Type 2 Diabetes Treatment Options Increasing

Las Vegas—Until the past decade, patients with type 2 diabetes had few treatment options. They were limited to animal insulin, sulfonylurea, or metformin. The US Food and Drug Administration (FDA) approved metformin in 1994; it is used in approximately two-thirds of patients. Now, patients have many more choices, with the FDA approving several drugs in the past few years. Still, the healthcare industry would help patients and reduce costs if an increased emphasis were placed on screening for and preventing diabetes through education and lifestyle interventions, according to Anne Peters, MD, FACP, CDE, director of the University of Southern California’s clinical diabetes program. “If I were to rule the world, everyone with prediabetes would be picked up and treated,” said Dr. Peters, who spoke at the Fall Managed Care Forum in a session titled Overcoming Challenges and Improving Outcomes in the Management of Type 2 Diabetes. Dr. Peters cited a report that said in 2010, 14.5% of the US population had diabetes. The percentage of Americans with diabetes is expected to rise to 17.5% in 2015 and 32.7% in 2050. By 2050, an additional 33% of the population will have prediabetes, according to Dr. Peters. She discussed the results of several studies, among them the Diabetes Control and Complications Trial (DCCT), which was conducted between 1983 and 1993 and funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). When the DCCT ended, >90% of patients enrolled in the Epidemiology of Diabetes Interventions and Complications study. A long-term follow-up to the studies, published in the New England Journal of Medicine [2005;353(25):2643-2653], found that patients undergoing intensive treatment had a 57% risk reduction of nonfatal myocardial infarction, stroke, or death compared with those who underwent conventional treatment (P=.02). Dr. Peters also mentioned the 2011 American Diabetes Association (ADA) recommendations for patients with diabetes. The organization said patients should strive for a hemoglobin A1c (HbA1c) level <7%, premeal glucose between 90 and 130 mg/dL, peak postmeal glucose <180 mg/dL, blood pressure <130/80 mm Hg, low-density lipoprotein cholesterol <100 mg/dL, triglycerides <150 mg/dL, and high-density lipoprotein cholesterol >40 mg/dL. Dr. Peters’ research has indicated that making lifestyle changes can help prevent or delay the onset of type 2 diabetes in high-risk patients, particularly those with a family history of the disease or elevated glucose levels. She said the focus of a program should be on balanced, low-calorie nutrition, regular physical activity, and frequent intervention and support. “We need to become community activists,” Dr. Peters said. “You don’t want to take care of diabetes in the doctor’s office.” Dr. Peters added that studies have shown the risk of diabetes is reduced by ≥50% if patients are exposed to lifestyle interventions. She mentioned the NIDDK’s Diabetes Prevention Program, a multicenter study that examined the effect that dietary changes and increased activity or treatment with metformin had on preventing or delaying the onset of type 2 diabetes [N Engl J Med. 2002;346(6):393-403]. After 3 years, the trial found patients in the diet and exercise group reduced their risk of diabetes by 58%, while those in the metformin group had a 31% risk reduction. In both cases, the reductions were statistically significant compared with a placebo group (P<.001). In 2009, the ADA and the European Association for the Study of Diabetes published a consensus treatment algorithm for type 2 diabetes, recommending how to evaluate and treat the disease. However, Dr. Peters said the algorithm is no longer relevant, and both organizations are developing a new one they hope will prove more effective. Dr. Peters said the best way to screen for diabetes is checking a patient’s fasting plasma glucose and/or performing an oral glucose tolerance test. If patients have prediabetes, they should undergo a lifestyle intervention consisting of an improved diet and increased physical activity. If they have diabetes, they should have the lifestyle intervention as well as take metformin. Metformin, which has been available in other countries since 1957, is the most commonly used therapy and the standard baseline treatment, Dr. Peters said. The drug is cheap and has been proven to be effective in numerous trials, typically lowering HbA1c levels by 1% to 2% and leading to no weight gain. Patients are advised to take 1500 mg to 2000 mg of metformin per day. The most common second-line agents are sulfonylureas and the meglitinides, which are inexpensive and lower glucose levels. However, Dr. Peters warned they are also associated with weight gain and the risk of hypoglycemia. Thiazolidinediones, including rosiglitazone and pioglitazone, are a newer class of diabetes drugs that Dr. Peters said are intended for patients with clinical markers of insulin resistance. There are also adverse effects associated with the drugs, such as significant weight gain and an increased risk of edema and long-bone fractures. In addition, data indicated patients treated with rosiglitazone had a possible increased risk for myocardial infarction, prompting the FDA to restrict the drug’s access. The FDA also warned that patients taking pioglitazone may be at an increased risk of bladder cancer. Rosiglitazone and pioglitazone both come with a black box warning alerting patients of possible increases in heart failure associated with the drugs. Dipeptidyl peptidase-4 inhibitors include sitagliptin, saxagliptin, and linagliptin. They can be used as monotherapy or combination therapy. According to Dr. Peters, the drugs are moderately effective, reducing HbA1c levels by approximately 0.5% to 0.8%. They are also well tolerated and do not lead to weight gain or loss or hypoglycemia. Glucagon-like peptide-1 agonists such as exenatide or liraglutide are another new class of drugs. They are both injectables and are typically used with 1 or 2 oral agents. Dr. Peters said patients taking the drugs normally have a 1% decrease in their HbA1c levels and lose an average of 12 lb after 2 to 3 years of therapy. The most common side effects are gastrointestinal-related, with approximately one-third of patients experiencing nausea. Despite the plethora of options, patients are still sometimes resistant to taking diabetes medications, according to Dr. Peters. She cited a survey completed by 910 general internal medicine physicians that found the most common barriers to care were patient nonadherence to nonpharmacologic or pharmacologic therapies as well as a lack of interest in and time to take the drug. Dr. Peters suggested that physicians, pharmacists, and patients work together to provide a team-centered approach and target therapies and make lifestyle changes that will be effective in dealing with diabetes. “Early, good treatment sets the stage for a lifetime of good health,” Dr. Peters said. “We can make a big difference. We can slow the development and progression [of diabetes].”