Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: We’ll discuss the traditional way of managing diabetes and then look at what happens nowadays. Did you want to say something? Are you with us on that 1?

Jaime Murillo, MD: I am.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: When we’re managing type 2 diabetes, we have to look at managing hyperglycemia. How do you manage hyperglycemia?

Eugene E. Wright Jr, MD: How I used to manage it?

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: No.How do you manage hyperglycemia based on the traditional model?

Eugene E. Wright Jr, MD: [The] traditional model is what I call the treat-to-failure model. We start with 1 drug, get them down to whatever their goal is, and wait for that to fail. Then we add sequentially another therapy.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: What medication do you use for that?

Eugene E. Wright Jr, MD: Typically, we use metformin as our first therapy, and we start patients on that. We see them back over a prescribed period of time. We look to see if we hit our target goal for A1C [glycated hemoglobin], and then we advance or maintain therapy based on that.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Very few people get to go on metformin. What’s the next drug in the sequential therapy?

Eugene E. Wright Jr, MD: If I’m looking at the patient holistically, I’m looking for risk factors for cardiovascular disease or chronic kidney disease.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: To manage hyperglycemia. We’ll get there.

Eugene E. Wright Jr, MD: We have therapies that treat hyperglycemia and also reduce the risk for these complications. Remember, it’s more than lowering glucose. I’m trying to get 2 for 1. If I can reduce their risk for cardiovascular disease with a therapy that also lowers their glucose, that’s where I’m going to go. The guidelines support that.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Which drug would you choose after metformin? We’re talking traditionally.

Eugene E. Wright Jr, MD: Traditionally, if they have cardiovascular risk, I like to go with a GLP1 receptor agonist. If they have chronic kidney disease or heart failure risk, I like to go with an SGLT2.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: So no sulfonylurea?

Eugene E. Wright Jr, MD: I don’t care for sulfonylureas that much. That’s the last resort for me. We have better therapies that do more than lower blood sugar.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: What if insurance companies tell you that you have to show them failing sulfonylurea first? What do you do?

Jennifer B. Green, MD: Before we move past that, I’d like to point out that metformin and sulfonylurea remained by far the most commonly prescribed medications around the world. We’re talking about an approach that’s not routinely implemented in clinical practice.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: That’s why I felt we could talk first about the traditional model.

Jennifer B. Green, MD: Exactly.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Then we’ll go to the new model.

Jennifer B. Green, MD: Exactly. There’s so much clinical incentive to use newer medications. It’s not just to reduce cardiovascular or kidney risk, it’s also because these medicines have little to no inherent risk of causing hyperglycemia, and they often provide favorable effects on weight. These are all things that affect almost every person with diabetes, whether or not they have cardiovascular risk. We can’t think about cardiovascular risk only for those individuals with diabetes because they care about hypoglycemia and their weight as well. In fact, the decision-making for an individual can’t follow a certain path. We need to make sure that whatever we’re recommending is medically appropriate for that individual but also something they can access and tolerate and would be willing to take. There’s no 1 size that fits all.

Transcript edited for clarity.