Susan Cornell, PharmD, CDCES, FAPhA, FADCES Associate Director of Educational Experience, Midwestern University, College of Pharmacy, Illinois, welcomes candidly Pharmacy Times at the APhA Meeting & Presentation on the rise of type 2 diabetes, chronic pain, and accessibility to life-saving agents and medications.
PT Staff: Can you highlight any major updates to medical treatment standards in diabetes – how does it affect the management of diabetes medications and comorbidities?
Susan Cornell, PharmD, CDCES, FAPhA, FADCES: I was so excited about the changes with the guidelines this year that I predicted this for gosh, I’m going to say at least 5, if not 7 years. But finally, and I’m very happy to say this, Metformin is no longer the first line out there. Now I know people are probably going, “Hey, what’s he talking about? Why is she happy about it? Metformin, a good drug in its time (and like the rest of us) is getting old. And you know, it’s time to relax. So Metformin is now approaching its retirement. Not to mention that he’s stepping back from managing diabetes and releasing “New Kids on the Block,” but he’s moving on and having a post-retirement gig. So it’s not going away, but it’s no longer in the spotlight. What you are asking us, again, many people have more than diabetes. So, when we are dealing with diabetes, we need to look beyond sugar – we need to look at obesity; we must look at cardiovascular disease, and kidney disease, and liver disease. There’s a big uptick in nonalcoholic fatty liver (NAFL) [and] Obesity rates are going through the roof. So I think one of the most important things is to address all these situations in 1 time. Therefore, short-acting glucagon-like peptide 1 (GLP-1) receptor agonists, sodium co-glucose 2 (SGLT2) inhibitors, are really coming to the fore as first-line therapeutics, either alone or in combination. . So I believe that’s where we’re going to see big changes coming down the pipeline, because we’re dealing with more than just sugar.
PT Staff: In what ways are diabetes driven by health inequities?
Susan Cornell, PharmD, CDCES, FAPhA, FADCES: Great question. You know, there are so many people who struggle with diabetes first and foremost; [and] rely on access to care. I work in a state-maintained clinic; I work with people who don’t have insurance, or underinsured, and they’re struggling. Sometimes they don’t even have access to a doctor. And with the fact that we have a shortage of primary care providers, it can be 3, 4, 6 months with a provider. And this time a lot of withered. So this is where I believe pharmacists can really step up to the plate to help people better manage their diabetes, not only in terms of medication, but also in terms of lifestyle. And if we think about it, life is really a lot of diabetes management – 90% is managing diabetes and always adding drugs to the lifestyle. Therefore, drugs do not replace lifestyle, they are added to lifestyle. But let’s think about this. Some people live in neighborhoods where it is not safe to walk. So how do we expect someone to get out of a bad neighborhood, or do you know a safe neighborhood? Exercise? You know, there are food deserts, there are food insecurity, there is instability in housing. So again we have to learn to do what I like to say – we have to learn to do the right thing from the wrong thing. And this is where he works with the individual person, which is necessary, and knowing that there is no 1 size fits all.
PT Staff: What are some of the worst culprits of health inequities and how do diabetes diagnoses arise in the United States?
Susan Cornell, PharmD, CDCES, FAPhA, FADCES: Yeah, we have the best medicine here, we have the best technology. But if we cannot get into the hands of a person with diabetes, it is useless. And the most important thing is that it is affordable. About half of these drugs or devices people want to know. Again, there is a lot of misinformation about life, and we need to get the right information to the people. So I think that the biggest misconceptions are out there 1 , probably the biggest reason for the rise in diabetes. And the continued trend of obesity is a rising factor. And just to speak a second time. So before COVID-19, 42% of the United States was obese. I’m going to say it again because it’s really impactful. 42% of the United States is obese. I’m not talking overweight, I’m talking obese. We do not have post-Covid-19 data. It is very interesting to see what those numbers are. Another interesting point is the new information that has just come out about the appearance of people with one type of diabetes. You know, historically, we’ve always looked at type 1 people as thin people with type 2 being overweight or obese. Now, it doesn’t matter. Two-thirds of people with type one diabetes are overweight or obese. So that 66% of people with type 1 have an obesity or overweight problem. So they are beginning to see not only the impact of life, but we are beginning to see common drugs type 2 leaves, but they have weight loss capabilities, they must be used in type one. Another thing is that we are diagnosed younger with obesity, let’s recognize obesity as a disease and treat it. If we don’t treat obesity, we don’t get control of diabetes. So diabetes, high blood pressure, cardiovascular disease are all equal. And we really need to address all 3 of those, as well as kidney disease and liver disease. So all 5 of them in 1 season.
PT Staff: How do the guidelines recommend remediating/treating patients with diabetes?
Susan Cornell, PharmD, CDCES, FAPhA, FADCES: Well, once again, the way of life is still the cornerstone; medication helps. So we can expect medicine to restore our way of life. and [that’s] As a result, we see people taking drugs, then stopping and then going back to their behavior. That’s where weight gain comes in. The standard of care focuses on the actual patient, and what comorbid conditions the patient has. So when we look at the guidelines today, as I mentioned, Metformin is no longer the first line, we look at: Does the person have cardiovascular disease? Do you have kidney disease? Do they have heart failure? In these cases, definitely GLP-1’s or sGLT2′. But we can look (and say) OK. Perhaps the person does not have a cardiovascular risk – which I find impossible with someone with diabetes, but the handwritten side – but then we must look at obesity. And when we look at obesity, GLP-1 antagonists really come to the fore because many of them are also known to have significant pain relief. So that’s where we’re going to see these newer drugs, double-dip for lack of a better term, that not only help lower blood glucose, but lower weight while protecting the heart at the same time. And that’s where we want to be. So again, I think newer drugs are going to be the front line. We are going to anticipate the anxiety because they know that eventually these drugs were really used, which they were at all. But we are finally beginning to see that it is time to enter the spotlight. And now there is a shortage of many of these drugs. You know, then, that something has happened, and that it will be healed in the very near future.