One of the leading diabetes researchers in the world, Dr. Aaron I. Vinik leads the EVMS Strelitz Diabetes Center’s quest to cure diabetes. Internationally renowned for his research in the areas of hormone secreting tumors and the chronic complications of diabetes, Dr. Vinik has presented his work all over the world….
Our publisher, Steve Freed, contacted Dr. Vinik recently to check in on the latest on GLP-1 therapy….
Where do you feel the GLP-1 compounds fit into the spectrum of treating type 2 diabetes?
Dr. Vinik: As second tier compounds and particularly in obese patients.
In which type of patient do you feel they are most effective?
Dr. Vinik: In people close to the desirable goal in whom a change in A1c of a little more than one half percent will suffice. Also in those patients in whom there is a discrepancy between the A1c levels and the glucose monitoring levels suggesting that post prandial hyperglycemia may be playing a significant role in preventing getting to goal.
Dr. Vinik: The ability to lower blood glucoses without induction of significant hypoglycemia.
Dr. Vinik: Usually about 4-5%. There is always the occasional patient in whom spectacular results are to be had but these are the exception rather than the rule.
Dr. Vinik: I tend to do the following: I use the lesson learned from the ACCORD trial and the VADT as to who the patients are we place at risk for sudden death. Within this framework my goal setting is relaxation of the ADA and ACE targets in specific populations. Despite this I tend to divide people who are less than 7.5, 7.5-9.0 and more than 9.0 A1c. I use a treat to target approach ( as opposed to treat to failure) allowing a single agent to lower A1c about 0.6-1.0%, a combination will do about 2.5 percent and insulin can do it all. The higher the A1c the greater the response. So if all I need is 0.5% I will add a GLP-1 compound. If I need up to 2.5% then I will use combination therapy which will include a GLP-1 compound. If it is more than 3% then I favor insulin early and only if there is a weight issue will I use a GLP1 compound. In patients who are older and or have impaired renal function I favor GLP-1 compounds.
Dr. Vinik: Most recently I’ve become excited about the use of bromocryptine since this is the first compound to change sympathetic and parasympathetic balance. With the scare about lack of effects of greater glycemic control and increase in events and mortality it is salutary to know that even in short term trials in a small cadre of patients’ MACE (major adverse cardiac events) can be reduced by up to 55%. This is particularly important now that we have become aware that a major contributor to these events appears to be autonomic neuropathy and a history or objective evidence of peripheral neuropathy.
Dr. Aaron I. Vinik has written five books, published more than 250 papers in medical journals, and is recognized as a pioneer and scholar. Dr. Vinik has received research funding for his studies from the National Institutes of Health, the National Cancer Institute, the Kroc Foundation and the American Diabetes Association. He is a leader in research on the diagnosis and treatment of diabetic neuropathy with a particular expertise in the area of autonomic diabetic neuropathy, a complex and challenging condition. Dr. Vinik has also been a leader in research on new approaches to generate islet cell tissue from pancreatic duct tissue which may one day lead to a true cure for diabetes.