An Interview with Dr. Anne Peters
Individualizing therapy, the newest drugs and devices, and what she thinks a cure for type 1 diabetes will look like.
By Adam Brown, Joseph Shivers, Alasdair Wilkins, and Kelly Close
Dr. Anne Peters, Professor of Medicine at the Keck School of Medicine of the University of Southern California, has served as chairperson of the ADA Council on Health Care Delivery and Public Health, spearheaded the Keck Diabetes Prevention Initiative with Dr. Fran Kaufman, and managed diabetes for premier athletes like Olympic Gold Medalist Gary Hall, Jr. and Indy Car driver Charlie Kimball. She is a principal investigator for the Helmsley Charitable Trust's T1D Exchange Clinic Registry, a co-author of the ADA/EASD Position Statement on the medical management of type 2 diabetes, and a practicing clinician who gives her cell phone number to every patient.
In our interview, she highlighted the importance of individualizing therapy, the value in people with diabetes working in partnership with their physicians to manage their diabetes, and three simple instructions that one of her patients relayed from the pioneering diabetologist Elliot Joslin. Dr. Peters also discussed the recently approved anti-obesity medications Qsymia and Belviq, new and upcoming devices for glucose monitoring and insulin delivery, and therapeutic areas (notably, diabetic neuropathy) where new medications remain especially needed.
Joseph Shivers: As diabetes becomes an even bigger public health challenge, isn't a universal A1C target a useful way to see how well we're treating diabetes as a state or a country?
Dr. Anne Peters: Let me start by talking about type 1 diabetes. A patient with type 1 diabetes, by the nature of their disease, is forced to be more involved than the average patient with type 2 diabetes. But if you look at the Helmsley Charitable Trust data from 66 of the best centers in America, the average A1C in adults with type 1 diabetes is 7.7% to 7.8%. Even among those individuals that have all the options and all the pumps and sensors, many people still don't get to target. Given that, it does become about individualizing.
I'd love for everybody to be at an A1C of less than 7.0%. I would love everybody on the whole planet to have an A1C of less than 6.0%. Frankly, it's my ideal...much of this issue has to do with patients and what their perception of their target is.
I have a friend, and I've encouraged him strongly for 20 years to get his A1C below 7.0%, because he's getting complications and because he's had diabetes for a long time. He wore a pump briefly and he did brilliantly, but didn't like the thing. He's somebody who in my mind, more than most people I know, really needs to have an A1C in the sixes. And I can't get it there. This friend of mine is a smart, intelligent, motivated, dear man. And you know what? He could do it. But I don't know what the variable is, I can't make it work. It's so hard, and that's what I mean about targets. I still believe his target is less than 7.0%; I think he does, too. Targets are such a complicated thing.
In the type 2 diabetes world, so much has to do with diet and exercise, and patients' sense of motivation with lifestyle. The number of people who stop their pills is shocking. They think, "I don't feel sick." So adherence rates are so low. That's part of this notion of target. You've got to make a target a partnership. Every single doctor will say, "My real target is to get everyone back to normal." And then on the flip side, I'll have a patient whose cardiologist will yell at them because their A1C isn't low enough. And I'll say, "No, that's absurd, this patient is 89 years old, has end-stage congestive heart failure and is on insulin, and does not need an A1C of 6.5%."
Some people, if they had an A1C of less than 7.0%, would be dead from hypoglycemia. And you're talking to somebody who lost two patients due to severe hypoglycemia in the past year; I know how bad this is. You can die from severe hypoglycemia. If I take some 85-year-old patients of mine who are on multiple daily insulin injections and try to get their A1C down to less than 7.0%, trust me, I will kill them. Getting certain patients to 7.0% is not something that I feel I can safely do, even though that is exactly what other patients need, so I want the message to be about individualization. I see patients on both sides: some people are over-treating and others are under-treating. It's about finding where that balance is.
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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...