Practical Decisions in Type 2 Diabetes

Mark Warren, MD: When I’m deciding about what medication to use in our patients, whether it’s to change medications or choose a new medication that they’ve not been on, I have to look at multiple things. I have to look at how they are doing on their current regimen. Are they compliant with it? Is it too complex for them? Is there something that I could do to make their lives easier and decrease their complexity, improve their compliance? Are there some duplications in the pharmacologic regimen that they’re on? Can I switch to a drug that’s more effective than another drug? It’s a very complex decision, and it’s not just based on 1 or 2 things. It’s based on multiple things. And finally, I think I look at the safety and the efficacy, how these medications work, what the trials have shown, and what their comparators are. Are they better than the previous medications that we had? Are they the same or are they more convenient? There are a lot of things that go into my decision process. I think it behooves the practitioner to know the new medications as well as the old ones, so that they can make the best decision for their patients.

Complexity of therapy does determine compliance. The more complex we get in our therapy, the less compliant a patient will be. It’s more difficult to take multiple daily injections, for example, than just taking 1 shot a day. So, I think that we’re trying to make things simpler, more convenient, for patients. Diabetes is not a very convenient disease, so we’d like to try to make it as convenient as we can. For example, can we have an insulin that can be dosed at any time of the day? Is there some flexibility in the time of the day that they take it? If patients forget it when they’re supposed to take it, when do they take it? When should they take it? So, if we have insulins that have less complexities, it would be better for our patients as far as compliance.

Compliance with any therapy does translate into changes in the medical cost of diabetes. So, if someone is poorly compliant, their A1C and their glycemic control is not going to be as well controlled as it should be, therefore causing more complications, admissions—hypoglycemia admissions, for example—or long-term complications that we see with diabetes, such as blindness or coronary disease. All of those have a very big cost, and most of the cost of diabetes is not pharmacologic, but it’s really more inpatient-based or hospital-based.