More aggressive, practical oral drug regimens necessary for type 2 diabetes
LAS VEGAS —The number and combination of effective oral medications for America's 24 million patients with type 2 diabetes is growing, with nearly 60% of patients receiving oral medications alone.
But many clinicians are not working close enough with patients to develop well-tailored, affordable treatment strategies, according to a researcher at the American Academy of Nurse Practitioners 26th Annual NP meeting.
“We'd have to be living under a rock not to know that we have a huge epidemic of type 2 diabetes,” Jane Faith Kapustin, PhD, CRNP, BC-ADM, of the University of Maryland School of Nursing in Baltimore, Maryland, said. “1.3 million patients are diagnosed each year.”
But too many clinicians fail to keep patients “at goal” or even try to get patients to goal, Kapustin said.
“We're finding there's a lot of clinical inertia,” she explained. “We leave patients at suboptimal levels before we treat them aggressively.”
Patients sustain elevated glycated hemoglobin A1c (HbA1c) levels for far too long, according to Kapustin, who explained that the clinical goal is to achieve the lowest possible HbA1c without hypoglycemia.
The American Diabetes Association now recommends a treatment goal of HbA1c < 7%, while the American Association of Clinical Endrocrinologists recommends a goal of <6.5%.
Patients presenting with 7.5% HbA1c or lower can usually be treated with lifestyle changes and oral drug monotherapy, Kapustin said. Patients with A1c between 7.6% and 9% may need dual-drug combination therapy, and those with HbA1c exceeding 9% are candidates for triple oral medication therapies and may need to progress to insulin, she said.
Kapustin urged practitioners to remind patients of the importance of lifestyle changes — especially exercise and better dietary decisions — at every meeting.
And don't overlook cost and co-pays when designing a treatment strategy, she warned.
“If you don't keep it simple, they won't take your advice —and if you don't keep it cheap, some patients can't afford it,” she said.
The monthly costs of oral medications vary dramatically, Kapustin emphasized, from as little as $13 a month for glyburide or glimepiride, to more than $200 a month for repaglinide (Prandin, Novo Nordisk), sitagliptin (Januvia, Merck) and saxagliptin (Onglyza, Bristol-Myers Squibb).
Metformin is now available in generic form and can cost as little as $4 a month, Kapustin said.
Metformin is a “treatment cornerstone,” widely prescribed as an oral monotherapy agent. It targets the liver to reduce glucose output and increase insulin sensitivity while reducing fasting glucose levels. Typical HbA1c reductions for this drug are 1.5% to 2%, Kapustin said.
Metformin can also be used in combination with several other oral medications, including DPP-4 inhibitor and GLP-1 hormone medications, which attack disease processes in different ways.
GLP-1 is a hormone that is decreased in the diabetic gut and is rapidly degraded by the DPP-4 enzyme. GLP-1 and DPP-4 agonist agents slow gastric emptying and affect neurotransmitters for satiety, making patients feel “fuller,” Kapustin said.
“They're very safe but some patients have pancreatitis, so you have to be careful,” she said. “The biggest downside right now is that these drugs are very expensive.”
Metformin is contraindicated in patients with kidney or liver disease, heart failure, alcoholism or those undergoing imaging involving contrast agents.
Clinicians should not be afraid to “experiment” if a given regimen is not achieving a patient's goals, Kapustin said — but always keep contraindications in mind when doing so.
More oral medication options are on the way, including oral insulin and a total of nine applications have been filed with the FDA for a new drug class, selective sodium glucose co-transporter 2 inhibitors (SGLT2s).”
Oral insulin is undergoing phase III clinical trials and “polypills” containing metformin, statin, aspirin and angiotensin-converting enzyme inhibitors, are also being developed, Kapustin said.
Kapustin reported no financial conflicts of interest.