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Melanie Cole (Host): There have been recently updated comprehensive recommendations that reflect the latest advances and evidence-based research to improve care for millions of people with diabetes. My guest today is Dr. Owaise Mansuri. He's an endocrinologist with the Carle Foundation Hospital. Dr. Mansuri, explain a little bit about diabetes. What are you seeing as far as prevalence and awareness of the disease?

Dr. Owaise Mansuri, MD (Guest): Sure. So we are seeing an increase in type II diabetes lately, and we're also seeing patients present earlier in life compared to other family members with the diagnosis. Just this weekend I saw a patient just twenty years old with new onset type II diabetes and that's unfortunately the trend now. The rates of diabetes are increasing, and in general obesity is also increasing, and so we need to do a better job with screening for type II diabetes and preventing type II diabetes.

Melanie: Dr. Mansuri, as far as providers are concerned, do you feel in this day that- you mentioned that you had a twenty-year-old that came up with type II diabetes. Are providers able to not see the future, but see this pattern whether it's in a family, or see that a child is becoming obese and possibly going to be a type II diabetic? Are you seeing that providers are aware and able to engage their patients with discussions about this?

Dr. Mansuri: I think we are doing a better job. There was a recent study that showed that childhood obesity rates are decreasing actually recently. And so that's a good sign that we are attacking that epidemic earlier and hopefully slowing the progression down or hopefully preventing diabetes for them in the future, or at least delaying when they will develop diabetes.

Unfortunately some patients, their family histories are so strong that they're still going to develop diabetes, but it's just not really- it's just unfortunately a matter of when they're going to develop it.

Melanie: Tell us about some of the new recommendations in the 2018 edition of the American Diabetes Association's Standards of Medical Care. Tell us what's new and different.

Dr. Mansuri: So the big change is now what the second line therapy of medication should be. So always it's been Metformin is always the first line therapy for controlling diabetes, but now the second line therapy- it depends on what other comorbidities or what other risk factors the patient has. And so there's two new big classes of medications that have been- that are about- the one class is called the GLT-1 receptor analogs. They've been around for about ten years or so, and then the other class are called SGLT2 inhibitors which have been around now for maybe three or four years I would say.

So the recommendations include these medications because we're seeing a lot of increased risk of heart disease along with the diabetes, and so these medications have been shown to reduce cardiovascular mortality. And so it's recommended that these two medication classes be used earlier on in the diabetes management as opposed to later on, especially in these high risk classes.

Melanie: And how do you think the integration of new technology is affecting diabetes management?

Dr. Mansuri: So there's- and we're getting a lot of questions like this from patients. There are new glucose sensors which has been the biggest trend now for even- in the past we've mainly used them for type I diabetics, but now we're seeing that more patients with type II diabetes are requesting them. The pharmaceutical industry is doing a good job with advertising as usual, and so we're being asked by patients for using them to monitor their blood sugars instead of having to test their blood sugars.

So I think as time goes on, we're going to continue to see these sensors where right now the current sensor- there's a current- what's called a hybrid closed loop insulin pump which has a sensor built in with it, and this sensor will work with the pump by- it'll sense the blood sugar, that blood sugar will be sent to the insulin pump, the insulin pump will see what the trend is in the blood sugar, and then change the basal insulin, which is like the background insulin rate based on what the blood sugar is doing. If it's going up, then it'll give more insulin. If the blood sugar is trending down or even if it gets too low beneath a certain point, then it'll shut off insulin delivery for about two hours.

Patients will still have to give insulin based on their carbohydrate intake, but eventually we're going to see where pumps are going to do everything. They're still in trial phase at this point, but that will be game-changing for especially our type I diabetics who have been using injections for their whole life, and now they can almost be hands off with their diabetes, which will be huge.

Melanie: And what's changed as far as routine screening for type II diabetics? For example, high risk youth that have a high BMI, or they're talking to their pediatricians at their well visit. What's changing for routine screening?

Dr. Mansuri: So there was increasing- I mean just checking their blood sugars more often for patients who are at high risk. We weren't doing that as often as before, but now it's recommended for youth that are at risk to get their blood sugar tested or their hemoglobin A1C tested earlier on than waiting until they were over eighteen.

Melanie: Tell us about the coordination of care, the management of several aspects of care that you see going on for diabetics. It takes a lot of different providers, doesn't it?

Dr. Mansuri: It does. I mean diabetes is a team approach. In our office, we work closely with our dieticians and diabetes educators, and those two groups are very important, and patients should actually be seeing them before they even see an endocrinologist, especially when they have pre-diabetes. The recommendation is that the patients sees the dietician and diabetes educator and hopefully make lifestyle changes to prevent developing full onset type II diabetes.

But also, I mean we need to work closely with podiatry, cardiology, and nephrology, especially when the patients are developing microvascular or macrovascular complications from the type II diabetes.

Melanie: Doctor, patient-centered care and the cost of care impact of diabetes is being studied much more lately. Tell us what you see as far as these new recommendations, and how that's going to change this model of standard of care for patients with diabetes.

Dr. Mansuri: Unfortunately, those two groups of medications that I mentioned are some of the most expensive medications that are on the market. And there are coupons, there are patient discount cards for patients to use, but that only works for some patients who don't have government insurance. And for those patients, it can be very difficult to get those medications which will help them deal with the difficulties with type II diabetes. Especially those two medications, they help with weight loss, and so obesity is so prevalent with type II diabetes, but if they don't have the right insurance, or if they're on government insurance, then it's much more difficult to get those medications, and then they need to basically get to start insulin sooner than other patients which leads to more obesity, and then much more difficulty losing weight.

So we need to- we still have some work to do to try to get patients the best medication regardless of the cost for them, but that is unfortunately a major role in what patients can take for their diabetes.

Melanie: In summary as a wrap-up, Dr. Mansuri, tell other physicians what you'd like them to know about diabetes and the new medications and recommendations from the American Diabetes Association.

Dr. Mansuri: So the two big things are the two new medications; the SGLT2 inhibitors, which are the flozins. The empagliflozin is the main one in that group, again that has been shown to reduce cardiovascular mortality. And then the other group are the liraglutide, and those are the GLT-1 receptor analogs. These medications also have been shown to have a cardiovascular benefit.

So I think we need to use those more to help with weight loss, help with glycemic control. The SGLT2 inhibitors have also been shown to reduce blood pressure, and so if we use these medications earlier on in their diabetes diagnosis, this may help with other complications from the diabetes later on. So I think going along with the American Diabetes Association recommendations from using those medications, and then if we still need additional therapy, then going to a sulfonylurea, and then eventually adding long-term insulin- long-acting insulin after that is what we should be doing.

Melanie: Thank you so much, Dr. Mansuri, for being with us today and sharing your expertise for other providers to explain these new recommendations and the new medications available for diabetes that might change the standard of care that we're seeing now. You're listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers or to view Carle sponsored educational activities, please visit www.CarleConnect.com. That's www.CarleConnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole, thanks for listening.