Diabetes Drug Options
Standard medical treatment protocols for Diabetes 2 always mention "lifestyle
changes" and then quickly proceed to medication options. While diet is
sometimes mentioned , the critical, decisive importance of diet revision and
exercise is not emphasized and in practice, diet revision is often neglected in
favor of drug treatments.
Drug treatments of Diabetes 2 present some problems. The main problem is the
false belief that a drug or combination of drugs can rescue an individual from a
disease-causing lifestyle. While there are benefits to be had with the newer
medications, a diabetic should learn expert self-management skills and
exercise all the therapeutic and preventative options available before
The most negative aspect of medication is that a drug prescription may be
taken to mean that the patient is passive, dependent and has been excused from
making all the important changes that will preserve body parts and ultimately
save his or her life. If the drug is taken as permission to postpone or forego
the vitally important changes in food choices, eating behaviors and exercise,
then the prescription has done a great disservice.
Other hormones besides insulin
regulate blood sugar. Glucagon is another hormone made by the pancreas that
causes cells to release sugar into the bloodstream. By blocking glucagon, blood
glucose levels can be lowered. Drugs that inhibit the action of two other
hormones that increase blood sugar levels, glucocorticoids and growth hormone,
could have a similar effect.
A single, ideal drug with long-term benefits may never be found since
there are likely to be many different mechanisms behind the failure of glucose
regulation. Thus, drug combinations are becoming more popular, although
reassuring evidence of long-term efficacy and benefit is still limited. The
dietary and environmental determinants of glucose-regulation failure are likely
to be multiple. Drug studies tend to produce a distorted view of diabetics and
are seldom compared to successful attempts to control the disease with diet
revision, exercise and weight loss. Medical treatment plans for DB2 give lip
service to the “life-style changes” that are required to control this disease.
Medical treatment plans underestimate the intensity of compulsive eating
experienced by diabetics.
Drugs to Lower Blood Sugar
Our perspective is that the drug treatment of diabetes is lacking in
convincing long-term efficacy and there are an number of important concerns
about side effects and long-term adverse effects. Oral medications should not be
considered as primary treatment. MDs tend to be drug prescribers and do not
teach self-management skills.
There is also uncertainty about the different mechanisms at work in diabetic
patients and the selection of medication is not based on solid foundation of
understanding who benefits from what pharmacological interventions. The current
choice is between a group of drugs which improve glucose clearance from
the blood but do not raise insulin levels and another group of drugs
(sulphonylureas) which increase insulin secretion. A drug which would
restore the function of insulin sounds like a good idea. A single, ideal drug
with long-term benefits may never be found since there are likely to be many
different mechanisms behind the failure of insulin to work properly and the
dietary and environmental determinants of this failure are likely to be multiple.
Medical treatment plans often give lip service to the life-style changes that
are required to control this disease and seldom are realistic about the
difficulties encountered by anyone who attempts major diet change. Medical
treatment plans also are unaware of or underestimate the intensity of habitual
eating patterns and the compulsive eating aspect of the diabetic experience.
Drugs are prescribed as soon as a patient fails to achieve diet control and
often provide a false of security that the problem is being handled. Drug-taking
patients often continue to eat too much of the wrong food and exercise too little.
Metformin (Glucophage) remains the “first drug of choice” for diabetics who do
not control their blood sugar with diet revision and exercise. The U.K.
Prospective Diabetes Study (UKPDS) demonstrated that metformin is as effective
as sulfonylureas in obese subjects and is associated with less weight gain,
fewer hypoglycemic episodes, and better cardiovascular outcomes. In addition,
they found that Metformin was equally effective in normal weight subjects.
Pharmaceutical companies have been busy developing new drugs for the
increasing populations of diabetics worldwide. A variety of drug targets have
been selected. After a flood of studies and some encouraging news, the old drugs
- metformin and the sulfonylureas, appear to be as effective as most of the
Tucker summarized a review of the new drugs:" There are currently 11 classes
of approved glucose-lowering medications. Metformin has a long-standing evidence
base for efficacy and safety, is inexpensive, and is regarded by most as the
primary first-line treatment for type 2 diabetes. When metformin fails to
achieve or maintain glycemic goals, another agent needs to be added. However,
there is no consensus or sufficient evidence supporting the use of one
second-line agent over another. And in the past decade, the mix of secondary
agents used in the treatment of diabetes has changed significantly, with
increasing use of newer glucose-lowering agents such as dipeptidyl peptidase-4
(DPP-4) inhibitors and glucagon-like peptide-1 (GLP-1) agonists in place of
older and less expensive drugs such as sulfonylureas, resulting in a dramatic
rise in the cost of diabetes medications and management. However, the long-term
clinical benefit of this shift is uncertain...Average medication costs per month
were $81.75 for metformin, $54.85 for sulfonylurea, $232.84 for DPP-4 inhibitor,
$325.97 for GLP-1 agonist, and $245.70 for insulin.
Vega summarized SGLT2 inhibitors that work in the kidney to
reduce glucose reabsorption in the nephron.
"A1c levels decrease 0.5% to
1.0%. In a study evaluating dapagliflozin (Farxiga™), patients with higher
baseline A1c levels experienced an even greater drop in A1c—between 2.6% and
2.9%. Unlike the sulfonylureas, SGLT2 inhibitors do not promote weight gain.
They are actually associated with mild weight loss. SGLT2 inhibitors are
associated with higher rates of dysuria vs placebo, but it remains unclear
whether they promote a higher rate of diagnosed urinary tract infections.
The most concerning safety issue regarding SGLT2 inhibitors is the potential
development of cancer of the bladder or breast. There are small signals of
higher risks for these tumors among patients treated with SGLT2 inhibitors
vs placebo in clinical trials, but the risk was not substantial enough to
justify a delay in the FDA approval of canagliflozin (Invokana®).
Empagliflozin and dapagliflozin have alse been improved.
OUTCOME study of sodium/glucose cotransporter 2 (SGLT2) inhibitor
empagliflozin that reduced the occurrence of cardiovascular death or heart
failure (including all-cause and cardiovascular death) in the range of about
a 30%-40% relative risk reduction. Metformin, the first-line drug costs
less compared to $4800 (USD) for SGLT2 inhibitors.
At the International Diabetes Federation (IDF) Congress 2017, SGLT2
inhibitors and GLP-1 agonists were elevated to second-line therapy in type 2
[i] Charles P. Vega/. Antidiabetes
Drugs: Really New and Improved? Medscape Internal Medicine. September 19,
[ii] SGLT2 Inhibitors as First-line Therapy
for Diabetes With CVD. See 2018 Standards of Medical Care in Diabetes were
published online December 8, 2017 in Diabetes Care.
Insulin Therapy for Diabetes
Eventually, many with type 2 diabetes have to take insulin to utilize blood
glucose properly. Beta-cell function declines progressively creating insulin
dependency. In other words type 2 diabetics tend to become type 1,
insulin-dependent, diabetics. Success depends on maintaining a stable
insulin intake, adjusting food an exercise to keep blood glucose levels
within the normal range. Hirsch suggested: “Treatment goals for glycemic
control in patients with type 2 diabetes are often not achieved or are
difficult to maintain as the disease progresses. Too often, insulin therapy
is either delayed or is less than optimal. New insulin analogs may help
overcome some of the barriers to insulin use. If combination therapy with
oral agents does not achieve glycemic control, the addition of a once-daily
intermediate- or long-acting insulin is a simple strategy for initiating
insulin. The combination of basal insulin with short acting insulin with
breakfast and dinner is a better choice. Fixed-ratio, premixed insulin
allows 1-2 fewer injections than pre meal insulin but there is increased
risk for hypoglycemia if adherence to mealtime and activity schedules is not
maintained.” My first choice for starting insulin therapy is Novlin
Insulin Mix 50/50, available in 3 mL cartridges and used in a pen delivery
system developed by Novo Nordisk. The Novo pen is a marvelous invention that
is easy to use and painless. The premixed insulin contains soluble,
short-acting insulin and; intermediate-acting insulin. One
injection per day may suffice, but two injections – one before breakfast and
one before dinner is often a better strategy.
Self Management is Essential
We realize that the task of changing and then controlling eating behaviors
long-term is not an easy one. The task is to realistically assess your own
eating behaviors, understand what has to change and then recruit the necessary
resources to make this change. According to
the National Institute of Diabetes and Digestive and Kidney Diseases, U.S.
Public Health Service."Oral diabetes medicines, or oral hypoglycemics, can lower blood glucose in
people who have diabetes, but are able to make some insulin. They are an option
if diet and exercise don't work. Oral diabetes medications are not insulin and
are not a substitute for diet and exercise. These medications are
most effective in people who developed diabetes after age 40, have had diabetes
less than 5 years, are normal weight, and have never received insulin or have
taken only 40 units or less of insulin a day. Pregnant and nursing women
shouldn't take oral medications because their effect on the fetus and newborn is
unknown, and because insulin provides better control of diabetes during
There is also some question about whether oral diabetes medications increase
the risk of a heart attack. Experts disagree on this point and many people with
noninsulin-dependent diabetes use oral medicines safely and effectively. The
Food and Drug Administration (FDA), the agency of the Federal Government that
approves medications for use in the USA requires that oral diabetes
medicines carry a warning concerning the increased risk of heart attack. Whether
someone uses a medication depends on its benefits and risks, something a doctor
can help the patient decide.
The purpose of oral medications is to lower blood glucose. Therefore, the person
taking them must eat regular meals and engage in only light to moderate
exercise, to prevent blood glucose from dipping too low. Medications taken for
other health problems, including illness, also can lower blood sugar and may
react with the diabetes medicine. Therefore, a doctor needs to know all the
medications a person is taking to prevent a harmful interaction. Lowering blood
sugar too much can cause hypoglycemia with symptoms such as headache, weakness,
shakiness, and if the condition is severe enough, collapse. "
Most studies of drug-treated diabetes patients show a progression of the
disease on medications, often with failure within 5 years. There are concerns
about side effects and long-term adverse effects. Unfortunately taking the older
oral hypoglycemic medications may not reduce the long-term complications of
diabetes. Newer medications may be promising but long-term outcomes will
not be known for many years. New problems continue surface with drug use. I
share the concern with most MDs that the majority of diabetic patients will
continue their disease- producing lifestyle and will just take drugs, hoping for
the best. Only the most intelligent and most determined diabetics will change
their disease-causing lifestyle and will not take drugs passively.
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self-help book explains how to manage diabetes.
The book offers the good news that the impending disasters are optional if
eating and living conditions are changed correctly. Newly diagnosed diabetics
should act to design a new diet with increased physical activity. 2018
Edition 170 Pages
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