Diabetes Diabetes Solutions

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  • 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 considering medications.

    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.

    Newer Drugs

    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 newer drugs.

    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.

    SGLT2 Inhibitors

    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.
    The EMPA-REG 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 diabetes.
    [i] Charles P. Vega/. Antidiabetes Drugs: Really New and Improved? Medscape Internal Medicine. September 19, 2014
    [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 pregnancy.

    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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