DSM: The field of available medications for
Type 2 diabetes continues to expand. How
important do you believe this expansion is for
optimal treatment, and is it important to make
better use of drugs that are currently available?
Lee: The more choices, the better is my belief.
Just a few decades ago, the number of oral
medications providers could prescribe was just
a handful, and you were pretty limited in what you could
prescribe if a patient had an allergy or an intolerance.
There are many different reasons behind why someone
has diabetes; it may not be a simple matter of insulin resis-
tance or insulin secretion. By having a bunch of medica-
tions that attack different aspects of the pathology, you can
really customize the regimen for the patient. And we have a
few more options to entertain before we jump into insulin.
Some of the newer medications, such as SGLT-2
inhibitors, are not only helping with diabetes but also
protect your heart and cardiovascular function. And
that’s huge. To know that some newer medications are
doing multiple good things is even more reassuring.
Nathan: A greater array of medications with
different mechanisms is, of course, welcome,
but their greatest utility will be realized when we
better understand [how they work] in specific subgroups
of patients with diabetes. This understanding will allow
us to individualize therapy to maximize benefits, reduce
adverse effects, and improve cost-effectiveness.
At this time, we don’t have the information neces-
sary to individualize therapy. Studies like GRADE [a
comparative-effectiveness study led by Dr. Nathan]
will help generate the insights necessary to individu-
alize therapy.
Vella: I, for one, welcome the proliferation of
new medications for the treatment of Type 2
diabetes. While they may not necessarily replace
the old stalwarts, they certainly provide more choice and
the ability to individualize therapy for a given patient.
That said, more traditional medications for the treat-
ment of Type 2 diabetes still have a role to play, and
there is still some uncertainty about when to use the
newer medications in the treatment algorithm.
DSM: There has been steady progress in insu-
lin pump technology in recent years. Do you
think expanded use of pumps would be a posi-
tive development in diabetes care? What are
the main barriers to that expansion?Lee: The current technology is really exciting
because the pump is linked with a CGM, and they
talk to each other. They’re becoming semi-closed-
loop; some of them shut down when your sugar is too low.
It’s going to take some time [to get to a fully closed loop],
but we’re headed in the right direction.
For those with insulin-treated diabetes who are inter-
ested, you should go for it. I have a few patients who are
still wary of having something on their body at all times.
Some may have heard of someone who [experienced
adverse effect] while wearing a pump, which may have
had nothing to do with the pump. Some are adamantly
anti-pump, for whatever reason. But for folks who are
engaged and willing to use the technology, they’re often
pleasantly surprised at how good the technology is.Nathan: We must not lose sight that Type 1
diabetes therapy is largely patient-driven. Ther-
apies that are unacceptable to patients can-
not and should not be forced on them. Ultimately, the
choice of therapy should be decided with joint decision-
making, keeping patient preferences at the forefront and
taking into consideration practical issues such as cost.
Many patients don’t want to wear an external device or
catheter, and their choices must be respected.Vella: Ultimately, an insulin pump is a com-
plicated insulin syringe. Few patients with
poor glycemic control using multiple daily
injections of insulin improve their situation merely by
transitioning to a pump. In much the same way that you
cannot hand the keys to a Ferrari to a new driver, educa-
tion is necessary to achieve the best results with insulin
pump therapy.
That being said, if I had Type 1 diabetes, I probably
would want to at least try a pump at some point.24 May/June 2019