In part 4 of this Exclusive Interview, Dr. Yehuda Handelsman talks with Diabetes in Control Publisher Steve Freed during the AACE 2017 convention in Austin, Texas about safe A1c levels and safely lowering patient A1c to their particular goal without hypoglycemia.
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: So the next big question that I have is, I know the ADA says if you have diabetes, your A1C should be below 7%. And the ACE says it should be below 6.5%. Who do we believe?
Yehuda: You believe the patient. I think the ADA says less than 7.0%, that’s 6.9 and ACE says 6.5% and below so we are very close. But Steve, last week, a very elegant study from Denmark looking at 28,000 patients and Denmark is a very controlled place. They looked at the patients started on metformin from year 2000 to 2012-2014, around there. They looked at several aspects of that. One, they looked to see to which goal they got to the metformin. The people that were at 6.5% or less had less events and it was gradual then 7, then 7.5, then 7.5 to less than 8, then less than 8.5. To the 6.5 then less than 7. That is the study in Denmark. I know in United States, we are not as the Danish. We have different body composition, if you will, but in that particular group less than 6.5 was better than less than 7. But get me to patient to 6.8. I am not going to fight over it and that’s not the issue. Even people at ADA will agree with you that if you can get them to a good goal safely without hypoglycemia, sure, of course it’s better. Another trial. In older people, comparing A1c less than 6.5 vs above 8 in people 55 to 80 years old. Less death, less heart attack and less stroke…6.5% vs 8%. In the older population, what does it tell us? It tells us that there was a time where we had to be more careful about the goals. Because to get to 6.5%, would give hypoglycemia. Remember, sulfonylurea that’s what we had and insulin and we put them back both together and you reduce them down. We just published an editorial in Diabetes Care. Because there was a publication in Diabetes Care saying that people that are older should not have too low or too high goals because it can cause a lot damage if it’s too low or too night whatever it is. And we don’t think that’s correct. It’s not the age that determines. It’s the comorbidities that create an issue and if you cause them damage giving hypoglycemia with metformin, GLP1 and SGLT2, I can get the majority of patients from 9.5% even 10% A1c with down to 6.5% with no hypoglycemia. By the way, that study in Denmark also showed that the faster you reduce the glucose, the better outcome you had. It also showed that those people with very high glucose reduced by far more had better outcomes. Sometimes people say don’t do it too fast, it may cause damage. No, it doesn’t. if you don’t cause hypoglycemia, if you don’t take somebody with DKA and take 500 or 600 of glucose down to 120 in 12 hours, which can be risky because of osmotic changes, you can control glucose fast into goal. My issue is not the 6.9% vs 6.5%. We are close enough. My issue is to get there safely. My issue is to make sure if you don’t do sulfonylurea the people can get hypoglycemia, the number one cost in emergency room in hospital is hypoglycemia. We have to prevent it. I manage people with type 1 diabetes. They come to me with 5.8% diabetes, 6.2% A1C and how much hypoglycemia do you have? That’s part of their life. Not in my book. When I manage, you don’t have hypoglycemia. Every type 1 will eventually have hypoglycemia but if you teach them to first prevent hypoglycemia then working on higher number they are good to go. Everybody should be that way.
Steve: But don’t you find that a person who has A1C of 9 or 10 and you try to get them rapidly safely down to as low as possible in 6 range that they can’t deal with it because they feel the side effects of hypoglycemia at 8.
Yehuda: That’s correct. You do gradually if you start, let’s say at 10, by two month you are at 8. It’s not true hypoglycemia, you get little shaky and you get used to it. You take 3 to 6 months to get them to goal but I will tell you I had often those patients. It’s not true hypoglycemia; it’s not that they got huge amount of insulin in very little hypoglycemia is 40. Their sugar is relatively because of their pituitary, the set point, they changed it and they think that 140 is too low. Nothing will happen to them. They will not even have a car accident. I think we shouldn’t be afraid to get them to goal. I think they show that often and often again. Also remember that metformin, lots of side effects, so I titrate my patients. It takes a month to get them to goal. Some of the GLP1 works immediately, again actos. They will be generic and they are going to be inexpensive. You will see more actos coming now into the mix of managing diabetes. So you can give actos, but it takes 6 to 8 to 10 weeks to work. So, this SGLT2 works immediately. So even if you start it takes a month for them to start coming down. Put them on a diet. The sugar starts coming down. I can get people sometimes in 48 hours from a sugar which is as high as 320 down to 120 just with very intensive diet. It can be done. It’s done before. Their A1c will time to show it but glucose can come down. We live in a time right now we have such wonderful tools. I just wish that a lot people would know how to use it and, as you mention, get access to them. Some of them are expensive.