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Transcript is created by AI, please excuse any errors. Welcome
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to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts. Hosted by cardiologist and top medical researcher, Dr. Michael Koren.
Dr. Michael Koren:
0:11
Hello, I'm Dr. Michael Koren. I am the executive editor and the host of MedEvidence, and we have a really exciting podcast today. I'm really looking forward to this. I'm going to be talking with Arpeta Gupta, who's an endocrinologist for those of you not familiar with those medical terms, that's somebody who looks after hormones and treats diabetes and she'll tell us more about this in a second. We're going to have a really interesting conversation about changes in diabetic guidelines and what things that people with diabetes should know about when they're looking out for their health, and here at MedEvidence, we like to talk about what we know, what we don't know, and how we're going to learn about the things we don't know. So, with that introduction, Dr. Gupta, thank you for joining us at MedEvidence. And why don't you tell the audience a little bit about your background, who you are and what you do these days?
Dr. Arpeta Gupta:
1:03
Thanks for having me here. So this is Dr. Gupta. I'm an endocrinologist as Dr. Koren said endocrinology deals with anything hormonal that could be insulin related. So that's diabetes or thyroid or female hormones, estrogen, progesterone or testosterone in men. So it's a very exciting field that I'm very lucky to be specializing in because it affects our quality of life. It deals with everything that we face every day. I've been in Jacksonville now for five years. I'm originally from India and I've trained at the Thiebielen Clinic and then Mount Sinai for my fellowship, and right now I'm in private practice with the Millennium Physician Group.
Dr. Michael Koren:
1:50
Mount Sinai in New York or in Florida? Which Mount Sinai, New York?
Dr. Arpeta Gupta:
1:53
Mount Sinai in Manhattan, New York.
Dr. Michael Koren:
1:55
Right.
Dr. Arpeta Gupta:
1:56
And finished my fellowship in 2014. So I've been in practice for 10 years now.
Dr. Michael Koren:
2:03
VWell, just to share a little anecdote with the non-physicians, endocrinology is a subspecialty of internal medicine and we always say that the endocrinologists are the smartest of the internists and the cardiologists, like myself, are the most bold maybe, and maybe the most reckless, depending on your perspective. So we all have our reputation within the fields of internal medicine, but endocrinologists are known to be really, really smart. So thank you for joining us.
Dr. Arpeta Gupta:
2:30
Absolutely. I mean it is more academic, it's more cerebral. We do put more thought because you know these are diagnoses that nobody else thinks about. You know, these are always the last differential, the last thing you check. When everything else is checked out fine, like the heart and the kidneys and the liver, then one starts thinking of the hormones. So you know actually I'm glad you brought that up because that is the need of the hour I do think it is under-recognized and I do think that endocrinology deals more with prevention prevention medicine rather than treatment medicine. I mean, when they come to me, I can prevent them from going to you.
Dr. Michael Koren:
3:06
Right.
Dr. Arpeta Gupta:
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Yeah.
Dr. Michael Koren:
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And you know again, we love it. So thank you for preventing and there's still a lot of work for us, so we're not worried about it. So talk a little bit about type 2 diabetes. So you first explain to everybody what is diabetes. What's type 1 versus type 2 versus type 3? Now I think there's a discussion about? So let's just give everybody a definitional lesson about what you're talking about.
Dr. Arpeta Gupta:
3:36
So diabetes basically is high blood sugar, and the question is, why is it happening? And there are two organs that are mainly involved with glucose control in our body, and it is pancreas that makes insulin and liver that uses that insulin and breaks down the glucose that we absorb from our food. So with type 1, the problem lies with the pancreas. Pancreas are damaged, they don't make insulin, so you are dependent on insulin. So this is typically the diabetes you see in children and it's identified in like the, even three-year-olds, two-year-olds, like the really little guys. Type 2, on the other hand, has a problem in the liver. So the pancreas is okay, it's making enough insulin, but the liver is not using it. So there is a concept of metabolic syndrome, of insulin resistance, where the liver doesn't recognize the insulin that is being produced and so it does not break down the sugar,
Dr. Michael Koren:
4:47
And do you believe in type 3 diabetes or explain what that means? I've heard that term lately.
Dr. Arpeta Gupta:
4:54
So this is a newer concept that we are recognizing now and that's one of the big changes that the American Diabetes Association made in their newest guidelines in reclassifying diabetes, because there is a lot of overlap between type 1 and type 2. So you know, if you've had type 2 for a very long time more than 20 years, over time, the body is going to give up, the pancreas are going to tire out, they're not going to make enough insulin and so you become deficient in insulin. That's when you we call it type 3 diabetes, that you were born as a type 2, but you developed type 1 over time. Type 3 can also happen if you had surgery for the pancreas, like there was a growth on the pancreas, you needed surgery to take them out, or you had chemotherapy that damages the pancreas. So then again you convert from one category to the others.
Dr. Arpeta Gupta:
5:54
Different concept, where you are noticing presence of type 1 in older people, so not children, but we are diagnosing this in 50-year-olds, 60-year-olds because of autoimmunity. Now, is that caused by COVID? Is that caused by any other viral insult? Is that caused by, again, chemotherapy Keytruda is a very big chemotherapy name that will be thrown around that can cause autoimmune damage to the pancreas. So somebody who was supposed to have type 1 as a child didn't get it as a child, get it as an adult. So these are all these different variants that can all be clubbed under the category of type 3.
Dr. Michael Koren:
6:32
Beautiful, beautiful, great explanation. Thank you for that. So I know we wanted to talk about the new guidelines for treating diabetes, and I think most of the people who are listening and watching know that insulin is used for diabetes in certain circumstances and that we have pills and now we have other injections as well. So why don't you just, in a general sense, break that down for people to start, and then we'll delve into it a little bit more, with the tease here that nowadays, even cardiologists are using diabetes drugs? So we'll talk more about that as well, but go ahead.
Dr. Arpeta Gupta:
7:03
Correct. So when somebody comes to you for the first time and they say I have diabetes, you want to first see, you want to first know what kind of diabetes they have. You want to start that characterization from the moment that patient enters your door. What do they look like? Do they look as if they have type 1 or type 2? How have they presented? You do need a thorough evaluation before you jump into treatment, because the treatment is targeted, it's patient-centric. You cannot give the wrong treatment to a person. It's just not going to work. And that's the reason for the greatest frustration that we see as endocrinologists when patients come in and they say nothing works. And when nothing's working, why do I want to take any medicine? And that's when you see the A1C is going above 10, into the even 17% ranges, you know so.
Dr. Michael Koren:
7:53
And just for everybody's knowledge, hemoglobin A1C is a measure of your diabetic control over time by measuring the amount of glucose on hemoglobin. So just so people that are not familiar with that term go ahead. I'm sorry to interrupt.
Dr. Arpeta Gupta:
8:05
That is correct. It is a measure of your glucose control over the last three months. So it gives you an average of where your glucose numbers have been staying the last 90 days. So that is a marker we use to see how good the diabetes is being controlled. Are you optimized or not? So you know.
Dr. Arpeta Gupta:
8:26
First, you want to know what am I treating? Am I treating a person who does not make enough insulin or am I treating a person who is not using their insulin? And that's what you would start with. If it is somebody who has been losing a lot of weight they say I have lost 50 pounds, my sugars are in the 300, 400 range I am suspecting that this person is not making insulin then that is the route I will go. I will start them on insulin. But if it is somebody who comes to me I have been putting on so much weight, my diet has not been the best, I have been under a lot of stress and I suspect that they have insulin resistance, this metabolic derangement with high blood pressure and high cholesterol and weight gain, obesity then I don't want to go with insulin. Then I want to go with medicines that are going to fix that. Then you're looking at medicines like metformin and these other tablets we can go into, and then the shots that you alluded to, Dr. Koren, that have become very popular nowadays.
Dr. Michael Koren:
9:44
also reflect the science and here at MedEvidence we believe in evidence-based medicine. We do a lot of clinical trials that involve diabetic patients and a lot of this in the new guidelines is a reflection of recent evidence. So kind of break that down for folks.
Dr. Arpeta Gupta:
10:02
So really the biggest thing that the guidelines are focusing on is cardiovascular health, renal health. They are recognizing that diabetes is not isolated. You're not just fixing a glucose number. You need to take the patient as a whole. You need to recognize that diabetes is associated with other comorbidities. But then you also don't want to just write a prescription. You have to understand where is the patient coming from, what can they afford, what other medicines they are on, what are their cultural preferences, what are their side effects to medicine? So it is a discussion between you and the patient, where patient is the ultimate decision maker. It is patient-centric and that is what is wonderful about these new guidelines that everything revolves around the patient. It is a mutual decision, not a decision made by the physician for the patient.
Dr. Michael Koren:
11:00
Right, right. And so get a little bit more specific for people what might change based on these guidelines they go see their internist or their endocrinologist, and what might happen and what recommendations might occur because of the new guidelines.
Dr. Arpeta Gupta:
11:18
Perfect. So the comorbidities, basically the cardiac comorbidity and the renal comorbidity, we have a lot of literature that has come out the last few years where it shows we have medicines called these are called SGLT2 inhibitors and we have these GLP-1 analogs. They have robust data showing that they can prevent cardiovascular mortality. So death from heart disease, hospitalizations from heart failure. They can prevent chronic kidney disease, development of dialysis. So one steers patients towards those medicines now because they get multiple benefits from the same thing. In addition to optimizing diabetes, they also prevent heart disease and prevent kidney damage. And it is all evidence-based.
Dr. Michael Koren:
12:09
Yeah, throw out some of the names of those that people may have recognized for the SGLT2 inhibitors in the GLP-1 agonists. Go ahead.
Dr. Arpeta Gupta:
12:18
So the SGLT2 inhibitors are the oldest one was Invokana, and then we have Farxiga and then Jardiance. These are the three that people are aware of. GLP-1 analogs started off Byetta that that we don't have anymore. Then there is Bidurion we don't have anymore. There was Tanzeum that we don't have anymore, went on to Victoza, then we got Trulicity, then we got Ozempic. Ozempic came as a tablet version that is called Rybelsus, and the latest we have is Mounjaro.
Dr. Michael Koren:
12:57
And obviously they become very popular drugs for other reasons and you might want to just comment on that.
Dr. Arpeta Gupta:
13:05
Absolutely. We have seen a tremendous benefit in multiple organs because the way these medicines work, like this GLP-1 molecule, it works on our fatty cells, it works on our intestines, on our kidneys, on our heart. So we've seen benefits from those standpoints. The biggest benefit we've seen is weight loss. So they actually have achieved FDA approval for the diagnosis of weight loss alone, even in patients without diabetes. For the SGLT2 inhibitors like Jardiance, Farxiga and Invokana, we have seen approval for heart failure and that's where a cardiologist will prescribe diabetes medicines, not for diabetes. So they have approval in patients without diabetes for prevention of heart disease, in patients without diabetes, for prevention of kidney damage, reversal of kidney damage. That is why multiple specialists are now prescribing these medicines. But the popularity that you're alluding to, the reason why they're so popular, is because of weight loss.
Dr. Michael Koren:
14:13
Yeah, obviously they become in high demand from lots of people, many of whom may not have a clear medical indication for them. I'm sure you run into that, and it's one of the things we have to do as clinicians is to advise people when they're doing things for medical reasons or whether they're doing things for cosmetic reasons, and it's a little bit of a tricky issue that we all face. But we're going to take a quick break and then, when we come back, what I want to do is I want to explore a couple of things with you in a little bit of a tricky issue that we all face. But we're going to take a quick break and then, when we come back, what I want to do is I want to explore a couple things with you in a little bit more detail.
Dr. Michael Koren:
14:48
One is the concept of protecting these other organ systems, and you brought that up and I think it's fascinating, and obviously it's how different internal medicine subspecialties are coming together and working together, and we'll also talk about some of the dynamic between different specialties. How does that work? How do we cooperate? I think the patients are interested in that commentary. And then I also want to touch on the clinical trial world, which I've been very involved with. So, for example, we've been very involved in the development of smaglutide or ozempic and talk a little bit about that history and how that developed over time. So again, Arpeta, this conversation has been fabulous and we're going to pick it up on the other side.
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