An Interview with Dr. Anne Peters (Continued)
Kelly Close: How would you encourage people whose A1Cs are not at target to approach their doctors who aren't suggesting different diabetes management strategies?
Dr. Peters: Sometimes I find it helpful if a patient comes to me having identified areas where they have higher blood sugars — for instance, "I have been testing after breakfast, and I find that I am always above 200 mg/dl; how can I improve?" Other patients have suggested new medication options (although this isn't always a good strategy if the physician isn't open to being questioned). Other possibilities include asking for a referral to a registered dietitian or diabetes educator — again, using other, non-physician resources to work towards a goal. Additionally, asking the provider, "What is my A1C target and why?" can start a dialogue...perhaps the physician has a different goal in mind. Finally, asking for a referral to an endocrinologist might be useful.
It is important that both providers and patients approach the situation with an open mind — it is too easy to try to blame someone else for lack of success. I have a patient with type 1 diabetes and an A1C that is always around 9.0%. He tests his blood glucose levels, literally, 25 times per day. He is terrified of going low. He doesn't trust a sensor. It is almost a form of OCD since he doesn't use the data to lower his blood sugar levels and will often test five times in an hour. Initially, I found myself feeling almost angry with him: he didn't follow my advice and he was upset with me because he thought I was trying to force him to behave in a way he wasn't comfortable with. Eventually I decided I had become part of the problem. Now, instead of insisting he follow my rules I have learned to listen to his fears and we even laugh a little together. I can't report that he is much better, but I can say that we have learned how to work together, and I am much more an ally than a judge, which is a much better relationship.
New Drugs and Treatments
Adam Brown: Are you excited about any of the therapies and technologies that are coming down the pipeline, or is it mostly incremental benefit?
Dr. Peters: Yes. Incremental. If I never had another new drug for type 2 diabetes, but I could do one thing, it would be to diagnose everybody when they are in late prediabetes and start them on metformin, a GLP-1 receptor agonist, and maybe a little bit of pioglitazone — Dr. Ralph DeFronzo's triple therapy. If I could just take our therapies and use them early on everybody, that's all I need. Maybe you could argue that it could be a pill and not a shot, but if I give people therapies early, I don't need any new ones.
I look at my patients that I've followed for years, and many, many, many of them were on a TZD (a class of type 2 diabetes drugs that includes pioglitazone and rosiglitazone) starting with Rezulin (troglitazone). Their disease does not progress. They do amazingly well. A lot of those people have gone off pioglitazone (Takeda's Actos) because they're worried about cancer, and it's unbelievable, suddenly they're on insulin. I mean, the TZDs as a drug class were amazing, and they still are. I still use pioglitazone, and I saw a lot of bad responses when people went off of it because they were afraid.
I think the more important thing is treating type 2 diabetes earlier and being really aggressive early, rather than throwing new drugs at it. The new drugs I see in the pipeline aren't blockbuster drugs. They are not lowering anyone's A1C by two percentage points. They're giving you a little bit of A1C reduction, and sure it's without weight gain, but I can get a little bit of an A1C reduction pretty easily. The first thing I would like is earlier treatment.
The second thing would be additional drugs for treating high cholesterol. I know the statins really, really help, but they don't raise HDL cholesterol, and there's still a lot of residual risk. I feel that I need another drug that will further reduce the risk of cardiovascular disease in addition to statin therapy.
While we're at it, I want a drug that treats diabetic peripheral neuropathy, and makes the pain go away or — better yet — reverses the course of disease. A lot of people have neuropathy even early in the disease, which is devastating. Other complications would also benefit from better treatments. Additionally, it would be helpful to be better at addressing some of the adherence/addiction issues present in diabetes.
A utopian answer would be to shift our focus toward prevention, toward a healthier lifestyle for people who are at risk for obesity because then we could really work with them. It takes hundreds of millions of dollars to bring a new drug to market, and if you put that into bringing access to fresh fruits and vegetables in every big city in America, you could really make a difference. I don't know exactly what the policies or interventions would be, but I think once you become obese it's a difficult process to lose weight.
Salsa Con Queso Mandarin Pork Roast Italian-Style Chicken with White Beans Fishy Fettuccine Minted Green Pea Soup Summer Squash Pie Southwest Roasted Salmon and Corn Sopa Seca Mushroom Steak Stew Spicy Baked Tortilla Chips
As I mentioned in an earlier post, one of the benefits that made it cost-effective for me to go with the real healthcare (HSA) plan rather than the phony (HRA) plan is that my company is now covering "preventative" medicines at $0 copay. The formulary for these, as stated by CVS/Caremark (my pharmacy benefits provider), covers all test strips, lancets, and control solutions. I dutifully get my doctor to write up prescriptions for all of my testing needs, submit...