Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: I’d like to hear your point of view on the insurance companies. Insurance companies still look at it as a drug for glucose, and feel they need to fill metformin. But I want to prevent a kidney problem. I want to manage heart failure. I want to prevent strokes. What does metformin or sulfonylurea have to do with that?

Jaime Murillo, MD: We have 2 camps here. You’re with Eugene, and I’m with Jennifer [laughter]. What’s fascinating about what you’re just talking about is this: where’s the value? The value in terms of benefit for the patient outcomes in a way that’s not going to continue to burden the health care system. In the United States, $4.1 trillion is spent on health care, and 90% of that goes toward chronic disease. This is a big part of many comorbidities associated with diabetes. Where do you put the money, so to speak? We need the guidelines. But you’re talking about randomized clinical trials guiding the writing of those guidelines to some extent. What we need to do, at least for the time being, is see where can we create the most impact. That’s what Jennifer was talking about. If you have someone with a complication or who’s at high risk for developing a complication, then that’s someone you need to treat more aggressively.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Hold on. That’s exactly my question. You’re evading my question. I’m taking Jennifer’s patient, and I’m not giving them metformin. The patient has diabetes, with an A1C [glycated hemoglobin] level of 7.8%, an estimated GFR [glomerular filtration rate] of 58 mL/min, and a little albuminuria. I want to give an SGLT2 inhibitor.

Jaime Murillo, MD: You can.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: I don’t give metformin.

Jaime Murillo, MD: You should.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: They tell me, “No, give metformin first.” When do you allow us to treat [them]? By the way, with SGLT2 inhibitors, we’re also looking at individuals without diabetes if they have heart failure or kidney disease.

Jaime Murillo, MD: They have heart failure.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: When do you approve it?

Jaime Murillo, MD: Let me tell you the good news.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Go ahead. I’d like to hear it.

Jaime Murillo, MD: We go from the evolution that we mentioned earlier where you had to maximize 1 class and then move on to the next. Now we’re thinking that we should introduce several classes at a lower dose, so we can get multiple effects and the patient can benefit earlier. The same case that happened with heart failure is now happening within the diabetes space, thanks to those studies. More important, we should talk about the guidelines. The guidelines carry a lot of weight when it comes to an insurance company making decisions about what to reimburse and cover. In a heart failure space, we saw medications that were considered second or third line had already demonstrated real benefit. That step therapy that we talked about has been eliminated. If 1 of those 4 classes has an indication, a patient has heart failure regardless of diabetes.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Would you convince the other insurance companies to do what you’re saying?

Jaime Murillo, MD: I hope everybody is doing it.

Jennifer B. Green, MD: Absolutely true.

Jaime Murillo, MD: We should be doing it. The same thing happens in diabetes. If you have diabetes, which already has chronic kidney disease or heart failure, and so on, you shouldn’t have to fail metformin. We know metformin at that stage isn’t going to do anything. That’s the good news. We’re evolving and treating patients according to their risk profile in a timely fashion.

Jennifer B. Green, MD: Before we get too far down that road, it’s very clear that the vast majority of prescriptions for SGLT2 inhibitors and GLP1 receptor agonists [in the United States] are prescriptions for these lower-risk individuals. They’re prescribed primarily for the control of hyperglycemia. In fact, implementation of these beneficial treatments in the higher-risk group is very low.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Let me ask you, Eugene. Go ahead.

Eugene E. Wright Jr, MD: You hit on something there. The message about SGLT2 and GLP1s that’s in the guidelines hasn’t made its way into the clinical practice protocols. In many cases, the practitioners are still using sulfonylureas and metformin. This is a third or fourth thought for them. It’s incumbent on not just us as clinicians but for the insurers and the IT [information technology] systems to say, “You have a patient at risk. Tell me why they’re not on this therapy.”

Jennifer B. Green, MD: Exactly.

Eugene E. Wright Jr, MD: If I have to stop and think about that, I’m much more likely to move.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Here’s the issue. The way I see it, it’s the price. In the late 1990s, metformin was very expensive and NAC [N-acetyl L-cysteine] was expensive. There was a war between the companies. Should we prescribe metformin or NAC? They worked very well together at the time. Later on, when metformin became generic, they combined them to work very well because it cost very little. At that time, when we write guidelines, we look at the signs first. We make a cost assessment by other individuals later on despite the guidelines. For example, if I look at an SGLT2 inhibitor for patients with CKD2 [chronic kidney disease, stage II], estimated GFR [glomerular filtration rate] of 68 to 72 mL/min, I can see that they almost flatten the deterioration of kidney function. Give it a clearance, where they’ve got a much lower estimated GFR. It improved the care but doesn’t flatten the curve, and they continue to lose. There will be many benefits for the kidney if we start at CKD2. Two years from now, 1 of the SGLT2 inhibitors will become generic. What would you say then if it costs $5 a month?

Jennifer B. Green, MD: I’d say the same thing. I’m a believer in the evidence. But in the present, some decisions need to be made.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: We agree.

Jennifer B. Green, MD: To be a devil’s advocate, it would be absolutely appropriate and probably would positively affect population health if we started using those drugs very early on in the course of diabetes. No question.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Jaime.

Jaime Murillo, MD: That’s definitely the right direction. You mentioned the cost. It’s also about the patients. Eugene, you’re talking about who’s getting it because you’d like to give it to them earlier. It makes me think about low-risk patients. Who can afford $2600 to $2800 co-pays? And that’s if the insurance company approves them.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: They can’t afford it.

Jaime Murillo, MD: Some patients said, “There’s no way I’m going to be able to afford those co-pays.” When you say we’re going generic, there’s an opportunity to extend care to those patients. We have to be mindful of that. At the same time, it’s another call to go back to value-based care. If you have a population of patients with diabetes, and you’re not thinking about billing for every procedure, visit, and test, then you think about the patient as a whole. You start thinking; we can afford this specific medication for this particular group. We’ll just continue to monitor and screen them. That could bring that balance that you’re talking about, Jennifer.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: A couple of things have emerged in our discussion. One thing is that individuals who already have an established cardiovascular disease or kidney disease are at very high risk. We need to look at those medications. Managing them very early on with everything we can is very important. In this case, if somebody has an established cardiovascular disease, they’re at risk for heart attack, stroke, heart failure, and maybe also CKD. In that respect, SGLT2 and GLP1 would both work in this particular patient. The earlier we gave it, the better the patient will be. This is for the established disease. On this, we can probably agree.

Transcript edited for clarity.