‘Disrupt’ therapeutic inertia with precision medicine to achieve diabetes remission
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BOSTON — The concepts of precision diabetes medicine, including individualized therapy, carefully tracked progress and a team approach, can break down therapeutic inertia barriers and help patients achieve remission, according to a speaker.
The pharmacologic definition of therapeutic inertia is a provider’s failure to increase therapy when treatment goals are unmet, Louis H. Philipson, MD, PhD, FACP, professor of medicine, director of the Kovler Diabetes Center at the University of Chicago School of Medicine, and former president of medicine and science for the American Diabetes Association, said during a keynote presentation at the Cardiometabolic Health Congress. However, the broader concept of “clinical inertia” is defined as the underuse of interventions known to prevent negative outcomes. This can encompass care deficits such as lack of screenings, risk assessment, preventive measures, attention to adherence barriers and referrals, Philipson said.
“Despite the development of new technologies, drug therapies and education programs, the average HbA1c for a person with diabetes has not changed in the past 20 years,” Philipson said. “The number of patients with an HbA1c over 9% has actually increased. Moreover, less than 20% of patients have lowered their HbA1c, BP and LDL to target ranges.”
Within 1 year of diagnosis, less than half of patients are taking their medications as prescribed, Philipson said.
“We are stuck. In fact, things are getting worse,” Philipson said. “Exactly what is going on and how do we address this? The idea is doing all of this: risk assessment, referrals. We need to be disruptive.”
Consider social determinants
Today, cardiometabolic-related risk factors and diseases now affect an estimated 47 million people in the U.S.; caring for people diagnosed with diabetes accounts for one of every four health care dollars, making diabetes the costliest chronic condition in the U.S., Philipson said. Without change, one in three people will soon have diabetes; already, one-third of Americans have prediabetes.
Diabetes and cardiometabolic disease are not just medical or health care problems but societal problems, Philipson said, noting that social determinants of health, including where a person lives and works, are major risk factors for disease as well as therapeutic inertia.
“There is no device, no drug powerful enough to counter the effects of poverty, pollution, stress, a broken food system, cities that are hard to navigate on foot and inequitable access to health care,” Philipson said. “All of these things are part of what we can do — we can advocate [for change], and it is critically important to do that.”
Combatting inertia with precision medicine
To “bust the barriers,” disease risk needs to be tackled at every level, but clinicians typically have about 12 minutes with a patient, Philipson said. The six key “pillars” of precision medicine — diagnostics, prediction, prevention, prognostics, treatment and monitoring — are an emerging approach for disease treatment and prevention that takes everything into account, including genes, lifestyle and the environment. A narrower view might be “find the right drug for the right patient,” Philipson said.
“We need to think about both of these things,” Philipson said. “You have an opportunity, not only for that patient, but for their family and their friends. That is part of the educational outreach of this ever-spreading stream. I repeat the family history at every visit. I want to know, ‘How is Uncle Fred?’ We can track family history in the medical record and be sure we understand the background. Often it is environmental as well as genetic, and it is not often clear which is more important.”
Precision medicine — sometimes used interchangeably with personalized medicine — uses the available strategies of diagnostics and therapeutics tailored to subgroups with similar characteristics, such as nonresponders vs. responders, with or without adverse effects.
“’Personalized’ is simply the last step, but it also means that if a patient is unable to sleep or eat, that we incorporate that into the clinical experience,” Philipson said. “What do our patients teach us? Take a minute to say, ‘What are you thinking? How are you doing?’”
The future: Diagnosis, prevention and remission
The diabetes and cardiometabolic disease epidemic require big-picture actions with health equity at the center, Philipson said. A national diabetes strategy is needed to enhance collaboration and coordination across all federal agencies for diabetes and treatment, improving things like dietary quality, marketing oversight and food labeling, as well as improving access to comprehensive, high-quality and affordable health care for people at risk for and with diabetes.
“We do not often zoom out this large to examine the sectors of influence ... we need to continue to work on this and not just leave it for somebody else,” Philipson said.
“We have to disrupt therapeutic inertia. We must use these principles to achieve these goals, including the newer idea of remission. We can make [diabetes] stable with the right tools. We can integrate these ideas, make the diagnosis as best we can, track progress, think about the whole family, emphasize the team approach and collaborate.”
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Philipson LH. The future of cardiometabolic disease: Overcoming therapeutic inertia. Presented at: Cardiometabolic Health Congress; Oct. 19-22, 2022; Boston.
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