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Director, Diabetes Clinical Research
Brigham and Women’s Hospital
Harvard Medical School
Vanita Aroda, MD, has disclosed that she has received consultant fees from Applied Therapeutics, Duke, Pfizer, Novo Nordisk, and Sanofi; funds for research support from Applied Therapeutics/Medpace, Lilly, Novo Nordisk, Premier/Fractyl, Sanofi/Medpace; and that her spouse is an employee at Janssen and Merck.
When I am considering advancing therapy for someone with type 2 diabetes, I am reminded of a time 15 years ago and the lesson I learned from my mom about setting up patients for success.
It was 2005, when the first glucagon-like peptide 1 (GLP-1) receptor agonist was approved for clinical care. I had learned a lot about this novel treatment class during my training and, based on the published data, I told my mom to talk to her doctor about trying this new medication.
“Mom, you need to try it. The data look good,” I excitedly said. “This will help lower your A1C and your weight!”
But neither I nor her own doctor worked with her so she would understand how the medication worked and what to expect. We had not prepared her for the new feelings of satiety or even temporary nausea, which occurs in approximately 10% to 20% of patients, and she stopped after her first dose.
Worse than that, when I suggested she should work with her doctor to retry the medicine, she jokingly said that she didn’t trust our advice, that she knew what was best for her body (“mother knows best”). My heart sunk and I wondered where I, her daughter, an endocrinologist, had gone wrong.
To this day, it remains a missed opportunity for her to receive a treatment with proven glucose, weight, and cardiovascular benefits.
This epiphanous experience made me realize how important it is to let patients know what to expect with a new medication—and to help them understand how the therapy will work with them to help them get to where they want to go.
I now emphasize to patients that our approach is not either/or; it’s not lifestyle change or medication. These strategies are tools in the same toolbox, and some medications can help advance us on the journey toward disease control.
I would certainly place GLP‑1 receptor agonists in that category. As a class, they address glucose control from a physiologic level and help address behavioral change by helping patients feel a sense of satiety and fullness.
As part of the patient‑centered conversation, I aim to explain to patients how GLP‑1 receptor agonists will work with their bodies. I describe how these agents enhance insulin secretion when the body needs it—when glucose levels are high— and how they help the patient’s sense of fullness and satiety so that they can more easily reduce the number of calories eaten. When they experience it, they then recognize that the medication is working as designed.
With the recent cardiovascular outcomes data, I also explain that some of these medicines have direct anti-atherosclerotic effects and reduce the risk of heart complications.
I have found that providing anticipatory guidance really turns the tide for patients, taking them from a possible reaction of “This medication doesn’t suit me” (flashback to my mom) to, “You are so right, doctor. You told me what I might experience, and now I feel how the medication is working with me.”
When we are considering advancing therapy in type 2 diabetes, a lot of times it is because the patient’s hemoglobin A1C is inadequately controlled. For the patient, this can be associated with a sense of guilt and responsibility.
If we frame this for patients as, “Your numbers are too high, your treatment has failed, so now we have to add another medicine,” this only adds to that sense of guilt. It is not accurate, and it is really not helpful. It may lead to the patient trying to negotiate (eg, “Give me 3 more months. Give me 6 more months first. I will try to lose that couple of pounds. I will try to change what I eat.”). They may inappropriately view the medication as punishment or a sign of failure, rather than a tool to support them on their health journey.
Instead, I remind myself about the UK Prospective Diabetes Study (UKPDS), which demonstrated that diabetes is chronically progressive. In the natural course of the disease, glycemic control typically deteriorates over time, through no fault of the patient, medication, or provider.
Instead, I try to focus on working with patients from where they are, to help them feel empowered to take control of their diabetes—to let them know that they are not defined by their diabetes and that we have tools that can help them achieve their diabetes care and health goals.
When a patient understands how a medication works, it can help them achieve the goals that we agreed on as a patient-provider team, including minimizing exposure to high blood sugar, achieving and maintaining A1C at their treatment goals, and minimizing their risk of long‑term complications. When I approach the patient as a collaborator with mutual goals, the therapy is viewed as a strategy we are implementing together instead of something I am imposing on the patient.
As in many other aspects of life, I learned an important lesson from my mom. Talk to your patients about what to expect. A shared journey and a shared experience is one that is more likely to succeed.
Thank you, Mom, with love and appreciation.
How do you introduce new medications to your patients with type 2 diabetes? Answer the polling question and join the conversation by posting a comment in the discussion section.