Finding the Sweet Spot of Primary Care Diabetes Management

Jay H. Shubrook, DO: Hi. I'm Jay Shubrook, DO, professor at Touro University California, continuing our series Everyday Diabetes: Practical Management for Primary Care. Today I am delighted to have with me Kwabena Adubofour, MD, an internist and primary care diabetologist. He is the medical director at the East Main Clinic and the Diabetes Intervention Center in Stockton, California. We recently caught up with each other at the Stockton Diabetes Conference, a conference focused on enhancing the diabetes skills of primary care providers (PCPs). Thanks for joining us today.

Kwabena O. Adubofour, MD: Hello, Jay. Thanks for having me.

Shubrook: I recently had the opportunity to hear you discuss your recommendations for PCPs to consider before they prescribe medications to patients with type 2 diabetes. As you know, this is a tough task in primary care. We deal with many different medical problems and there are so many medications to choose from. Your pointers about what we should do before we prescribe were quite important. Share some of your recommendations with us.

Adubofour: We continue to see a large number of patients with type 2 diabetes in the primary care environment, and pharmacotherapy has become quite elaborate in terms of the sheer number of agents available. So, if you ask me what three things one needs to appreciate to be an effective clinician when managing diabetes, I would say that first is education; second is education; and third is education. You cannot medicate without educating your patients.

The number of patients we see in the clinic who have had diabetes for 10, 15, 20 years but who know very little about what an A1c really means, or what their target blood sugar is, is appalling. That needs to change. After all, knowledge is power, as the adage goes.

Before starting pharmacotherapy, you need to set the stage during your one-on-one with the patient. Explain what you are trying to achieve with the medications. What does the patient need to know in terms of blood sugar targets? What A1c level are you aiming for? How do you avoid hypoglycemia?

Setting the stage also means that you encourage the patient. You need to empower the individual who is beginning drug therapy, because the patient has to deal with this disease 24/7. Without the assurance that they can reach you whenever they need to, and without the assurance that they understand exactly what these medications do, you will not get the level of adherence you need.

Shubrook: First: Remember to educate before you medicate. What is your next key point for PCPs when they prescribe for diabetes?

Adubofour: Every professional organization is calling for individualizing diabetes drug treatment. That is absolutely crucial. Now we have agents that also reduce cardiovascular risk, which is the number-one cause of mortality in patients with diabetes. So, risk-stratify from day one to see whether that individual will benefit from the introduction of those agents that we know reduce cardiac risk. That is absolutely crucial. Not everyone has to begin with metformin and only later add something else, as the disease progresses. From day one, decide whether that individual has an increased risk for cardiac mortality and then stratify appropriately.

I believe that if you do those two things initially, you will be successful in preventing cardiovascular complications. After all, why is the patient coming to see you? When it comes to diabetes management and primary care, I am bewildered by the number of individuals who do not really know how malignant type 2 diabetes can be if left uncontrolled. I tell patients, "Diabetes doesn't cause strokes; it doesn't cause blindness; it doesn't cause heart disease; it doesn't cause kidney failure. What causes all of these complications is uncontrolled diabetes. The reason you are here today is so that we can make you the captain of the ship. You are in charge of this. We are just the technicians who will give you everything you need to allow you to do well. But you have to know everything there is to know about the disease in order to enhance your management."

Shubrook: That's a very important point. Second: Remember to individualize therapy not only to the person, but also by cardiovascular risk. Cardiovascular disease is the number-one complication that kills people with diabetes, so that needs to be included as part of the individualization of treatment.

Adubofour: Knowing that type 2 diabetes progresses and that we will eventually use insulin, I begin my third recommendation by asking, "Do you kiss?" That is, K-I-S-S: Keep Insulin Sweet and Simple. I always put "sweet" first, because a large number of patients will come to the clinic and say, "I'm here to see you because my other clinician said I needed to be on insulin and I don't think that's a great idea." When you dig deeper, you find that the conversation was always, "If you don't shape up and behave yourself, we're going to put you on insulin." That is the wrong tactic.

Insulin is a vital tool, and to make it sound as if it's a threat, as if you're punishing the patient when you begin insulin, is a huge mistake. That's why I say, "We're going to keep things as sweet as possible. This drug really works. It's very effective if we use it appropriately. These are the reasons we are adding insulin to the medication you are already taking, because you are not here because you want to suffer the adverse consequences of uncontrolled diabetes. You're here because you want to do well. And so we'll do everything we can to make sure that happens."

Then, keep it simple. If you ask me what should be normalized first—fasting blood sugars or postprandial blood sugars—I believe that the evidence supports making sure the patient begins the morning on a good glycemic note. If I wake up with a blood sugar of 120 or 140 mg/dL, I'm starting the day on a good note, compared with someone who is waking up with a blood sugar of 350 mg/dL, who is starting the day on a terrible note. It takes forever to normalize blood sugars in that kind of environment. We also know that if I begin at 120 mg/dL, my first-phase insulin response plus my second-phase insulin response may help with postmeal glucose levels. Why not make sure that every single patient understands this and work with them to ensure that they are starting the day right?

Shubrook: Third: Remember the KISS principle. It's important to remember that insulin is overwhelming and scary for patients, and the more we can keep it simple and they can see results, the better and the happier they're going to be.

Adubofour: Another thing that really bugs me: I cannot believe that this is the 21st century and yet I have patients coming to the clinic for the first time and they are on a sliding-scale insulin regimen. I have no idea where the sliding-scale thing came from. But how is a patient who is eating breakfast, lunch, and dinner allowed to decide that if the blood sugar before breakfast is 90 mg/dL, he doesn't need to give himself any insulin? I don't know where this comes from.

I say, if you want to optimize pharmacotherapy, then do biomimicry. Mimic what nature does. Nature doesn't say, "Well, here's a person who's normoglycemic, and because everything is normal, even though this person is going to have breakfast, lunch, and dinner, I'm not going to allow the pancreas to secrete any insulin."

We need to get rid of sliding scale as monotherapy without any long-acting insulin involved, in patients who are seen in a primary care environment. To this day, at least twice a month, I will see a new patient who has known diabetes and is on insulin monotherapy, but for some strange reason is using a sliding-scale regimen. We need to do everything we can to stop that.

Shubrook: What I heard today is that when you're working with your patients, you want to make sure you educate before you medicate. You want to make sure that you individualize therapy, not just to the patient; now, we also have the benefit of individualizing cardiovascular care. Third, remember to KISS. I love that, because insulin does not have to be scary; it can be simple for the patient and there is good evidence that we can control glucose by fixing the fasting glucose levels first. Finally, I heard you say, very clearly, that you must have a good connection with your patient. Your patients need to trust you, your patients need to understand, and they need to know that you've got their backs, because this is really scary for them.

Thank you so much for sharing these important points today.