In part 2 of this Exclusive Interview, Stanley Schwartz talks with Diabetes in Control Publisher Steve Freed during the AACE 2018 convention in Boston about the philosophy behind using multi-drug diabetes treatment to more aggressively treat diabetes earlier in the life of the disease.
Stanley Schwartz, MD, FACP, FACE is an Emeritus Associate Professor of Medicine at the University of Pennsylvania.
Transcript of this video segment:
Freed: You know it used to be that diabetes was a simple disease. We had one oral drug. And the patient goes to a family doc and he knew what to prescribe, sulfonylurea. And now it’s so cheap, the doctors still use it. And then [Ralph] DeFronzo started to look at multiple combination therapies.
Freed: And he’s very aggressive in using two and three therapies to knock out the diabetes. And what’s the philosophy for doing that? Because some doctors, they say diet and exercise for a couple of years and then they put you on a single drug for a couple of years. And by the time you get to multiple drugs, your cardiovascular risks are way up. And you have all kinds of complications, because it wasn’t treated aggressively. So, what’s the real philosophy for being more aggressive and treating people right at the start with multiple treatments?
Schwartz: It has to do — and I’ve written a paper on this, that the same mechanisms that damage the beta cell are responsible for your risk of diabetic complications. So, genetic mechanism information, insulin resistance and environmental factors, diet, exercise, so forth are the things that put somebody at risk for complications of diabetes. And so, you have a damaged beta cell, raises the sugar, that means it also raises lipids, so there’s your glucolipotoxicity. Those go to the peripheral tissues. I get away from using this, the sense that there’s micro- or macrovessels, these are the same pathophysiologic process. I get away from using type 1 and type 2 having different complications. It’s all the same complications, depending on which cells are being affected and how susceptible you are to them. And the logic then becomes let’s — by these markers, identify which things are going on in any individual patient. And we’ve learned usually multiple things are going on and they’ll be different in different individuals. And that gives you a logic. Not an arbitrary, “Oh, use three or four drugs,” but a logic for combining drugs. Again, most number of drugs that treats the most number of mechanisms of hyperglycemia. But by the way, use the appropriate drugs that would prevent or treat the complications that this person is at risk for depending on their level of inflammation or insulin resistance, and other things like reactive oxygen species and so forth. So, there’s truly now a pathophysiologic basis for combination therapy for diabetes and its complications.
Freed: So, give me a description of a patient that comes to you that you diagnosed with Type 2 diabetes that you would put on combination therapy day 1.
Schwartz: Well, I was part of the committee that — from AACE 2009 we were the first that then said, “Well, if your sugar is 6.5 to 7.5 use one drug, 7.5 to 9 two drugs, and over 9 use three drugs from the get-go.” And so, I feel proud I was on that committee that helped define that. So, I have no hesitations. Somebody comes to me the first time, they’re 7.6, I have no hesitation starting them on two drugs at the same time.