No one ever said treating type 2 diabetes is easy, but there are certainly two distinct schools of thought on how to do it: the physicians who use insulin, and the ones who don’t.
This month, I covered a diabetes meeting, the European Association for the Study of Diabetes (EASD) and, 2 weeks later, a primary care meeting, the American Academy of Family Physicians (AAFP), and they posed a contrast in styles for managing obese patients with type 2 diabetes whose glycemia doesn’t improve with two or so oral drugs.
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Among the diabetologists and endocrinologists at the EASD, opinion seemed tipped toward using insulin when type 2 patients get hard to manage. "We want to encourage physicians to use insulin earlier in type 2 diabetes in general practice, but doctors are afraid of using insulin. They are afraid of hypoglycemia," Dr. John Leahy told me at that meeting. He applauded the results of a study that randomized patients with type 2 diabetes with inadequate glucose control on one or two oral drugs to treatment with insulin or sitagliptin (Januvia), a popular oral drug. The findings showed that insulin did significantly better controlling glucose levels than sitagliptin, with a decent safety profile.
But the fear about insulin goes beyond hypoglycemia, noted Dr. Frank Domino, when he spoke last week at the AAFP meeting in Philadelphia.
"I hate putting patients on insulin. It will only make the patient more obese and insulin resistant," he bemoaned. "If you just treat the [hemoglobin] A1c, it doesn’t improve outcomes and probably make some things worse," he said.
Obese patient’s whose HbA1c remains above 9% despite treatment with two or three oral drugs need treatment for their chronic disease, obesity, said Dr. Domino, and that means treatments that go beyond HbA1c. He then gave a qualified shout out to the two newly FDA-approved weight loss drugs, Qsymia, which combines phentermine and topiramate, and lorcaserin, Belviq. While he characterized the Food and Drug Administration as "finally coming to the rescue" by approving this pair of weight-loss drugs, he quickly added: "I’m not encouraging you to use these drugs. I’m encouraging you to think of obesity as a chronic disease that needs all modalities of treatment."
Dr. Domino isn’t alone being cautious with weight-loss meds. An article in the Oct. 25 issue of New England Journal of Medicine from staffers at the the FDA laid out their rationale for approving the two formulations (2012; 367:1577-9). Also in the issue is an interview with drug guru Dr. Jerry Avorn, who spells out his reservations about using these two drugs in practice right now.
Dr. Avorn’s concern is the dicey safety history of weight-loss drugs of the past, and the scant safety record that the two new agents have so far.
"The average doc with a patient who wants to lose weight would be advised to wait until we have a known track record on these drugs, and restrict their use now to patients with morbid obesity" who face substantial health risks from their high excess weight." Dr. Avorn said he would have preferred Qsymia and lorcaserin get qualified FDA approvals that restricted the drugs to patients who met obesity thresholds and were treated by obesity specialists. But the FDA does not do qualified approvals.