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The Evolution of Managing Diabetes

Arti Bhan, MD
Division Head
Endocrinology, Diabetes, Bone and Mineral Disorders
Henry Ford Health System
Detroit, MI

In my training years, the only medications we had were Metformin, Sulfonylureas, and insulin. These are really exciting times in diabetes, not only because of the advancements in finding out the pathophysiology of the condition and how to treat it in a multifactorial way, we now have a new armamentarium of medications which don’t only talk about lowering the blood sugar, but go to the basic cause of the disease.

With GLP-1’s, not only do they help the pancreatic function and help people with weight loss and increase the durable response to medications, they also go to the basic cause of what diabetes was resulted from. They also have multiple other beneficiary effects on the body in terms of reducing your cardiovascular risk and reducing the risk of kidney damage.

The same goes for the SGLT2 inhibitor class of medications, which are so dramatic in decreasing your risk of being hospitalized for congestive heart failure, that we are really at the brink of a revolution in diabetes care these days. I tell my patients that it’s not a good disease to have, but it’s the right time to have the disease, not only with the new medications but with the new monitoring devices that we have for diabetes.

Understanding the Side Effects of GLP1s and SGLT2s

For the GLP-1 class, one of the beneficial side effects is weight loss, but sometimes we see patients inappropriately being treated with the GLP-1 when they have, for instance, gastroparesis. Gastroparesis is a condition where the nerves that supply the intestines and stomach are damaged from longstanding diabetes. These patients do not have very good emptying of the stomach, and the GLP-1’s also reduce stomach emptying over time. I sometimes see patients who are in misery because they got started on a GLP-1, they already had gastroparesis, and now they cannot eat and they have severe abdominal pain and severe weight loss. That would be one of the contraindications in my opinion to using a GLP-1. In addition, people who have a family history of medullary thyroid cancer or multiple endocrine neoplasia should not be started on GLP-1’s, because in animal models there was some signal in increasing certain types of thyroid tumors. I don’t prescribe GLP-1’s to patients who have a very strong family history of pancreatic malignancies, because there is some background signal regarding that as well.

People who have had pancreatitis in the past, I do not give them GLP-1’s either because again, people with diabetes are more likely to have pancreatitis. People who have hypertriglyceridemia, which is again, a feature seen in some patients with diabetes and can have pancreatitis. So if they have very high triglycerides, they’ve had a history of pancreatitis, I stay away from GLP-1’s until I get their weight down and I get their triglycerides down; I modify their other risks and then I may consider using a GLP-1.

As far as the SGLT two inhibitor class of drugs, you have to be very careful as to when you start the medications. They work beautifully, but they do work as a diuretic. So I make sure that these patients, if they are taking a water pill already, I reduce the dose or decrease it. I make sure that their renal function is sufficient enough to see the effect of the medication.

Some of the newest studies that are coming out on SGLT2’s are relaxing the kidney function standards because they’re thinking that even with poor kidney function, patients get a cardiovascular benefit. That’s an evolving field right now, but I don’t really prescribe it to patients right now who are likely to get dehydration and then develop kidney issue issues.

SGLT’s work by causing a lot of blood sugar decreased through the urine. So you’re basically peeing the sugar out. People who cannot maintain genital hygiene, I’m very careful about not giving them an SGLT2, because you can get yeast infections, local infections in the genital area, which can be quite devastating. So I’m very careful about that.

There was some data on foot amputations with one of the SGLT2 inhibitors, although the follow-up study that recently came out showed no increase in foot amputations, but I always make sure a foot exam is done. If patients have foot ulcers or compromised circulation, or people just are at very high risk for having a foot ulcer, I may be very careful about prescribing in SGLT2.

Overall, however, these two classes of drugs have completely revolutionized diabetes care for our patients. Not only controlling blood sugar, but the other salutary effects on the kidney and the heart.

The Importance of Monitoring Your Thyroid If You Have Diabetes

I tell my patients, especially who have type 1 diabetes, that since it’s an autoimmune condition, you are more likely to have another autoimmune condition like hypo or hyperthyroidism. We always screen their lymph thyroid dysfunction. Also, patients who have significant uncontrolled hypothyroidism, tend to have difficulty losing weight, so I make sure that everybody’s thyroid is tested.

Hyperthyroid is a more overactive thyroid by itself and can cause uncontrolled blood sugar, so it’s very important to make sure that people are getting the right doses of antithyroid drugs or medications to keep their thyroids in check. All endocrine diseases can sometimes go hand in hand.

The Henry Ford Hospital System

Henry Ford has had a big legacy of providing excellent diabetes care, starting with Dr. Fred Whitehouse, our past Chairman, who was also a Past President of the American Diabetes Association and the recipient of the Banting Medal, an award known for contributions to the diabetes field, patient care, and scientific research. We all followed his lead. It’s not only a question of giving patients medication, but we have a dietician on site and we have a multidisciplinary approach to our patients with diabetes.

The Henry Ford Health System by itself has a very unique approach to diabetes. At every Henry Ford Satellite and every Henry Ford Clinic location, there is a diabetes control connection office. Which includes a diabetes educator, a dietician, and a nurse who helps the primary care physicians and the endocrinologist in managing patients.

Education is the key. If you do not have good diabetes education, if you don’t have good dietary support, and you can prescribe many medications at people and there will be no effect. We believe in the multidisciplinary approach to diabetes. So that’s where the strength of the Henry Ford Health System is. We don’t see that in all places. Every primary care physician has embedded diabetes care personnel who help patients achieve their goals. And it’s not all about medications and insulin, it’s all about the lifestyle modification that we focus on.

We have several ongoing NIH (National Institutes of Health) studies related to diabetes and we are always researching newer drugs and devices. Given that we have a very diverse population in the City of Detroit, we can offer patients the opportunity to participate in these trials who generally don’t get to participate in clinical trials in other parts of the Country. It is what makes the Henry Ford Health System unique where we are on the forefront of research so we can provide the best care for our patients and strive for the best outcomes.

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