comes to diabetes, most people don’t die from diabetes. They die from heart disease, strokes, heart attacks, cancer, Alzheimer’s, every disease known to man.

Dr. Edelman: Aspirin has a lot of side effects. More than some of our diabetes drugs.

Steve Freed: The SGLT-2 drugs have been shown, it increases your risk of amputation of your toes primarily.  So far. It seems as time goes and more patients are on the drugs we find out more things. What are your feelings about the GLP-1s and the SGLT-2s?

Dr. Edelman:  Well, don’t forget GLP-1s, they have been out over 12 years. They have withstood the test of time in terms of safety. What is the common denominator with all of them? The practical ones are nausea, if you titrate it too quickly. Occasionally you get vomiting. The whole issue of association with pancreatitis, it’s an association, no direct cause and effect relationship. And this whole C cell hyperplasia, that’s laboratory animals, never seen it in humans. That class of medication that leads to weight loss, really nice drops in A1C and now you can take home once weekly. Maybe in the future with the Intarcia implantable micropump, once a year. I think that class is incredibly important and safe in terms of, we haven’t discovered anything. You remember the old troglitazone story. The first TZD that led to idiopathic liver damage, and it got taken off the market. So, with SGLT-2s, I think we’re going to need a little more time to be honest with you. We’ve got the DKA issue, we’ve got the amputation, which is kind of strange with canagliflozin or Invokana, it’s only seen in the cardiovascular outcome trial. The phase 3 trials, which were over 8,000 people, they saw a decrease. Not statistically significant, but a trend. Is it because the older folks that were a good candidate for CVOT trials had reduce circulation, because they already had some evidence of heart disease. I think we just have to be careful not to jump onto these side effects, make them a class effect. Or even, wait till they’re proven to be due to the drug itself. I’m not trying to defend any of these drugs, I just know that when you get an imbalance in side effects, relatively small numbers, like DKA. That news release today was double the rates. 1% to 2%, it’s a relative versus absolute risk. I do think that we need to have them on the open market for a while before we really know the true safety.

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