Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're offering an update in standard of care for diabetes treatment. Joining me is Dr. Alexandra Dodd. She's an endocrinologist and an Assistant Professor at UAB Medicine. Dr. Dodd, it's a pleasure to have you join us today. With the growing prevalence that we've seen of diabetes worldwide, it's really an epidemic, both in adults and children. What do you believe are some of the key factors that are contributing to this increase?

Alexandra Dodd, MD: Hey, thank you for having me, Melanie. It's a pleasure to be here. I think there are a number of things that are contributing to the increased prevalence of diabetes. Certainly, I mean, there are a lot of genetic factors, certainly in type 2 diabetes, that can play a role. But I think lifestyle is probably the biggest influencer there. And usually, it's a combination of things like, for example, diet. You know, especially in the American diet, there's a lot of added sugars and preservatives and foods are very high calorie, so that's contributing to obesity, which is, you know, a driver for insulin resistance and diabetes. And then also, a lot of people are just sedentary, which, you know, with the decreased physical activity is contributing to obesity and weight gain. And that's the main thing, I think those are the biggest factors that are contributing to the rise in diabetes.

Melanie Cole, MS: I feel it's such a complicated issue. There are so many factors, as you said, and we could really just talk about those factors for an entire episode. But as we look to the treatments, I mean, you are in a field, Dr. Dodd, that is ever evolving. It's getting advanced so quickly, really an exciting time in your field. How are you seeing the landscape of diabetes treatment expand and grow? And how have you seen some of these treatments change over the last decade or so?

Alexandra Dodd, MD: Absolutely. I agree. I mean, we've, in the diabetes world, come a long way from just, you know, one or two types of insulin and maybe one or two different pills, especially also with the technologies standpoint. And as far as in the medication realm, some of the big game changers have been the class of medicines, which we call GLP-1 receptor agonists, which stands for glucagon-like peptide 1. There's one called like a combination of a GLP-1 plus a GIP, which stands for a glucose-dependent insulinotropic polypeptide. And those medicines have been huge as far as they can not only help with blood sugars, but they have significant benefits with weight loss. And just kind of, you know, looping back to the earlier question, I mean, especially since being overweight and obesity is a big driver of diabetes, just, you know, having medicines that actually work really well for that has been huge.

And then also, another class that's really growing to prominence is what we call the SGLT2 inhibitors, sodium glucose cotransporter 2s. Those drugs just work on the kidneys to help eliminate blood glucose. But similar, they not only help with the blood sugars, but there's also benefits, helping with cardiovascular risk reduction as well as helping in diabetic kidney disease. And also, you know, going back to the GLP-1, it's not just with the weight loss, but there's also some benefits as well, helping with things like cardiovascular disease, liver disease, and it's just really helped a lot. And I've seen just, you know, big benefits in my own patients as well.

And then, as far as for technology as well, that's also been huge. I mean, I think, back in the day, I mean, really the only way diabetic patients could check their sugars was, I mean, they just do finger sticks. But now, especially with the advent of continuous glucose monitors or CGM, that's really given patients that real time feedback where they can see what their sugars are doing in real time. Just that increased awareness can help a lot. But then especially even for patients, like type 1 diabetics, for example, who can have a tendency to be very brittle with wide swings in their blood glucoses, those CGMs have been very, very helpful and can even be life-saving at times and can warn them before their blood sugars get to critical levels. And then also, there's with the growth of insulin pumps, now some of these pumps are actually communicating with these continuous glucose monitors and can give really fine glucose control.

Melanie Cole, MS: I agree with you and it is amazing how these things are helping to manage. And when we talk about the medication and you think of also the comorbid conditions that go along with diabetes, you mentioned cardiovascular and, of course, there's high blood pressure. And then, there's all these external things that are as a result and/or caused by diabetes. Tell us about the availability as we think of these treatment, medications, and how they have impacted your patients because now they're more readily available.

Alexandra Dodd, MD: Absolutely. Yes. I've especially seen the availability issues with the GLP-1 receptor agonists and the GLP 1 or GIP receptor agonist. And that drug is tirzepatide. Because I think now, people are recognizing that these drugs, I mean, not only help with diabetes, but they can also help people lose a lot of weight. I mean, in some of these clinical trials, people are losing, you know, up to 20% of their body weight, which is huge. And it's not just for diabetes, but I mean, people even without diabetes are trying to get ahold of these drugs as well. And sometimes that leads to big shortages at the pharmacy. And I've had some of my diabetic patients, the pharmacist told them it's on backorder and they may go weeks or sometimes even months without access to these medications. And I think, you know, I'm glad that these drugs are available. I mean, they seem to be helping a lot of people. But I agree. I mean, at least for now, sometimes, it causes problems where sometimes the patients who need them most aren't able to get them. And I know, especially from a cost standpoint too, I mean, these drugs, they work well, but because they're still relatively new, unless your, you know, insurance covers it, sometimes patients who need these drugs just can't get it due to cost. And I'm hoping in time that will change. But for now, that's still a very real issue.

Melanie Cole, MS: Dr. Dodd, while you tell us some of the most common complications that you've seen associated with diabetes, I'd like you to speak about your team and how UAB approaches treating patients with diabetes holistically, addressing all these complications, and your multidisciplinary approach.

Alexandra Dodd, MD: Absolutely. We'll start with maybe just, you know, the complications first. I would say probably the most common complications that we see with diabetes are neuropathy, which is like damage to some of the nerve endings. We also see what's called retinopathy, which is damage to the retina or the back of the eye. And also, we see kidney problems. And

at least as far as for neuropathy, I would say most of the providers here at UAB do a very excellent job, just asking patients about, you know, are they having neuropathy symptoms? And then ,even just doing a regular foot exam for our diabetic patients, just to make sure there isn't any wounds or anything that could lead to problems. And a lot of times, we will, you know, if the symptoms are bad enough, sometimes we will, you know, offer medications to help with that. And then even if we can't manage it ourselves, sometimes we can refer to our neurology colleagues. And they do a great job with that.

As far as for the retinopathy, which I mentioned is damage, you know, to the back of the eye, you know, I'd say most of us also, we do really good just asking patients about, "Are you getting regular eye exams?" Usually at least once a year, but more frequently if there is any concerns for vision impairment. And some providers, if they feel comfortable doing an eye exam themselves, we can do that in the exam room. But generally, I would say I often refer my patients to an eye doctor, whether that's optometry or ophthalmology to get a regular, a more thorough eye exam, and can offer treatment if needed.

as far as kidney disease or nephropathy, most of us, I would say we check labs on a regular basis. We can check things, something called a creatinine in the blood, or we can check a urine albumin or protein. And I would say most of us do that at least once a year, sometimes more frequently. And that'll just help us keep a close eye on the kidney function. And as far as treatments, there are medications available that can help preserve kidney function. And then, you know, like I said, if the kidney issues progress, then we also are fortunate to have great nephrologists here at UAB that we can refer to.

Also as other complications, cardiovascular disease is a big one. A good proactive standpoint is not just to keep the sugars under control, but keeping an eye on cholesterol levels, because sometimes keeping cholesterol levels down can help protect the heart. And a lot of times, you know, we'll prescribe medications like statins, for example, to help with cholesterol levels and regular monitoring of that.

Similar if the cardiovascular risk progresses, then we are fortunate to have cardiology colleagues and also just, like I said, going back to those medications, you know, we have some of those drugs like the semaglutide or something like the SGLT2 inhibitors like empagliflozin, dapagliflozin, all of those have benefits with protecting the kidneys. And so, it's kind of like a win-win. You can help the diabetes, but you can also help protect the kidneys.

And then also as far as other members of our team, you know, at our UAB endocrinology clinic, we are very fortunate to have excellent diabetes educators who can sit down with patients and, you know, for example, if it's a new diagnosis of diabetes, they can just tell them, teach them, the essentials like lifestyle, diet, how to use medications, check blood sugars. And they can be a great resource to us and can also help patients just, you know, learn how to use the newest technology like CGM and insulin pumps. And like I said, we're very fortunate at UAB to have a great team to care for our patients with diabetes.

Melanie Cole, MS: That's so important with the advent of COVID. One of the only good things to come out of that was telemedicine, making it so that patients of all different sorts could meet with their physicians in a way that they didn't have to travel, whether it was from rural or far away. Tell us a little bit how you're using that in your clinic. And are your patients liking that? Is that something that's helping to manage diabetes better than it was?

Alexandra Dodd, MD: Absolutely. And I think, in endocrinology where it's a field that is very amenable to using telemedicine and especially now where we have tools like continuous glucose monitors, for example, clinic patients, they have the option, the ability to actually share their CGM data with our clinic. And essentially, for example, if I am doing a telemedicine visit with a patient, or even if it's in between visits, like maybe they just call and have a concern, I can log into our system and see their blood sugars in real time and know exactly what's going on. So, that has been a very big help for the telemedicine standpoint.

And I think, you know, my patients, they do like it, especially for patients who are traveling far away. I mean, we still like to see patients in person from time to time, just good to meet face to face and check blood work and those kinds of things. But especially, the CGM has been a really big helpful tool for the treatment of diabetes remotely.

Melanie Cole, MS: As we wrap up, and this has been such a great update, Dr. Dodd, are there any new treatments that you are really excited about? Give us an update on anything that's changed, research studies, anything that you'd like other providers to know about or that you're very excited about coming in the future.

Alexandra Dodd, MD: Absolutely. And I think, going back to the class of medicines like, you know, the GLP-1 receptor agonists and the combo drugs like the GLP-1 plus the GIP. Like I mentioned, it's really been a game changer. I mean, I've seen my patients, their blood sugar control will improve significantly. And a lot of times they can decrease or even stop insulin because of that and, you know, the weight loss. It's just interesting. And the data that's coming out, I mean, it's just showing how well these drugs work. I mean, not just for weight loss, but there's even been studies showing that there's a cardiovascular risk reduction. It can help with fatty liver disease. And then even in the clinical trials, they just keep expanding. I mean, we have the GLP-1 receptor agonist, the GIP, but there's even a study showing that maybe there's we call it like a triple receptor agonist, which has even more glycemic control and weight loss benefits that are coming. So, that's very exciting.

And then, I think just like you said, the ability of these drugs to help prevent these comorbidities. So, it's very exciting for that. And then even with our type 1 diabetics and the kind of insulins that are out now, I mean, it used to be, like I said, maybe just one or two types of insulins out, but now we have dozens of different types of insulins with different durations of action and different concentrations. For example, even now, like our long-acting insulins, they might last 24, even there's one out there that can last up to 40 hours, but there's studies looking at insulins that you only have to take once a week. And so from a compliance standpoint, that can be a big deal.

And then especially, I just think the technology is also just growing leaps and bounds. And CGM, there's several good sensors out there on the market now, and they keep upgrading to newer editions with better accuracy, and then just even the sensors themselves, like how the patients are able to wear them, and they're just getting a slimmer profile. And the CGM, I mean, great for type 1s and type 2s. And then just the insulin pumps as well, the way that these pumps are able to integrate with the CGM and just essentially can adjust insulin levels in real time without even the patient having to input things. And there's even sort of research now working on something called a bionic pancreas, which is still sort of like an insulin pump, but it's just taking less and less of the human involvement into the picture. And I think at some point too, I mean, we may have essentially a device where it'll give insulin. And the patients will have hardly anything to do with it. It'll just keep their blood sugars under control. And I know there's still a lot of research left to go, but very exciting time to be in diabetes.

Melanie Cole, MS: Thank you so much, Dr. Dodd. I agree with you and thank you for all the great information. For more information, you can always visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast .For updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole. Thanks so much for joining us today.