Drs Goldman and Meece explore an array of drug therapies available to treat diabetes.
Jerry Meece, RPh, CDCES, FACA, FADCES: Let’s move on to the wheelhouse of pharmacists: drugs and medications. As pharmacists and diabetes educators, we have this incredible array of drugs that address at least 8 different targets for diabetes management. We’re getting more as we get into more research. But how do you recommend and select a drug therapy? What are your primary concerns? How do you recommend one drug over another? What goes into your choice?
Jennifer D. Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP: The American Diabetes Association [ADA] algorithm has addressed a lot of these questions because we have evidence to support the use of certain classes of drugs and specific drugs. The ADA guidelines recommend inpatients with atherosclerotic cardiovascular disease [ASCVD], regardless of their A1C [glycated hemoglobin] and metformin use, to use an SGLT2 inhibitor or a GLP1 receptor agonist [RA] with cardiovascular outcome data. Once you use one of those drugs, if they need more additional glycemic control, then you would choose the other one that you didn’t start with. If you started with a GLP1 receptor agonist, you would add an SGLT2 inhibitor, or vice versa.
In patients with heart failure or chronic kidney disease [CKD], the recommendation is an SGLT2 inhibitor with outcome evidence in support of those particular disease states. If you can’t take one of those SGLT2 inhibitors, the recommendation is to use a GLP1 receptor agonist with cardiovascular outcome data. In those situations, that’s what’s recommended. But they also address situations outside that. If you have patients who are interested in weight loss and don’t have a background of CKD, heart failure, or ASCVD, you would use a GLP1 receptor agonist or an SGLT2 inhibitor that has weight loss. If they have a history of hypoglycemia and you want to try to avoid hypoglycemia, you’re going to use drugs that have a low incidence of hypoglycemia: metformin, DPP4 inhibitors, GLP1 receptor agonists, and SGLT2 inhibitors.
They also have a section on cost. We can use patient-assistance programs, co-pay cards, and the formulary to try to get patients what they need. If they have a background of ASCVD, heart failure, or CKD, we can work to try to get them those drugs with those outcomes. But in the event that cost is an issue, we can look at lower-cost insulin. If we’re going to use a sulfonylurea, use the ones that have the lowest type of glycemia, such as glimepiride. That’s all covered in the ADA guidelines.
Jerry Meece, RPh, CDCES, FACA, FADCES: A couple of years ago, the snow globe in diabetes management was shaken up. When we start looking at your diabetes, the first question I’m going to ask is: do you have one of these 3 major comorbidities? If you do, then we aren’t going to start you on only metformin and physical activity. We’re going to start you with an SGLT2 inhibitor or GLP1 RA. If you don’t, we’re still going to work on your control, and your individualization goes down to cost, hypoglycemia, etc.
We’ve changed the way we look at diabetes dramatically, even in the last couple of years. But like everything else, it’s going to take a few more years for all of us to get comfortable with how we’re going to approach that. But this is what pharmacists can do. The ADA 2022 guidelines look like an overwhelming algorithm when you look at that page that you just mentioned. But break it down to the left side and the right side, and then you can help physicians determine what could be the better recommendation for this patient instead of going for metformin, waiting for failure, adding 1 drug, waiting for failure, and moving on.
Transcript edited for clarity.