Where to use GLP-1

When I finish a speaker program, the most common questions pertain to what I like to use for diabetes.  What do i use first, second, why?

I usually ask a group of family physicians on what they would do with a patient that came to their office on insulin and sugars were stable.  He was taking 4 injections a day of two different types of insulin.  He is having no pain, no trouble taking the injections, and remarkably he has perfect sugars.  (Yes, I know… it’s hypothetical). No low sugars and no highs. 

What would you for this patient?  Would you continue the insulin and see your next patient.  Why not?  insulin is approved for diabetes?  He is doing perfect.  Would you stop the insulin and change to something else, or nothing at all because he is eating better and lost a lot of weight and he may not need anything anymore?

There are some smart asses in the room that say, keep him on the insulin.  I love that though.  I say, so why not, it’s approved.  There is nothing wrong with that.  There is some whispering and at the end of it, it all ends with stop the insulin and start metformin.  Every single time. 

Why? Why do we use metformin first line?

Do we have to use it first?  There are so many meds approved for diabetes, but we go to that one first.  It’s not even the strongest medication that we have.  Because it’s in the guidelines.  It’s from the American Association of Endocrinology (AACE), American Diabetes Association (ADA) and many others.

The rational for why is a very long list.  This includes cost, safety, weight loss, effect on blood sugar, as well as other changes not related to sugars. 

Ok, so we all get it.  Use metformin first.  Ok, lets move on.

Then the question is what do you use after metformin?  This is huge toss up. Or is it?

I ask the audience this question on their preference after metformin.  Some say insulin, actos, DPP-4, GLP-1, SFU, the whisperings become more vocal.  Well, why did you use metformin first?  The guidelines told us to.  Well, the guidelines are crap after metformin.  Sadly, most physicians just look at the pretty flow charts and tables.  They all say the same thing.  Use what ever the heck you want, we don’t care.  Yes, AACE and ADA do not care.  Why should they, it’s up to the doctor and patient on what to do next.  Otherwise, we are all computers or assembly line workers doing what we are told.

But, when you actually read the 50 page document, it spells out what you should really really do.  It’s use a GLP-1.  They go in detail of all the benefits of GLP and strongly encourage you to do it.

Maybe one day, it will be mandated like metformin.

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