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TEAM
Interview with Dr. Zach Bloomgarden
I sat down recently with Dr. Zach Bloomgarden, who is noted not only for his huge clinical practice (more than 1,000 patients) on New Yorks Upper East Side but also for his many articles on diabetes (nearly 250). Since 1994, he has also written over 150 columns, Perspectives on the News for Diabetes Care. Dr. Bloomgarden studied mathematics at Princeton University and received his medical degree from Albert Einstein College of Medicine, followed by postdoctoral training at Montefiore Hospital in the Bronx and a fellowship at Vanderbilt University Hospital in Nashville, Tenn. He is currently a Clinical Professor of Medicine at Mount Sinai School of Medicine. Dr. Bloomgarden is a reviewer for Diabetes Care, Mayo Clinic Proceedings, the Archives of Internal Medicine, Practical Diabetology, Diabetes Management and Health Outcomes, Journal of Clinical Endocrinology and Metabolism, and Metabolism. He also advises managed care companies on diabetes as well as manufacturers, and has served as a Principle Investigator in dozens of clinical trials. He is a founding member of the Metropolitan Diabetes Society of New York and his personal research interests include insulin resistance and diabetes technology. He spoke to us about the latest controversy with Galvus, the importance of rimonabant, the potential of continuous glucose monitoring, and much more.
Kelly Close: Dr. Bloomgarden thanks so much for taking time to talk with us.
Dr. Bloomgarden: Oh, its my pleasure.
Kelly: Were very excited to speak with you about newer drugs because we know you have a large clinical practice in New York and weve been following your articles in Diabetes Care about the ADA over the last few months especially closely. We wanted to dive right in and ask you about your experience with some of the latest therapies for patients with type 2 diabetes. For example, weve heard a lot about how in the real world, with Byetta, patients go through a cycle of success, where they see some weight loss and they become more encouraged and they experience drops in A1c, which in turn makes them more motivated about eating well and exercising. Do you see that with your patients?
Dr. Bloomgarden: I think thats an interesting way of conceptualizing it. Weight is such an important issue for people with diabetes that those people who lose weight with Byetta find it tremendously empowering to continue with the treatment. There may be other benefits as well in stimulating endogenous insulin. Its interesting that Byetta has been mainly used by endocrinologists off-label. Rather than treating people on monotherapy with sulfonylureas or metformin or on the combination of the two, most endocrinologists use metformin in persons who are already on insulin. There are quite a few advantages to administering Byetta to that group. They do get the benefit of weight loss, counteracting the weight gain, which we recognize as an adverse effect of insulin therapy. They have less hypoglycemia than they encounter using rapid-acting insulin. This sets off a positively reinforcing cycle of therapeutic success. Another benefit is the lack of need for time-consuming titration as required with insulin. By allowing endogenous insulin to drive postprandial insulin excursions, it becomes easier to achieve a stable level of glycemia.
Kelly: Its interesting because this kind of behavior was the whole point of the Diabetes Prevention Trial in many ways, no? That makes us wonder about the power of giving patients sort of a jump-start with Byetta obviously, we know no one would recommend putting Byetta in the water, on the other hand, isnt the whole problem with diet and exercise that its hard to convince people to continue working on better diet, better exercise?
Dr. Bloomgarden: To an extent. Recall, though, that weight loss and exercise particularly increase insulin sensitivity, while Byetta has an entirely different set of actions in increasing insulin secretion.
Kelly: How about Januvia can you give us any broad thoughts on the drug and what you think will happen with patients over the longer term with this therapy? Are you seeing A1c drops?
Dr. Bloomgarden: Yes, with some, although not all patients show dramatic improvement.
Kelly: And the approvable letter for Galvus?
Dr. Bloomgarden: From my perspective, there are three possible explanations (not mutually exclusive):