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, Shagun Bindlish, MD, and Peminda K. Cabandugama, MD, discuss obesity and type 2 diabetes (T2D), including the most significant complications associated with these conditions that a primary care clinician is likely to encounter, how to best treat patients with obesity and T2D, and their suggestions to primary care clinicians on managing this patient population.

Dr Bindlish is a board member of the American Diabetes Association and medical director at One Medical in Dublin, California. 

Dr Cabandugama is the director of Digital Obesity at the Cleveland Clinic and a member of the Obesity Medicine Association.

 podcast features informative conversations with health care experts, opinion leaders, and practicing physicians, about what impacts primary care medicine today. 

 to subscribe on your favorite streaming service.

Podcasts

In our latest episode, 2 obesity experts discuss the importance of early intervention to reduce risk for complications, suggestions for managing patients in primary care, and more.

Obesity & Type 2 Diabetes: An Expert Discussion

The Primary Viewpoints podcast features informative conversations with health care experts, opinion leaders, and practicing physicians, about what impacts primary care medicine today.

In episode 17, Dr Hiddo Heerspink, joins us to discuss findings he recently presented at the American Diabetes Association 2022 Scientific Sessions from a 

 he led of the SURPASS-4 clinical trial of tirzepatide that looked for the first time at the effects of the novel GLP-1 receptor agonist on kidney function in patients with type 2 diabetes.

Hiddo Heerspink, PhD, PharmD, is professor of clinical trials and personalized medicine and a clinical pharmacologist/trialist in the department of clinical pharmacy and pharmacology at the University Medical Center Groningen in Groningen, Netherlands; he is also Codirector of the Better Treatments Program at the George Institute for Global Health in Newtown, Australia.

 to subscribe to the Primary Viewpoints podcast. Be sure to leave a rating and review for the show. Thanks for listening!

"Primary Viewpoints," a podcast from Patient Care Online, brings you an exclusive interview with Hiddo Heerspink, PhD, PharmD. 

Episode 17: Kidney Outcomes with Tirzepatide in Type 2 Diabetes

is a 49-year-old man with type 2 diabetes mellitus diagnosed 18 months ago. Treatment with metformin, 2500 mg/d, was started. His HbA1c was 8.6 initially: it’s now 7.6. His BMI decreased from 35 to 32 with lifestyle changes. Should I be any more aggressive with him or is the current A1C goal adequate?

 Does Mr Jones have any microvascular or macrovascular complications of diabetes?

He has no evidence of eye disease, renal disease or neuropathy, or cardiovascular events.

 Is he active and has he the resources to provide self-care?

 He plays tennis 4 or 5 times a week. He has good insurance coverage, has a supportive family, and has learned a lot about his diabetes since his diagnosis.

With no evidence of complications, a good support system, adequate insurance, capacity to self-manage, and recent onset of diabetes, I would be more aggressive with him. I would try to get his HbA1c as close to 6 as possible.

The UKPDS trial with patients who had recent-onset diabetes demonstrated a decrease in both microvascular and macrovascular complications with more aggressive early management. More recent trials, such as the ACCORD,

 demonstrated effectiveness and safety for a lower A1c in younger patients with no microvascular and macrovascular complications and diabetes of less than 10 to 15 years’ duration. Safety is important with aggressive treatment, so I would choose medications carefully and monitor his progress with frequent follow-up and good self-management.

 I would have used 2 medications initially because of the A1c >8. One oral agent usually will reduce the A1c about 1%. I’d add another oral agent or a GLP-1 receptor agonist. Adding a sulfonylurea such as glipizide or a glitizone such as pioglitazone will provide an additional decrease of 1% but both can produce weight gain, and hypoglycemia is a problem with the sulfonylurea.

A DPP4 inhibitor such as sitagliptin or saxtagliptin will produce about a 0.5% reduction in A1c and is weight-neutral. A GLP-1 receptor agonist will provide about a 1% drop in A1c and weight loss but must be injected.

If cost is an issue, a sulfonylurea is least expensive. Since the patient has good insurance coverage and his BMI is 32, I would opt for a GLP-1 receptor agonist such as exenatide (bid or once weekly) or liraglutide.

1. The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. 

http://www.nejm.org/doi/pdf/10.1056/NEJMoa0802743


2. Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veterans with type 2 diabetes. 

http://www.nejm.org/doi/full/10.1056/NEJMoa0808431


3. The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. 

http://www.nejm.org/doi/full/10.1056/NEJMoa0802987

The patient, an active 49-year-old man, had an HbA1c of 8.6 after diabetes was first diagnosed. It’s now 7.6 with metformin and lifestyle measures. Is the current A1c goal adequate, or should you treat more aggressively?

Man With Newly Diagnosed Type 2 Diabetes: What HbA1c Goal-And How to Get There?

70-Year-old Mrs Smith has a 7-year history of type 2 diabetes. Her medications include glipizide, 2.5 mg a day, and lisinopril, 10 mg a day. She weighs 175 pounds and her BMI is 30. Her HbA1c is 7.5 and her blood pressure 130/80. Recently she has experienced 2 episodes of dizziness and her blood sugars were 50 and 55. 

 I was surprised that her blood sugars were so low with an HbA1c of 7.5. Does that surprise you?

  I also have had similar patients. Remember that HbA1c reflects the average blood sugar for the last 2 to 3 months. So an HbA1c of 7.5 probably means a mean plasma glucose of about 170; but this number doesn’t tell us the about the variability or swings in daily glucose levels. This patient probably has daily drops below 70 and post meal increases to 200 plus to give her a mean blood sugar of roughly 170.

  What do you suggest for this patient? 

  We usually think of hypoglycemia in patients taking insulin or a sulfonylurea but it can occur for reasons other than medication. For example, as patients  age, their eating habits change. This patient may be eating erratically. Excessive alcohol ingestion, chronic renal disease, and poor sleep habits are other factors. About 42% of type 2 diabetes patients experience hypoglycemia, but it is usually mild (>50). 

For this patient’s management, I would stop the glipizide and obtain a creatinine and GFR. If her GFR is > 60, I would start metformin. If her GFR is lower, I would consider using a DPP4 inhibitor or GLP-1 receptor agonist that has limited renal clearance. Linagliptin, a DPP4 inhibitor, and liraglutide, a GLP-1 receptor agonist, are good options in patients with lower GFRs and higher creatinine.

Don’t forget to discuss the other possible causes of hypoglycemia like skipped meals and excessive alcohol ingestion. A tip to overnight hypoglycemia would be nightmares and night sweats. If the patient wakes up in the middle of the night, ask her to check her blood sugar.

  Are future episodes of hypoglycemia a concern?

Yes-prior hypoglycemia is a predictor of future hypoglycemia. More frequent self-monitoring of blood sugar should help.

Hypoglycemia in type 2 diabetes patients can be the result of insulin or sulfonylureas.

Challenging Case: A Patient With Hypoglycemia and High HbA1c

Believe it or not, as many as 30% of patients with the trifecta of cardiovascular risk factors are able to achieve control of HbA1c, blood pressure, and low-density lipoprotein (LDL) cholesterol at the same time. These results from two very different healthcare systems in Denver,  as measured over the course of years, show that estimates from earlier studies of the question are unduly pessimistic.

However, the factors that correlate with success are not necessarily the ones that you might predict. In this podcast, Dr. John F. Steiner describes the study and its implications for primary care physicians. Dr. Steiner is senior director of the Institute for Health Research at Kaiser Permanente Colorado and professor of general internal medicine at the University of Colorado School of Medicine.

Clues to Simultaneous Control of Diabetes, Hypertension, and Hyperlipidemia

1.  What were you looking to learn, and what did you measure?

2.  What was already known abou the likelihood of simultaneous control of all 3 risk factors?

Achieving sustained reductions of hyperlipidemia and blood pressure in a patient with diabetes is not impossible, but it's a challenge. A new study comparing two health systems shows which factors increase the odds of success.

Diabetes

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