Issue: 74

March: The Value of Suffering!
This may seem odd, coming from a physician committed to the alleviation of suffering.  However, anyone who has suffered, which is most of us, has learned there is value in the ordeal.  Passover and Holy Week remind us that suffering, if endured patiently and prayerfully, can transport us to a better place where "He shall wipe every tear from our eyes" (Rev: 21:4).  My role, as your physician, is to be among those who help you navigate that difficult journey. 

John A. Schmidt, MD 
The Reverend Billy Graham, the Greatest American Evangelist, Will Be Missed!
The Reverend Billy Graham  recently completed his life journey on February 21 at the age 99 and was an outspoken champion for Gospel values.  Like the tele-evangelist, Rev. Fulton J. Sheen , his clarion voice reminded us of our obligation to lead moral, just lives, and care for others.  A pastor to many presidents, he always remained above the fray, carefully avoiding the temptation to endorse one candidate over another, preferring to challenge all of us to aspire to a higher standard regardless of party affiliation. How we miss him today!  Pray for us, Reverend Billy, that we might remember that God is not a partisan.  "For His sun rises on the bad and the good, He rains on the just and the unjust" (Mt 5:45).
Hemoglobin A1c Targets Relaxed by the American College of Physicians!  Holy Smokes!
As published in the March 6 issue of the Annals of Internal Medicine , the American College of Physicians , based in Philadelphia and the Professional Society of Internists  of which I am a long-standing member, having carefully reviewed all the available outcomes data with respect to pharmacological treatment  of type 2 Diabetes Mellitus , says that the current hemoglobin A1c  (HbA1c) goal of less than 7% is too strict and causes more harm than good.  Here are the guidance statements nearly verbatim:
  1. Clinicians should personalize goals for glycemic control (blood glucose) in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients' preferences, patients' general health and life expectancy, treatment burden, and costs of care.
  2. Clinicians should aim to achieve a HbA1c level between 7% and 8% in most patients with type 2 diabetes.
  3. Clinicians should consider de-intensifying pharmacologic therapy in patient with type 2 diabetes who achieve HbA1c levels less than 6.5%.
  4. Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia (excessive thirst, excessive urination, blurry vision).
  5. Clinicians should avoid targeting (and monitoring) the HbA1c level in patients who have a life expectancy less than 10 years, who are advanced in age (80 years or older), reside in a nursing home, or who have severe chronic conditions such as dementia, cancer, end-stage kidney disease, severe chronic obstructive pulmonary disease or congestive heart failure because the harms outweigh the benefits in such patients.
Outcomes Rule, Lab Values Drool!   
At first glance, the ACP's guidance seems misguided. Why?  Because as pointed out in the article and seen in my practice every day, "the metabolic derangements  associated with diabetes may lead to vision loss, painful neuropathy  or sensory loss , foot ulcers , amputations , heart attacks strokes , and end-stage renal disease ."  In short, diabetes is a curse. So why not try to normalize the HbA1c?  Answer: Because the arsenal of medicines used to lower HbA1c ( insulins , sulfonylureas , metformin , DPP-4 inhibitors glitazones, etc.) do not prevent these terrible outcomes!  Worse yet, they have the potential to cause weight gain and dangerous hypoglycemia. Who cares about HbA1c! It's just a lab value! We need medicines that provide better outcomes, not better lab values! It's just like the discussion on cholesterol .  I prescribe statins because they prevent heart attack and stroke, not to lower your cholesterol!  It's just a lab value.  Outcomes rule, lab values drool!
Pills Can't Compete with Lifestyle Modification
PS: Vigorous aerobic exercise , avoidance of high carbohydrate foods , and weight loss work better than any medicine to avoid/reverse type II diabetes and its complications. Why? Because these lifestyle modifications reverse the pathophysiology underlying type II diabetes. The pharma industry has yet to put the benefits of lifestyle modification into a pill! Type II diabetes is not a life sentence. Embrace lifestyle modification and chances are good you can return to a life free of diabetes and its disastrous complications!  I have many patients who have thrown away their pills after embracing a healthier life style!  With a little suffering, you can be one of them!
Breakthrough Treatments Have Arrived!
But not so fast!  Medical therapy for type 2 diabetes is changing for the better with the introduction of two novel classes of medicines.  The first is the oral SGLT2 inhibitors  ( empagliflozin / Jardiance®  and canagliflozin/Invokana®).   The second is the injectable GLP-1 receptor agonists  ( liraglutide/Victoza®  and semaglutide / Ozempic® ).  These medicine not only lower HbA1c (so what, who cares) but improve outcomes patients and I care about.

As nicely summarized in Table 8.1 of the American Diabetes Association's 2018 Treatment Guidelines  entitled " Drug Specific and Patient Factors to Consider When Selecting Antihyperglycemic Treatment in Adults with Type 2 Diabetes ," only oral empagliflozin/Jardiance®  and injectable liraglutide/ Victoza® are recognized by the Food and Drug Administration  to achieve better cardiovascular outcomes .  Among the once weekly GLP-1 receptor agonists , only semaglutide / Ozempic®  has demonstrated a cardiovascular benefit and is therefore preferred over competing agents such as Dulaglutide / Trulicity® .  Furthermore, only empagliflozin/Jardiance®, canagliflozin / Invokana® , and liraglutide / Victoza® reduce the progression of diabetic kidney disease , an important outcome.  Thus, while these new medicines don't reduce all diabetes complications, they do address two of the most important, namely cardiovascular disease  and renal disease .  Now that is genuine progress.  Moreover, both classes lead to weight loss and rarely cause hypoglycemia. They are new and, depending on your plan, can be expensive.
Guidance from the American Diabetes Association
So where does this leave us?  Here is an abridged summary of the Recommendations for Pharmacologic Therapy for type 2 Diabetes as published in 2018 by the American Diabetes Association :
  1. Metformin is the preferred initial pharmacological agent for the treatment of diabetes.
  2. Long term use of metformin may be associated with vitamin B12 deficiency and periodic measurement of vitamin B12 should be considered in metformin-treated patients.
  3. Initiate insulin therapy in patients who have very high hemoglobin A1c levels (>10%) and/or blood glucose levels > 300 mg/dL.
  4. Initiate therapy with two medicines in patients with HbA1c > 9%.
  5. In patients with established atherosclerotic cardiovascular disease, antihyperglycemic therapy should begin with lifestyle management and metformin and subsequently incorporate an agent proven to reduce major adverse cardiovascular events and cardiovascular mortality (currently empagliflozne/Jardiance®, liraglutide/Victoza, or semaglutide/Ozempic®).
  6. For patients not achieving glycemic goals, drug intensification, including consideration of insulin therapy, should not be delayed.
  7. Metformin should be continued when used in combination with other agents, including insulin, if not contraindicated and if tolerated.
  8. GLP-1 receptor agonists (liraglutide/Victoza® and semaglutide/Ozempic®) should not be used in combination with oral DPP-4 inhibitors (sitagliptin/Januvia®, etc.)
Can oral SGLT2 inhibitors and injectable GLP-1 receptor agonists be used in combination?  Theoretically, yes, because of their complementary mechanisms of action.  I have seen patients do well on the combination.  reports no harmful interactions between these two new classes of medicines.
Now Hear This!
My dear wife, Rita, retired cardiologist extraordinaire, is now walking up to 4 miles per day at a good clip, after her open heart surgery on January 15!!  She has been simonizing her golf cart in preparation for the 2018 season at Fairway Mews .  We are eternally grateful to Dr. David Johnson , Dr. Brook Dejeni , and their talented open heart team at Jersey Shore University Medical Center .  We are also very grateful to the members of Monmouth Cardiology Associates , especially Dr. Thomas Rizzo  and Dr. Jeffrey Osofsky , for restoring Rita to health! Thanks also to our wonderful friends at Fairway Mews for their prayer chain!  As I said at the beginning, patient suffering often takes us to a better place and it certainly has in Rita's case.

Congratulations to St. Catharine School in Spring Lake for receiving special recognition from Project Lead The Way , a national initiative to teach STEM (science, technology, engineering, and math--yeah!) to K through 12 students. St. Catharine was one of only ten schools, and the only Catholic School, to receive the award in New Jersey. Special congratulations to Mr. Michael Perez, M.S ., who leads the program at St. Catharine.

WRT March Madness, my loyalties are torn between the Villanova Wildcats and Sister Jean Dolores Schmidt's Loyola Ramblers ! Their unselfish team work is a joy to watch!

Valerie, Ms. Clark, and I wish you a Passover and Easter full of blessings!!  
In This Issue
March: The Value of Suffering!
The Reverend Billy Graham, the Greatest American Evangelist, Will Be Missed!
Hemoglobin A1c Targets Relaxed by the American College of Physicians! Holy Smokes!
Outcomes Rule, Lab Values Drool!
Pills Can't Compete with Lifestyle Modification
Breakthrough Treatments Have Arrived!
Guidance from the American Diabetes Association
Now Hear This!
John A. Schmidt Jr., M.D.
Board Certified Internist
Dr. Schmidt is one of the leading internists in Monmouth County offering  Medical Home  services.  
He is an attending physician at Jersey Shore University Medical Center.
Dr. Schmidt is enrolled in the Maintenance of Certification Program of the American Board of Internal Medicine
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"He who has learned to pray has learned the greatest secret of a holy and happy life."

- William Law


John A. Schmidt Jr., MD
Meaningful Medicine in Your Medical Home
2006 Highway 71, Ste. 3, Spring Lake Heights, NJ 07762
Phone:  732-282-8166  
Fax:  732-280-0147 
Disclaimer: The articles in Healthy Living are for general information only and are not medical advice.
Discuss all medical concerns and treatment options with your physician.