GETTYSBURG MEDICAL NEWS
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
08, February 2001

 A New Drug for Diabetes Mellitus

 This past week my wife, Peggy Hoffsten, R.N., B.S.N., and I traveled to Dallas to receive information on a new medication to treat diabetes mellitus. Peggy helps with patient education and attends all the continuing medical education programs with me. The speakers reviewed various aspects of diabetic disease and the treatment options available. One of the points made during the presentation was that diabetes is epidemic in the United States. One of the most feared and certainly unpleasant diseases in our society is AIDS. A comparison between diabetes and AIDS will add perspective to the gravity of the diabetes problem. First, there are approximately 750,000 cases of HIV infection in the United States. HIV is the virus that causes AIDS and about 5% to 7% of the people who are infected with this virus will develop the flail AIDS disease complex each year.

 By comparison, there are about 30 million people in the United States who have high blood sugars. Approximately 15 million of these people have diabetes mellitus. Thus diabetes is 20 times more a problem than AIDS. Only about S million people are being treated for their diabetes. Approximately 2 out of 3 people that have diabetes mellitus don’t even know it and are not receiving any treatment for same. While the AIDS epidemic in the United States is being slowed through various public health interventions, the diabetes epidemic in the United States is exploding. AIDS is spread by intravenous thug abuse and by risky sexual behavior both of which have been decreased in the United States population by educational efforts. High blood sugars and diabetes mellitus are the result of inactivity and overnutrition neither of which have been favorably impacted by public health education efforts. Unfortunately, the people of the United States persist in their pursuit of labor saving devices. They seek easy modes of transportation rather than walking and while they sit in front of their computers and TV sets, they eat. It is estimated that there has been more than a doubling of the diabetic population in the United States in the past 20 years. This is about the time that personal computers and all of their laborsaving aspects have come into use. The AIDS epidemic is now better controlled while the diabetic epidemic is exploding.

 Both diseases are devastating to the individual’s health. Diabetes has approximately a 10 year “honeymoon” during which the disease silently causes degeneration of the blood vessels that supply the nerves, the kidneys and the eyes. Once this blood vessel damage has occurred, it is very unforgiving and regaining fimction is unlikely. In addition, diabetes leads to abnormalities of the blood cholesterol and blood pressure thereby being responsible for approximately 15% of the 600,000 heart attacks that occur in the United States each year. Diabetes is a very burdensome disease with a prolonged unpleasant course. 

That much said, the question is raised as to the appropriate interventions. First and foremost is dietary control and adequate exercise. As has been mentioned many times before, the national prescription for exercise is a minimum of three miles per day walking or more. Dietary control means getting within 10% of your ideal body weight and maintaining this level. Unfortunately, 33% of the United States population exceeds 10% of ideal body weight. The healthcare industry has been woefully ineffective in helping people control their weight or achieve adequate exercise. This is going to take a massive public health service and governmental intervention to discourage excess calories and encourage increased activity.

While we wait for society’s habits to change, there are medications that can be used to better control diabetes and slow the rate of progression of the complications. Recently two drugs of a new class of medication became available to improve the diabetic’s sensitivity to the insulin they already have. These drugs have already been shown to decrease the complications from diabetes including the heart attack rate. The two drugs in this class are called Avandia and Actos. Unfortunately, they are very expensive but are very effective and useful drugs.

 The second class of anti-diabetic drugs is called metformin. This medication decreases the amount of sugar that is made by the liver and thereby lowers the blood sugars. This medication is not quite as expensive; unfortunately it has symptomatic side effects in a number of people but it is also is effective in decreasing the ravages of diabetes.

 The third class of medications to treat diabetes are medications that stimulate the pancreas to make more insulin. This is the oldest class of oral diabetes medications, and while they are marginally effective in lowering blood sugars, to this time there have been no major studies which have been able to demonstrate a life-saving or complication-reducing effect of these medications in regard to diabetes care. Common drugs in this group include glyburide (Micronase, DiaBeta, Glynase), glipizide (Glucotrol), and repaglinide (Prandin). There are many older brands of medication in this group that seem to be less effective than the three named above.

 The new drug that will be released this week is called Starlix. This medication has the advantage of much better control of blood sugars after eating. The pill is taken with each meal and prevents the jump in blood sugars that occurs when people eat. It is too new to know if there will be reversal of the ravages of diabetes over the long run but it is clear that this medication is effective in lowering the person’s average blood sugar and stopping the substantial rises in blood sugar that occur after a meal. 

For those of you who have diabetes and who use blood sugar measurements to help control the condition, it would be recommended that blood sugars be checked two hours after a meal to see the worst values. Most people are taught to check their blood sugars before they eat. This gives a rosy picture of how low the blood sugars are but never really reveals how high blood sugars are after a person eats. Note that at least one-half of the day is included in this period two hours after a person eats. For some people who munch all the time, the two-hour period after eating never really ends and a single early morning blood sugar check gives a very false representation of what the average blood sugars are. To get a better picture of what blood sugars are doing and how Starlix might help, checking blood sugars two hours after a meal may give a much better representation of what the person’s average blood sugar is.

 The above three medications are very useful for the 25 million Americans with diabetes who are not already using insulin. Note that by the time a person finally has to use insulin, their condition is far advanced and pills such as the above have relatively less impact. The above medications can be prescribed through your local healthcare providers at your local clinic along with help and monitoring the diabetic condition to ensure adequate treatment. The proper choice of medications for both effectiveness, affordable price and avoidance of side effects is a critical part of diabetic care.