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Yehuda Handelsman Part 2, Prescribing SGLT 2 Inhibitors

In part 2 of this Exclusive Interview, Dr. Yehuda Handelsman talks with Diabetes in Control Publisher Steve Freed during the AACE 2017 convention in Austin, Texas about prescribing SGLT 2 inhibitors and the actual cost to the lives of patients who are put on more expensive, but life-saving, diabetes drugs.

Yehuda Handelsman, MD, FACP, FACE is a past president of the American College of Endocrinology and Medical Director of the Metabolic Institute of America in Tarzana, CA.


Transcript of this video segment:

Steve: You know it gets a little confusing. We now have a drug called SGLT2, empagliflozin, and that showed a reduction of heart risk by 36-38%. So, do you treat people with an SGLT2? Do you treat people with one of the new hypercholesterolemia drugs? So, you can only….the new drugs are very expensive. You can’t take everybody with diabetes and put them on that because insurance companies would go bankrupt. So, what do you do?

Yehuda: I think we are looking here at two different aspects. One aspect says people that have lipid disorders that propel their cardiovascular disease, we put them on astatin and they don’t go to goals. We can put them further on goal and put them on drugs like ezetimibe, which would probably go first before we put them on PSCK9. And there could be group of people we could get to goal with a lesser expensive drug. If I see a person and they keep having atherosclerosis-related MIs or strokes, I will give them a lipid lowering drug. This is true whether they have diabetes or not. Somebody with kidney disease not necessarily with diabetes can also be extreme risk. It does not have to be just diabetes. The SGLT2 inhibitors are terrific drugs for people with diabetes. In fact ACE recommends them as first therapy after metformin even before this very nice study EMPA-REG. In the EMPA-REG study, there was a reduction in CV mortality starting the first 3 months corresponding to a reduction in congestive heart failure hospitalization. So, we don’t know yet why people did not die because of that, but they have to have diabetes and when you have to control glucose and they already have an established disease, yeah, that is a drug of choice.  And we don’t know. A month from now, American Diabetes Association and other trials, CANVAS, CANVAS-R, looking cardiovascular outcome with the drug canagliflozin may also show the same thing. We don’t know yet. We have to see. So yes, the SGLT2s are important but we also have GLP1 receptor agonist drug like liraglutide, Victoza. They have a reduction in CV mortality and we’re waiting to see if FDA will give them that indication. So now we are in better conversation with diabetes drug. Remember until two years ago we said they kill patients. Don’t give diabetes drugs! Avandia kills patients. Actos give cancer, you know? Januvia gives pancreatitis or this or that. All of this became bogus. It was a very hard place to discuss. All of a sudden in the last two years we are seeing the drugs trial after trial after trial to show how safe the drugs of diabetes are and now trials to show not only safe but to also reduce cardiovascular mortality. And I think that will obviously make us that we will need to take into account these drugs you know it’s a big problem now. Insurance companies say I only chose metformin and sulfonylurea because they are cheap. I don’t blame them. It’s cheap. They save money. But guess what? You give SGLT2 and you reduce mortality. That’s expensive. Why? It’s expensive because they live longer. It cost more to insurance. I think people will have to evaluate what is the cost of life again.

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