"One Month I'll take it, Next Month I Wouldn't" - Type 2 Diabetes (Part II)

In the second episode of our type II diabetes series, our patient Tabby joins us for a discussion on non-insulin therapies.

Share your reactions and questions with us at Speak Pipe . We might feature you on a future episode!

=== Outline ===

1. Introduction
2. Chapter 5 - Patient Centered Approach
3. Chapter 6 - Medication
4. Chapter 7 - Comorbidities
5. Chapter 8 - Barriers to medication
6. Conclusion

=== Learning Points ===

1. There are several non-insulin medications for diabetes that can be differentiated by their mechanisms and all have different indications on when to use them
2. A patient’s comorbidities may guide your choice for starting a non-insulin therapy. 
3. Explaining the side effects of a medication in the context of its mechanism of action may go a long way in helping the patient manage expectations around new medications. 
4. Addressing mental health comorbidities such as depression and anxiety can be key to initiating and maintaining the management of diabetes.
5. Create adestigmatizing environment when asking patients about their medication consistency

=== Our Expert(s) ===

Dr. Tracy Rabin is an Internist and Pediatrician who joined the Yale faculty in 2011 as a member of the Section of General Internal Medicine (YSM Department of Internal Medicine), and currently serves as the Associate Program Director for Global and Community Health in the Yale Primary Care Internal Medicine Residency Program (YPC). She attends and teaches on the medical wards at the St. Raphael's Campus (SRC) of Yale-New Haven Hospital; directs care and precepts residents in the SRC Adult Primary Care Diabetes Clinic

=== References ===

1. [American Diabetes Association] Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers: https://diabetesjournals.org/clinical/article/40/1/10/139035/Standards-of-Medical-Care-in-Diabetes-2022  
2. Figure depicting patient and disease factors that may be used to determine optimal HbA1C targets: Inzucchi, S.E., Bergenstal, R.M., Buse, J.B. et al. Management of hyperglycaemia in type 2 diabetes, 2015. Diabetologia 58, 429–442 (2015). https://doi.org/10.1007/s00125-014-3460-0 
3. Herkert D, Vijayakumar P, Luo J, Schwartz JI, Rabin TL, DeFilippo E, Lipska KJ. Cost-Related Insulin Underuse Among Patients With Diabetes. JAMA Intern Med. 2019 Jan 1;179(1):112-114. doi: 10.1001/jamainternmed.2018.5008. PMID: 30508012; PMCID: PMC6583414.

=== Recommended Reading ===

1. American Diabetes Association; 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2021. Diabetes Care 1 January 2021; 44 (Supplement_1): S111–S124. https://doi.org/10.2337/dc21-S009

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine where give patients the autonomy to participate as experts of the lived experience of their condition.

Hosts: Katie Gielissen, Maisie Orsillo
Post-Production Assistant: Christina Liu, Helen Cai
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: Mini Vandals, Kevin MacLeod, Patrick Patrikios, Dan Bodan, Nate Blaze

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

Transcript

Introduction

[00:00:00] Maisie: Hi. Welcome to primary care pearls. A podcast made by learners for. learners Led by our patient stories today

[00:00:09] Tabby: It's always a choice It's always, I'm going to prescribe you this. How do you feel about this? Is this something that you want to do?

[00:00:18] Maisie: we're talking about diabetes part two in our three part diabetes series on type two diabetes. 

[00:00:26] Katie: While some patients can have glycemic control with dietary modification, a large proportion of patients require treatment to achieve normal glycemia early and effective treatment has been shown to have many long-term benefits, including reduced rates of macrovascular disease, such as coronary artery disease, as well as microvascular disease, such as nephropathy and retinopathy.

[00:00:51] Maisie: During our discussion today, we'll be joined by Tabby a patient living with diabetes. 

[00:00:57] Tabby: Hi. I tabbed with a blunt. My age is 32. I go by Tabby 

[00:01:03] Maisie: we'll also be joined by an expert from the Yale school of medicine,

[00:01:07] Rabin: My name is Tracy Rabin, and I'm a med peds physician. I'm the associate program director for global and community health in the Yale primary care internal medicine residency program. And I'm also the director of our diabetes clinic within our resident and faculty practice.

[00:01:38] Maisie: And our faculty interviewer, Dr. Katy, Gillison

[00:01:41] Katie: I'm Katie Gielissen I'm an assistant professor of medicine and pediatrics at the Yale school of medicine, and I'm a primary care doctor. 

[00:01:48] Maisie: With the conversation facilitated by our resident interviewer, Dr. Alyssa Chen

[00:01:53] Alissa: I'm a third year resident in internal medicine in the Yale primary care program and will be chief next year

[00:02:00] Maisie: our discussion today is part two focused on non-insulin therapies. My name is Dr. Maisie Orsillo, and I'm a second year primary care internal medicine resident at Yale. And I'll be co-hosting this episode with Dr. Katie Gilson. We hope that through this discussion, listeners will become more familiar with some of the medications we use to treat diabetes

[00:02:23] Katie: Which don't include insulin. 

[00:02:25] Maisie: fortunately, in recent years, our repertoire of medications have expanded significantly, which provides many more options for patients and providers to meet their life and glycemic goals. When combined with lifestyle modifications, including dietary change and exercise, medications can form an essential component to prevent progression to kidney, eye and cardiovascular disease. 

[00:02:50] Katie: Before we get started, please know that this content is meant to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you or a loved one is suffering from anything covered in today's episode, be sure to discuss it with your medical provider while brand name metaphor, while brand name medications are discussed in the show. We do not endorse the specific use of any brand name medications now onto the show. 

Chapter 5: Patient Centered Approach

[00:04:39] Alissa: thinking broadly, what are your goals when you're treating diabetes?

[00:04:46]Rabin: the primary goal is to have a patient centered approach. There are fantastic evidence-based algorithms that exist to help guide us in choosing different types of medications for different individuals who have various comorbidities. Those are fantastic. But they don't work. If the patient doesn't take the medication and they don't work. If the patient isn't able to. The diet that they wished they were able to. And they're not, it doesn't work. If the patient doesn't feel safe, exercising or doesn't have access to a place where they can exercise the way that they would like to.

[00:05:22] So I think the most important goal is to achieve something that your patient feels that they can do. That's going to help them stay engaged in care for the long term.

[00:05:31] Maisie: Framing and embedding the conversation in an overall plan of lifestyle modification is absolutely essential. This must be led and informed by the patient's specific situation and their access to resources such as healthy food and safe places to engage in exercise.

[00:03:20] Katie: let's hear a little bit about what factors help motivate our patient Tabby to take medications in the first place. 

[00:03:38] Katie: you mentioned before having difficulty remembering your medicines, what things have helped you to stay on top of them? 

[00:03:46] Tabby: Uh, Feeling sick in the morning, feeling crappy Understanding that I'm feeling this way because you need to take your medication. And ginger ale is not going to help you soda crackers.

[00:03:57] I'm not going to help you. You have to take your medicine. That crappy down. I'm not feeling I'm just overall not feeling well. Is what's. I said, okay, I'm tired of feeling this way. And I had such a problem with actually committing with my medicine that it was an off and on thing for me. One month I'll take it and then the next month I wouldn’t.

[00:04:20] But then when I got in my mind, it's time for me to take it again. I would have to go through that all over again. I'm feeling sick and it's like Tabitha, aren't you tired of constantly feeling sick and I'm like, yeah. So it's just take it at this point. Just take it.

[00:33:39] Do you have a system or do you use your wife or anybody else to help you remember?

[00:33:44] Tabby: Yes, absolutely. So funny thing I have a visiting nurse and they come in seven days a week. They're wonderful. They prepare my meds every morning and. That's how I take them, because if it was left up to me, I'd feed the dog. I'd make breakfast. I'd watch the view before, you know what? It's 12 o'clock morning meds at Dawn.

[00:34:15] I'm taking a nap now. I'm at the grocery store. I'm at my mom's house. Noon meds have gone. Now are coming back home. I'm making dinner and playing with the dog. We're over here, looking at the newspaper. It's time to go pick up. My wife evening meds are done that whole day I’ve wasted. So I needed help.

[00:34:39] Was I ashamed of asking, so I'm 32 years old. Why do I need a visiting nurse? And I almost canceled them. I did. She came in and she was wonderful. She said where's all your meds embarrassed. You know why didn't. I didn't know where they were. So I'm like, I'm scrambling, but this is this.

[00:35:05] And that's that this is this. And, I ended up finding them all, whatever I didn't get, I would CVS and God, and they checked my, they made sure I checked my sugars and they checked my heart. She takes, checks my blood pressure. They hold me accountable because they have a lock box in my house, which I was upset about because it's like I’m a child.

[00:35:32] There's some reason for you to lock my meds up and I'm kicking you out. And then I thought about it and I said, no, let it stay. Now. This is the part where it clicked to me. Oh crap. They locked that box. So I can't put the pills back in. Whatever she left for me is shown. So if I didn't take it, it's there something like, oh, so I'm being held accountable and sometimes that's okay.

[00:36:02] That's okay. It's nothing to be ashamed about that. 

[00:36:05] Maisie: Tabby is fortunate to have a nurse to keep her accountable for taking her medications. Other strategies, such as engaging family members and recommending a pill box can be quite helpful. I'm a huge fan of the pillbox. Dr. Gillison it's really helpful. 

[00:36:19] Katie: I too am a huge fan of the pillbox. Um, the other thing that I've found to be really helpful are blister packs.

[00:36:25] Some pharmacies can prepackage a week's worth of medications. So patients don't have to remember each single pill. And then the other thing I find it really helpful for those, you know, who have trouble opening a pill canisters, or maybe have trouble reading either through eyesight issues or literacy issues. It can be really helpful to kind of put everything all in one place. 

[00:36:50] Maisie: Totally. And I think that in general, particularly if you have a patient who is resistant to visiting nurse services, I do have some patients who are worried about someone coming into the home. I think it's always critical when a patient's on multiple.

[00:37:03] meds To bring the pill bottles in with them, the whole brown bag thing. It really does work. You'll be surprised how people are taking their meds.

Chapter 6: Medication

[00:05:48] Katie: So let's start to talk about non-insulin medications, Macy, what medications come to mind when you're thinking about what to prescribe? 

[00:06:04] Maisie: Well Dr. Gillison I have a few favorites, but the ones we'll be covering today include Metformin.

[00:06:11] sulfonylureas, such as glyburide and glipizide; GLP-1 receptor agonists, such as and liraglutide, SGLT2 inhibitors, such as empagliflozin and dapagliflozin

[00:06:27] DPP-4 inhibitors, such as linagliptin and Sitagliptin and TZDs, which don't come up in this discussion, but they're an important class to chat about.

[00:06:37] Katie: I remember when I was first learning about these medications, I had the hardest time remembering what did, what 

[00:06:44] Maisie: agree and the different names and the generics forget about brand names for this conversation, but it gets super confusing. 

[00:06:59] Katie: the next step is to think about which medicines do I start first? 

[00:07:04] Alissa: After a patient has a diagnosis of diabetes and you feel like you have to start pharmacotherapy, what's the first thing you're reaching for.

[00:07:11] Rabin: this is changing a little bit over the past few months so up to now pretty much we were reaching for Metformin as our first medication. But due to the the increasing body of evidence, that's supporting the use of other classes of drugs, the SGLT two inhibitors, GLP one agonists for.

[00:07:32] folks who have specific comorbidities there, the American diabetes association in their 2022 update basically said that there may be compelling reasons to think about one of these other classes of medications as your first choice before Metformin.

[00:07:46] So I think that's really nice to see how the recommendations are evolving with this this growing evidence. 

[00:07:52] Alissa: my mind is blown. I can't, I don't just start metformin on everybody.

[00:07:57] Rabin: I know, I'm sorry. 

[00:07:58] Alissa: Three years of training, man. So talk a little bit more about that then. So what are these other medicines we might reach for first and what are the circumstances in which we might use?

[00:08:10] Rabin: Sure. Yeah. I think the ADA has done a really nice job of trying to review the evidence, but also lay it out in a nice graphic form. So the current standards of care has a really nice table that sort of talks about why you might choose different medications.

[00:08:25] I think the three key comorbidities really are, atherosclerotic cardiovascular disease heart failure and then chronic kidney disease. And so really we're talking about the classes, the SGLT two inhibitors and the GLP one agonists.

[00:08:41] And so thinking about, if somebody has. A history of heart attack, a history of stroke because of the morbidity and mortality benefits that have been shown with the GLP one and SGLT two inhibitors. The thought is that actually getting one of those two classes on board early on may actually be more beneficial.

[00:09:04] A number of years ago, there was some suggestion that Metformin also had some benefit on cardiovascular disease outcomes. But that hasn't necessarily borne out the evidence hasn't been anywhere near, as strong as we're seeing for these other two newer classes. And so that's the thought.

[00:09:19] So as far as CBD, thinking about one of those two classes to start first as far as folks with with Hartfield. Thinking about, the benefits of SGLT two inhibitors both in terms of just thinking about volume reduction, but then also the general effects of the medication itself.

[00:09:36] And similarly with chronic kidney disease and the data that's been emerging about how the SGLT two inhibitors can actually delay progression of chronic kidney disease. That's also something that's very compelling and there's also, some data showing that GLP one agonists can also have a positive effect on delaying chronic kidney disease though data's much stronger for the SGLT two inhibitors.

[00:09:57] So really thinking about, should we be reaching for one of those two classes of medications first though acknowledging that Metformin is still a very useful. Medication, it is very cheap, it's effective. And it importantly, it can be combined with some other medications too.

[00:10:11] So if you're worried about pill burden it still is very effective medication. And for all other patients, we still would consider Metformin as an appropriate first line medicine. With this update sort of thinking about maybe for these specific groups of patients, we might want to start with one of these other classes. 

[00:10:27] Alissa: Wow. So cool. I feel like the research is really getting into practice so quickly. That's such a cool thing.

[00:10:32] Maisie: So some fantastic pearls there let's review, which drugs are helpful. for what? For atherosclerotic cardiovascular disease we have SGLT two inhibitors and GLP one agonists. For patients with heart failure we have SGLT two inhibitors. And for patients with CKD, we have SGLT two inhibitors as well as in some instances, GLP-1 agonists 

[00:10:57] Katie: And let's not forget. Metformin is still an important first-line medication due to its safety and affordability.

[00:11:03] Tabby: When I take my medication, I feel like I'm the person that had no symptoms. So was that back to me and better?

[00:11:12] Yeah, absolutely. When I don't take my medication. I suffered through it. I suffered through it.Tabby, you need to take your medication because you don't feel like this. You don't have sharp pains in your feet, aren't swelling. You're able to walk around a little bit better. What time is it? What time is it? Okay, okay. I'm going to take my meds because I don't want to feel sick. I don't want to have pain. It's painful. It's painful. It's painful to walk. It's painful to sit. It's painful to lay down. You're not getting any comfort. And I know if I take my medication, I won't feel that.

[00:12:06] So now I have to take it. I have no choice. I have no choice.

[00:12:12] Maisie: Let's hear about the patient's experience with SGLT two inhibitors and Metformin 

[00:12:18] Tabby: So my primary care doctor prescribed me a medicine and I called it the PP pill. And so I'm taking the medicine and.

[00:12:35] I gotta go. I gotta go. And then I'm thinking to myself, oh my God, the number one side of using the bathroom all the time was such a sugar. So I'm checking my sugars check, and my sugars are fine. What is going on? What's going on in the middle of the night.I had to go so bad. And I said, I'm not taking this pill anymore because I feel like I can't go anywhere. So when I came back to my primary care doctor said, I don't want to take the baby pill anymore.

[00:13:19] I was on Metformin and I was told by my primary care doctor, this is the best medicine for you for your diabetes. She's the ticket. So I'm like, yeah, I'm going to take your ticket. I get into the bathroom and I get.

[00:13:36] So hard on my stomach. It was so hard on my stomach and I don't mean to be nasty or graphic, but the smell from my own feces, I was in the, I was in the bathroom gagging and I said, I can take this. I'm going take it. I'm not taking. And I came back to my primary care doctor and said, I'm not taking that's I'm gagging in the bathroom.

[00:14:02] Alissa: Another struggle that especially Tabby talked about was side effects especially things that she wasn't expecting. And so do you kind of address patients concerns about side effects? How do you help them take them consistently? Or how do you counsel them

[00:14:17] Rabin: Yeah. That's a great one. I think you have to be upfront that that the medications that we use to treat diabetes have side effects. They all have side effects. And I think being. Open and honest about that upfront and also why they have side effects. I think about, for example, the class of GLP one agonists, are DPP four inhibitors, right?

[00:14:37] And you think about some people will have bloating. Some people will have abdominal discomfort. Some people will feel early, satiety will, why is that? That's because the medicine is doing what it's supposed to do. It's part of what it's doing is it's slowing down the transit time of your food.

[00:14:53] The solution to that would be to try to eat smaller meals or listen to your body while you're eating and think about, oh, am I feeling full sooner than I normally would? Am I eating less? This is part of why, weight loss is an expected side effect of GLP one agonist too.

[00:15:08] And I think, I don't know if you explain to people how some of the side effects they might expect. Relate to the way that the medicines work. I feel like people are more forgiving or more apt to think about, is this something that's going to make me stop taking this medication?

[00:15:23] Or might I alter the way that I'm eating or might it alter the way that I'm taking the medication to try to reduce the side effect? It makes it less of a magic, the, I think about, oh, you might have these side effects. Will you magically have these side effects? If you can relate the way that you're feeling to the way that you understand the medication to be working in your body, it might make a little bit more sense.

[00:15:43] I feel like I've had some luck with that. But also when patients come in and they say, oh, I was taking Metformin, you're listening to Tabby's experience about having diarrhea with Metformin. I am completely sympathetic to that. That sounds like an experience that I would not want to have myself.

[00:15:57] And Metformin is a great drug for many reasons. And if people stick with it, if we find the right dose, sometimes it's a matter of just decreasing the dose until you find the one that the patient can tolerate. You can play around to try to minimize those side effects. But but again, it's not about, and I like to say to patients, I'm not going to ever force you to take a medication.

[00:16:17] I'm just going to say, this is a good one. We can do these things to try to minimize the side effects, but if really your body is reacting in this way to the medication, then we need to find something better for you.

[00:16:27] Katie: Managing expectations surrounding side effects and side effects themselves are a key aspect of diabetes management. Maisie. Can we quickly review the common side effects of each class? 

[00:16:38] Maisie: Ooh, maybe quizzing me a little bit, but. let's do it 

[00:16:41] Katie: Alright. 

[00:16:42] Maisie: Uh so first we have Metformin which can cause some diarrhea or GI upset and B12 deficiency.

[00:16:50] Katie: Second, we have sulfonylureas which can cause hypoglycemia, especially in older adults. And I always tell my patients about weight gain 

[00:16:59] Maisie: and then next we have GLP-1 receptor agonists, which can cause weight loss. In some instances that's a desired effect for patients, Uh, nausea, vomiting or other GI upset, a medullary thyroid cancer, which has only been shown in rat studies and pancreatitis, which has only been shown in the trials with GLP one agonists.

[00:17:22] Katie: Next, we have SGLT two inhibitors, which can have that desired side effect of weight loss, polyuria, and polydipsia, which can lead to dehydration, especially in older adults. In my, uh, female patients, I think about yeast infections and urinary tract infections. And then there's that rare side effect of euglycemic DKA.

[00:17:43] Maisie: And then finally we have DPP four inhibitors, which can cause some mild upper respiratory infection, like symptoms and GI upset. 

[00:17:53] Alissa: So I know there are still the other medications, a sulfonylurea is the other meds. And as a resident now it's their meds that just don't see that often. And certainly I don't think I've ever initiated them.

[00:18:06] But what do you feel like trainees still need to know about them? And when might we reach for those.

[00:18:12] Rabin: Many of the patients in our practice have Medicaid and we're very fortunate that Connecticut Medicaid is in a place where our formulary coverage covers at least, one or two medications from pretty much any class that you would want.

[00:18:25] So I think we are in a very fortunate position of being able to really prescribe whatever we want for those patients. And when I think about sulfonylurea is when I think about the the thiazolidinediones or TCDs, I think about the McClinton ad class. I think about the DPP four inhibitors, they all have a place.

[00:19:05] When you think about, side effects, when you think about, do you have a patient whose diabetes is poorly controlled and they're on an SGLT two inhibitor and they're on a GLP one they're on Metformin and they don't want to start insulin for whatever reason, right? so you need to have another class of medication that you're able to start. And depending on what their needs are, you may choose any one of these other meds. So that's still is something that's very much relevant. And yeah. So I think that, cost is certainly an issue side effect profile is certainly an issue.

[00:19:36] A1C reduction capacity is an issue. So that, so I think there, there definitely are places for those other medications  whenever we have the opportunity to have those conversations in clinic, I really love to be able to push push, to push everyone as to to think about okay what if we couldn't prescribe this?

[00:19:53] Or, okay. So what's the next step going to be if this doesn't work and try to think about why would I use one of these other classes that's not as common? 

Chapter 7: Comorbidites

[00:20:00] Alissa: Okay, let's talk a little bit about co-morbidities because I know there's so many diseases that kind of interplay with diabetes and so why which one, which cover buddies are you really looking for when you're treating diabetes? I'm why are they 

[00:20:14] Rabin: sure. So in terms of thinking about medication choices, and so it benefits, thinking about atherosclerotic cardiovascular disease, thinking about heart failure, thinking about chronic kidney disease, for sure. I think that. The mental health comorbidities also play a huge role in terms of someone's ability to do the things that they need to do to take care of themselves with diabetes.

[00:20:38] So thinking about depression, thinking about anxiety, thinking about diabetes distress, which is not an official sort of mental health diagnosis, but it is an entity that, that so many patients of ours are dealing with or struggling with. certainly thinking about sort of mental health co-morbidities Is an important piece.

[00:31:47] Tabby: I suffer from depression and anxiety, and that has a big role to play with not only my diabetes, but any other complications we're having. And that was a part of me going off of the medicine and coming on, going off and coming on.

[00:32:11] And it wasn't until my primary care doctor said to me in a visit what do you think is the reason why you keep doing that?

[00:32:22] And I was like, wow, that's a great question. why?

[00:32:27] And then I said to myself, it's my depression. It's my anxiety. I have to get that under control. Is diabetes number one? Yes. Is my mental number one, one, absolutely. Because without that under control, I can't take any medicine. I don't feel right. I'm depressed. I'm down. I don't feel like taking the medicine.

[00:32:52] So now I'm not taking the medicine. I'm not taking my depression medicine. Now I'm back to feeling crappy. My feet are hurting. It's a domino effect.

[00:33:03] Katie: that's probably one of the more common things that I encounter and it's a, in some ways related to diabetes distress, but in other ways it's, uh, a separate entity. So if somebody already has a history of depression or anxiety, um, it's really hard for them to be able to fully manage diabetes, which is a complex and multifactorial disease that requires a lot of sort of ongoing management and forethought.

[00:33:30] And so addressing the depression, anxiety can be really key to moving on to the next step of actually addressing the diabetes. 

[00:20:55] Thinking about obesity, thinking about sort of folks being overweight, thinking about folks being obese and the role that weight loss can play in helping to to bring down blood sugar. So that's an important piece as well. Also, other habits like tobacco use disorder other substance use.

Thinking about the increased risk of atherosclerotic cardiovascular disease, when you are engaging in tobacco smoking, things like that. And then also, other CVD risk factors. So think about hypertension thinking about hyperlipidemia.

[00:21:26] So there's a lot there's a lot that goes into it. And all of this is helping us think about how to craft the best management plan for our patient with the sort of psychosocial overlay and understanding of social determinants of health and their, support in the community, wrapping its arms around all of that.

[00:21:44] Alissa: Is there a way that you speak to patients about these comorbidities and how they come into play with their diabetes? Even the mental health comorbidities?

[00:21:52] Rabin: Yeah. I think, I try to stay focused on, why is it important to manage your diabetes? What are the end end organ damage, related outcomes, what are the things that we're trying to prevent? what can we do to try to get these under control in addition to your diabetes so that we reduce the risk that you're dealing with these things down. 

[00:22:31] Katie: In addition to the cardiovascular heart failure and CKD co-morbidities, we mentioned before, there are a few other considerations to keep in mind as you're initiating treatment for diabetes. Part of this is focusing either on conditions that can affect medication adherence or those that can worsen risk for diabetes related outcomes, such as heart attack and stroke.

[00:22:53] So some of the things I think about Maisie, when I'm thinking about other things to manage our, you know, does this patient have comorbid depression or anxiety? Do they have an elevated BMI? Are they using any substances like alcohol and, um, are there other things I should manage carefully given they have diabetes like hypertension or hyperlipidemia

[00:23:15] Alissa: And as patients age, how does your treatment of their diabetes change?

[00:23:20] Rabin: Yeah. So again, so this is another, I feel like everything is so individualized, but but certainly as folks get older we're taking stock of what, what is our goal in terms of A1C. And is there any reason why we should be more lenient in terms of, what we're trying to achieve with glucose control or less or more strict?

[00:23:39] As folks get older, as folks develop more comorbidities that may be higher priorities to them. 

[00:24:20] We still want to prevent these other complications from happening.. But I also, it's important for me to know, where it fits into the list of priorities. And certainly as folks get older as folks are more frail, maybe at more risk for falling thinking about cognitive impairment too not just related to typical aging, but also folks who have had cycles of hypoglycemia over time, putting them at risk for increased rates of Cognitive decline.

[00:24:46] So all of those things, play into what we're doing in terms of how aggressive to manage their sugar, but also what other support do we need? Is it time to see if we can get a visiting nurse to come into your home to help you with your medications? Are you using a pill box? Is there a family member that you live with who may be able to help out in all of those things and I think as folks get older becomes more pronounced and we start to think about are we, should we actually be stopping some of these medications in order to to try to balance some of these other factors.

[00:25:17] Maisie: individualizing therapy based on age situation. And other factors is essential for patient buy-in and successful management of diabetes. 

[00:25:26] so, Dr. Gillon, when you're thinking about setting an A1C goal for a patient, uh, what sort of things do you take into account? 

[00:25:34] Katie: There are a whole bunch of things I think about. And first I'd like to refer people to the ADA.

[00:25:39] There's a great image that I use as a reference in the way that I frame patients. One is, you know, do they have any comorbid conditions, uh, that could put them at risk for low blood sugars? Um, and if they have a lot of comorbid conditions having low blood sugars could actually exacerbate some of those things. So I tend to be a little bit more permissive with the A1C. In those cases, if I have a young, healthy person, I generally go for an A1C less than or equal to seven. If somebody has a lot of other health issues like severe cardiovascular disease or cancer, I might aim for an A1C of less than or equal to eight.

[00:26:18] The other thing that I think about is the age of the patient. So if they're above the age of 65, in those patients, having low blood sugars can be really dangerous. So I tend to be a little bit more permissive in those patients as well. So even in a relatively healthy older adult, I might, uh, aim for an A1C less than 7.5. If they have some comorbid conditions less than eight. And then for those who are bedbound, I usually aim for less than or equal to 8.5. 

Chapter 8: Barriers to Medication

[00:26:46] Katie: Let's transition to talking a little bit about barriers to taking medications 

[00:26:51] Rabin: I feel like you can't talk about diabetes management without talking about cost. Because again, as I was saying if the patient can't get the medicine and if cost is the barrier, they're not going to take it and you can craft, whatever fantastic regimen you like, but but if they can't afford it, then it's not going to Do anybody any good.

[00:27:09] So I think, when we're talking about different options for regimens, I think, we're often, we're always looking at what is the patient's insurance and trying to get an understanding of that. as I said, we are fortunate in Connecticut to have a pretty robust Medicaid formulary for diabetes.

[00:27:27] And so we have a sense of what the options would be. And it's easier to talk to patients about, here are a couple of different options. All of these would be covered by your insurance. I think when folks have private insurances, those formularies changed so often it's hard to really keep tabs on what will be covered.

the more communication that there can actually be about what a patient can actually get the better it's going to be in our diabetes clinic, fortunately, we have a pharmacist and pharmacy students who come and work with us.

[00:28:44] And one of the things that they can be so helpful with is calling the pharmacy. We decide, okay, we're going to prescribe this. So let's send the prescription over and then have one of our pharmacists call the pharmacy to see what's the co-pay gonna be. And then we can actually feed that information back to our patients.

[00:29:00] But of course that takes time and not everybody has a pharmacist who can just spend their time doing this kind of work in their clinic. So I think it's a big challenge.

[00:29:11] Alissa: Do you find that patients are forthcoming when prescriptions are too expensive for them? Or is that something you have to get out of them?

[00:29:17] Rabin: It's a good question. I think it's all about creating a safe space and normalizing the fact that we know that people miss doses of their medications. We know that that this happens that, I actually was fortunate to participate in a in a research project, looking at how frequently patients actually ration their insulin for cost and other reasons.

[00:29:37] And it's actually, it's more common than we think. And actually more common in patients that actually have some insurance as opposed to folks with with no insurance or Medicaid. So really, I like to think about creating a safe space where it's okay for someone to say, you know what?

[00:29:52] I took two doses out of seven of my basal insulin this week. Okay. I can work with that. If you tell me that you're taking your insulin every day, and these are the sugar numbers that I see, I'm going to have a very different plan in mind for you. And so I think part of creating that safe space is letting people know that the reason I'm asking is not to test them.

[00:30:13] I'm asking because I really want to know because I'm only going to be able to help them in a safe way, if I have a good idea of what they're doing., are patients honest about cost? I'm sure that there are folks who are not forthcoming all the time. I'm sure that there are folks who may see us, may see me multiple times and not necessarily share, but I think that our goal should always be to try to de-stigmatize.

[00:30:38] Sort of this variability in med adherence and just let them know that it's okay to talk about it because it's actually going to be a safer situation for them if they are forthcoming about it. 

[00:30:48] Katie: Have you ever had any trouble getting a hold of your medicines either? With the pharmacy or even like affording medicines? 

[00:30:55] Tabby: Absolutely. Absolutely. There have been some medications that my primary care doctor has prescribed to me that my insurance did not cover.

[00:31:05] There has been times where I had to pick and choose. If. I could get the brand. Sometimes I would ask is there a generic and then it was all your doctor has to write you another prescription. I can't give you generic. So at that point, I'm so frustrated.

[00:31:23] Forget it. I don't want it anymore. If it's going to be this hard to take the medicine that you tell me to take, I can't get ahold of it. It's too expensive. I'm not going to, I'm not coming back to you. I'm frustrated now. And I walk away. 

[00:37:12] Maisie: There are many options for the treatment of diabetes and first-line therapies have expanded to include multiple oral and injection medications. The selection of therapies should be based on the comorbidities present as well as patient preference, by partnering with our patients and leaving the door open to discussion.

[00:37:29] We can carefully monitor for barriers to taking medications, including intolerable side effects or cost issues. And that concludes our episode for today. 

Conclusion

[00:37:40] Katie: So let's walk away with some key points from the show. First, there are a ton of options that don't include insulin for treatment of type two diabetes first-line therapies include Metformin as well as some disease-specific medications, such as GLP one agonists and SGLT two inhibitors.

[00:38:00] Second, there are specific indications to use SGLT two inhibitors and GLP one agonists in patients with coexisting medical conditions, such as heart failure, atherosclerotic cardiovascular disease and chronic kidney disease. And third prescribing medications are a great first step, but we should be attentive to barriers that can impact a patient's ability to take their medications such as cost and anxiety and depression.

[00:38:30] Maisie: Be sure to tune in next time, wherever you listen to your podcasts to catch part three of the type two diabetes series, where we'll be discussing my personal favorite insulin, we hope you enjoyed this episode, which was made possible by contributions from our patient, Tabby, our resident interviewer, Dr.

[00:38:48] Alyssa Chen and Dr. Tracy Raven, who provided faculty peer review for the project and served as our. expert Special, thanks to Keval Desai, one of the key writers for this episode and our producers, August a Loco, Helen sigh and Joshua on Django as well as our faculty advisor, Dr. Katy Gillison. 

[00:39:06] Katie: That's still me be sure to follow us at PC pearls on Instagram, where you can expect to get sneak, peeks, additional learning content and the most up-to-date details on show release times.

[00:39:18] Thanks again for joining us today. Farewell from all of us at the primary care pearls podcast, and we'll catch you in the next one.

[00:39:28] I can't describe in words how happy I am when I walk in a room and see a bag full of medications. 

[00:39:34] It's pretty nerdy to say, but it's true. It's really