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ClinicalThought
Changing the System of Care for Type 2 Diabetes

Released: October 07, 2021

Expiration: October 06, 2022

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For the past 2 decades, healthcare professionals (HCPs) have focused on achieving metabolic targets for our patients with type 2 diabetes, primarily to avoid or delay the onset of associated microvascular (eg, diabetic retinopathy, diabetic nephropathy) and macrovascular (eg, stroke, cardiovascular disease CVD, diabetic neuropathy) complications and to achieve glycemic control through control of glucose, lipids, and blood pressure. Clinical practice guidelines issued by the American Diabetes Association, American Association of Clinical Endocrinology, American College of Cardiology, and American Heart Association are uniformly consistent in their messaging: Get A1C below 7.0%, get low-density lipoprotein cholesterol to an individualized target depending on the patient’s risk and presence of CVD, and control blood pressure to <140/90 mm Hg or <130/80 mm Hg.

Despite guidelines, only approximately 12% of patients with diabetes achieve all 3 target goals. There is a major discrepancy between guideline‑based treatment and the clinical reality at the patient level. That may be a fundamental issue related to a combination of therapeutic inertia by the HCP (eg, failure to initiate or titrate treatment to achieve goals) and possible misconceptions or inadequate education by the patient (eg, low health literacy, denial of disease) to understand why all of this intervention is necessary for their well-being.

Changing the System of Care
Thus, we have a clinical situation that begs for improvement. In a less-than-ideal system of care, HCPs need to understand how to make small changes in their practice to improve their care of this chronic, progressive disease. To this end, we must recognize where therapeutic inertia exists in our practice. For example, we need to ask: Do we intensify A1C targets? If so, why? If not, why not? Take a moment to reflect on your reasoning, and importantly, document it.

Next, we need to adequately educate our patients about our reasoning. For example, lifestyle changes are an important foundation, but they can do only so much in terms of therapeutic targets. Everyone with type 2 diabetes eventually will need medications to control their A1C, and most eventually will need cholesterol‑lowering agents and/or antihypertensives. This natural progression is important to explain to patients so they understand the process and what is needed to keep them healthy. We need to overcome the common patient perception that “bad things aren’t going to happen to me.”

By changing the system of care, knowing the guidelines, being introspective about our therapeutic decisions, and sharing our reasoning, we can better help our patients achieve their metabolic targets.

Holistic Patient Care
Ultimately, we should focus more on the entire patient. As noted earlier, we have traditionally focused on pathways for A1C, blood pressure, and lipids. But if we step back and look, we see that most of our patients with type 2 diabetes are overweight or obese. We know the relationship between excess weight and glycemia, blood pressure, and lipids. Indeed, even modest weight loss has benefits, and it is well established that greater weight loss leads to even greater health benefits. So we must ask ourselves if we can do better through more intelligent decisions about medications, specifically focusing on weight to address all of the patient’s metabolic abnormalities.

One thing the American Diabetes Association has done brilliantly through their treatment algorithm is looking beyond A1C to start a process best described as personalized medicine. This involves asking patients about their priorities and examining their medical comorbidities. In 2021, that means if patients have CVD, we are starting a glucagon-like peptide-1 (GLP‑1) receptor agonist or a sodium-glucose cotransporter 2 (SGLT2) inhibitor. If patients have heart failure or kidney disease, we are starting with an SGLT2 inhibitor. If the patient does not have known CVD, kidney disease, or heart failure, is it appropriate for them to lose weight? The answer is almost always yes, so we can bring those 2 factors together and choose medications that will have a positive effect on weight and help patients achieve their metabolic targets. In addition, providing positive feedback may help patients with their lifestyle goals. Currently, GLP‑1 receptor agonists and SGLT2 inhibitors are the preferred medications for weight loss in patients with type 2 diabetes. They also have the therapeutic benefit of being neutral in terms of hypoglycemic risk. When cost is a major issue, sulfonylureas, thiazolidinediones, and NPH or insulin are sensible therapeutic options.

Conclusion
With recent advances in diabetes treatment, I believe we have moved beyond the traditional metformin, sulfonylurea, and basal insulin decision-making algorithm. HCPs need to step back and try to be more holistic in their decision-making not only with the patient’s goals, but also with their medical comorbidities, and focus on what is appropriate for those targets. To maximize long-term outcomes in patients with type 2 diabetes, we should follow guidelines in providing individualized and comprehensive management of hyperglycemia, hypertension, lipids, and obesity. Patient education, shared decision-making, and changes in care will facilitate successful outcomes, and treatment directed at weight reduction will aid in further reducing cardiovascular risks in patients with type 2 diabetes.

Your Thoughts?
Have you incorporated a holistic approach to managing patients with type 2 diabetes? Answer the polling question and join the conversation by posting in the discussion section.

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Which of the following strategies have you implemented in your diabetes practice? Select all that apply.
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