Contributor: Frank Lavernia, MD
As the population growth of diabetes continues, thankfully it is mirrored by an increase in the number and type of effective medications. Women with diabetes often must deal with multiple issues concerning their trying and adopting new medications to treat their diabetes. These issues include clinical inertia, being able to consistently take meds as prescribed, and cost.
Clinical inertia can be defined as a health care provider not intensifying treatment in a patient whose various results are not meeting their evidence-based treatment goals. One of the first goals to discuss with health care providers is a target A1c level, and/or a target range for BG over time. That is dependent on a few factors such as if there is shorter life expectancy, multiple other chronic conditions, or other situations where lower A1c goals or target BG ranges may be difficult or counterproductive. Once treatment goals are set, office visits should be scheduled for every 3 months until that goal is met and is stable.
Early type 2 diabetes therapy is initially started with behavior changes such as diet, exercise, smoking cessation, medications, and metformin. After an initial three months, if the goal is not met, additional medications should be added. This incremental approach continues every 3 months until A1c goal is reached and stabilized. Other goals to monitor with this type of incremental approach include blood pressure (BP), lipids (LDL cholesterol), and other conditions. Empowering the patient through diabetes educational processes is crucial to the attainment and stability of all of these goals.
Patient-centered decision making is at the crux of positively impacting these chronic disease states. Diabetes is difficult to treat due to the issue of patients being mostly asymptomatic in the early stages. I cannot remember ever hearing a patient complaining that her BG, BP, and cholesterol at non-diabetic levels was causing them to have symptoms. Continual patient empowerment and education, and listening to the barriers that patients list for not taking medications as prescribed, are important points to cover at every visit.
US Surgeon General C. Everett Koop, MD, said that “Drugs don’t work in patients who don’t take them.” If a patient with previous history of in-range blood sugars, BP, and LDL cholesterol suddenly sees very different results, we may surmise that they are either not taking their meds daily or stopped them altogether - and it is important to find out the reasons behind the numbers. We often see this in patients that are rationing their insulin, perhaps due to cost, fear of hypoglycemia, stigma of injections, or memory lapses.
Medication compliance (synonym: adherence) refers to the degree or extent of conformity to the recommendations about day-to-day treatment by the provider with respect to the timing, dosage, and frequency. It may be defined as "the extent to which a patient acts in accordance with the prescribed interval, and dose of a dosing regimen." Unlike adherence, medication persistence refers to the act of continuing the treatment for the prescribed duration. In my clinical practice, there is a lot of time spent in driving both of these points home.
Finally, there are two sets of approved antihyperglycemic drugs approved by the FDA: GLP-1RA Byetta (2005) and SGLT-2i Invokana (2013). Since then, there have been other formulations launched from these groups. GLP-1 RA are the first injectables that can be used before insulin once weekly. They help by lowering A1c values, weight loss, can reduce BP, and lower risk of hypoglycemia events (if no insulin secretagogues are used- sulphonylureas and or insulin). They have been found to be cardioprotective in people with diabetes that have had cardiovascular events in the past.
There are now four SGLT-2i in pill form available in the marketplace. These once-daily tablets effectively block SGLT-2 receptors found in the kidneys, resulting in the excretion of glucose from the body. They can also result in increased in-range blood sugars, BP, weight loss, and less risk of hypoglycemia. These can also be cardioprotective and are soon to be approved for renal protection. They can be used in conjunction with GLP-1RA and insulin. There are some contraindications and side effects that must be discussed with your practitioner. Unfortunately and like other new drugs, these diabetes meds have a cost premium.
Dr. Lavernia has been a practicing diabetologist in South Florida for more than 35 years. He was the founder and director of the North Broward Diabetes Center in Florida. He is an adjunct faculty member of the National Diabetes Education Initiative (NDEI), Vascular Biology Working Group (VBWG), and for the Coalition for the Advancement of Cardiovascular Health (COACH). He is also a member of the American Diabetes Association, American Association of Clinical Endocrinology, European Association for the Study of Diabetes, and the National Hispanic Medical Association. He is a member of the DiabetesSisters Board of Directors.