In part 3 of this Exclusive Interview, Stanley Schwartz talks with Diabetes in Control Publisher Steve Freed during the AACE 2018 convention in Boston about the effectiveness of multi-drug treatment and the time needed to help a patient to achieve their diabetes management goal.
Stanley Schwartz, MD, FACP, FACE is an Emeritus Associate Professor of Medicine at the University of Pennsylvania.
Transcript of this video segment:
Freed: And how long, from your experience, to get that patient to goal on two or three drugs?
Schwartz: You have to understand the pharmacokinetics and the pharmacology of each of the drugs you’re using. So, two — actually there’s three drug classes — well, two drug classes; Incretins and SGLT2s, and Incretins have DPP-4s and GLP-1s. Those classes work in 24 hours. So, I can have no hesitation in saying, “Decide in one month,” because they’re working in 24 hours full effect of it. One month, are they having an effect or not? And the standard approach is wait three months and see what the glycohemoglobin [is], because glycohemoglobin represents three months of the lifespan of the hemoglobin molecule. But I use fructosamine which is glucose attached to all the protein in the serum. And that’s one month halfway. So, in one month, I can figure out if they’re working. If not, I have no hesitation one month later adding the third drug. And the third drug will depend on the patient. Again, ideally depending on what other things are going on if I can figure it out. You know, inflammation, resistance, so forth, as well as the nature of that specific drug. So, pioglitazone, let’s say, half effect in six weeks and full effect in three months, so I would wait three months for that. Metformin takes you two to four weeks to titrate it up, so I’ll probably wait three months for that. So, the second batch of agents works slower. You have to tie trade from an encrypting quick release, works slower. So, the first agents will be GLP-1, SGLT2, or SGLT2 and DPP-4, they work right away. One month later make a decision about adding third — three months later you can add the fourth. So, I can get people under control very quickly as opposed to the old habits of “clinical inertia,” where, “Oh, we’ll wait three months. Oh, we’ll see, I know you weren’t right and neither did I, so we’ll wait another few months.” And that’s how people got delayed therapy and increased the risk of complication.
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