November 2006 – A generation ago, there was just one kind of pill that could help people with diabetes keep their blood sugar levels down. But today, so many new options are available that it’s almost dizzying. Advertisements for the new medicines seem to be everywhere, and more new medicines are on the way. These are exciting times for people with diabetes, says a University of Michigan expert who has devoted his career to studying the best ways to prevent and treat the disease. He points to the broad array of new, and tried-and-true, diabetes treatments that can be swallowed, inhaled and injected — plus the powerful tools of healthy eating and regular exercise that are crucial to every diabetes patient’s treatment.
Virtually anyone with diabetes can now find an option that will work for them, and keep their blood sugar low enough to prevent or delay long-term problems like heart attacks, blindness, amputation and kidney failure, says William H. Herman, M.D., MPH, the director of U-M’s Michigan Diabetes Research and Training Center.
The big challenge now is making sure that doctors and patients work together to take advantage of all the options that are available, and making sure that insurance plans keep up, he says. Even with treatment, two-thirds of people with diabetes still have blood-sugar levels that are too high, which puts their future health at risk.
"Nearly 20 million Americans have diabetes, and it’s an enormous and growing problem," says Herman. "It’s been a long process, but I think we’re really beginning to understand much better what causes diabetes, and many of the new treatments are based on that improved understanding." Some people with diabetes will need one or two of these options to lower their blood sugar, while others will need several.
Today more than half of adults with diabetes take pills or other oral medicines to treat their disease, according to national statistics. Another 12 percent take pills and also inject insulin. Sixteen percent take insulin alone. And 15 percent don’t use any medications at all ? either because diet and exercise work well for them, or perhaps because they don’t have access to good diabetes care and medication.
As the newer treatments become more available, they should help people reduce their average blood-sugar levels, known as A1C levels. Most people should aim for an A1C level of 7, but even if levels are higher, they should try to reduce it as much as they can. Even bringing it down by one point can mean a 40 percent reduction in long-term risk of other diseases.
"It’s now well-proven from scientific studies that diabetes control matters, and that better glucose control over years and decades is associated with a reduced risk of complications affecting the eyes, the kidneys, the nerves and the heart and blood vessels," says Herman, a member of the Michigan Comprehensive Diabetes Center. "People with diabetes should speak to their physicians about whether they would be candidates for these new treatments, and how they might fit into their diabetes-management programs."
New guidelines issued this summer suggest that newly diagnosed diabetics should start by taking metformin, an inexpensive medicine that is the tried-and-true blood sugar drug. Those whose blood sugar is especially high at diagnosis may start taking insulin injections right away. After a few months, if those medicines ? and diet and exercise ? aren’t keeping blood sugar low enough, other medicines can be added. These can include the options introduced recently, and older drugs.
Among the new treatments are medicines that sensitize the body to the effects of insulin, new ways to deliver insulin into the body, and hormones that affect the way the body produces or responds to insulin. They include:
Pramlintide: A new synthetic form of the naturally produced hormone amylin was approved last year for use in diabetes patients who still don’t have their blood sugar under control despite using insulin. It can be used by people with type 1 diabetes (sometimes called juvenile diabetes because it begins early in life), and for people with type 2 diabetes whose disease is severe enough to require insulin and even additional medication. Amylin must be taken as an injection, separate from insulin injections, but it appears to help regulate blood glucose (sugar) levels and may even help with weight loss, which is often a struggle for people with diabetes.
Exanatide: Another manmade form of a hormone that’s naturally produced in the body, exanatide, encourages the pancreas to make more insulin, and helps to reduce blood sugar. The dose is the same every day, unlike insulin doses which have to be adjusted often. This drug is given as a twice-daily injection from a pre-filled pen, and a longer-acting form that can be given once a week is in development. It may help prevent the need for insulin injections in type 2 diabetes patients who haven’t been able to get their blood sugar under control with pills alone. And it may help diabetics lose weight, which in turn can help them control their blood sugar even better.
Long-acting insulin: For those diabetics who need insulin injections to control their blood sugar including type 1 diabetics, who need insulin injections in order to survive ? the introduction of new forms of insulin has been a boon, Herman says. "During the past several years we’ve witnessed a tremendous change in insulin therapy. There are new injectable long-acting insulins that have made diabetes management easier, helping to smooth blood sugar control and help patients avoid highs and lows."
Inhaled insulin: Millions of people with diabetes test their blood-sugar levels and inject themselves with insulin every day a task that requires diligence, and seems like an incredible burden to those who haven’t gotten used to it yet. Many diabetics adjust to the test-and-inject routine, Herman says, especially type 1 diabetics. But many type 2 diabetics don’t keep up with their insulin regimens because of the hassle. Many others fear the idea of having to use a needle every day, and go through life with uncontrolled blood sugar. Early this year, the Food & Drug Administration approved an inhaled form of insulin the first new way of delivering the drug in 80 years. It can be used in combination with injected insulin by type 1 diabetes, to replace one of the two injected forms they take. It can also be used by type 2 diabetics together with pills, or with injected insulin.
Combination pills: Another trend among diabetes treatment makers is combining several medicines into one pill to reduce the number of different pills patients have to take. This may help encourage some patients to keep up with their medicine. But if cost is an issue, it may be less expensive to get generic forms of the individual medicines and just take more pills.
Blood pressure and cholesterol medicine: Along with recent research on the importance of blood sugar control has come research on the importance of controlling blood pressure and cholesterol levels in people with diabetes. Because their disease can damage the blood vessels and heart over time, nearly everyone with any form of diabetes should have their blood pressure and cholesterol tested regularly.
People who don’t have diabetes yet, but are at high risk of developing it, are also benefiting from these exciting times, Herman adds. Recent studies have revealed the strong link between being overweight and developing type 2 diabetes. But they’ve also shown how diet, exercise, and other lifestyle choices can keep people from becoming diabetic even though they’re overweight and their bodies are starting to lose their ability to process sugar well. Some people with an especially high risk of developing diabetes may also benefit from taking metformin.
With 41 million Americans falling into the category of pre-diabetes, or high risk of diabetes, this kind of early intervention is more important than ever. "Preventing type 2 diabetes can prevent the need for treatment, and down the road can prevent the risk of complications, so prevention is hugely important," says Herman, who is a professor in the U-M Medical School’s Metabolism, Endocrinology and Diabetes Division.
For those who have already been diagnosed, he adds, the good news is that some combination of old and new treatments, and lifestyle changes, will work for virtually everyone. "The new treatments for diabetes present an exciting new opportunity to tailor treatment to the individual patient’s needs, and to the type of diabetes that they have," he says.
Source: University of Michigan Health System