Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, M.D.
 15 June 2005

“A NEW DIABETES MEDICATION”

            Although the problem of diabetes mellitus was known to the Greeks in 300 BC, there was no meaningful treatment for the problem until 1921 when Drs. Banting and Best isolated insulin.  It was another 30 years before an oral drug that stimulated insulin secretion became available in the 1950’s.  The family of drugs called the sulfonylureas is still used today as the so-called oral insulins.  Examples of these drugs are glipazide (Glucotrol) and glyburide (Diabeta).  These drugs act upon the Islets of Langerhans in the pancreas causing more insulin release.  Glipazide and glyburide don’t correct the basic problem of why the person needs more insulin.  Instead, they push an already fatiguing pancreas to make more insulin.

            It took 10 more years to the 1960’s for a drug called phenformin to come on the market as a drug that decreased glucose release by the liver.  This had the effect of lowering blood sugars and making the person slightly more sensitive to the insulin that they already had.  Because of side effects, this drug was taken off the market and replaced by another drug called metformin that is still one of the major oral diabetes pills used today.  Metformin makes the person a little more sensitive to the insulin that they already have and slows the release of sugar from the liver to keep blood sugars down.  It also has the effect of decreasing appetite and contributing to weight loss in the overweight diabetic.

            The fourth family of medications became available in the 1980’s.  These were drugs such as miglitol and acarbose which inhibit the intestine’s ability to absorb sugar.  This family of drugs has a relatively small role in diabetic control and has not been widely used.

            A last family of medications came on the market in the 1990’s.  These drugs are called the TZD’s.  They have the effect of making the person more sensitive to the insulin that they already have and thereby gave the insulin producing pancreas a rest while still lowering the blood sugar.  This family of medications (Avandia, Actos) is very expensive and has the side effect of contributing to weight gain and making heart failure worse in patients that are struggling with that problem.  Better TZD’s are in the development process but are not available at this time.

            Over the years, there have been many gimmicks in regard to insulin administration.  Different types of syringes for people that are visually impaired and different types of insulin tailored to individual needs have been developed.  But to this time, these 5 families of medications are what the diabetic has had available.

            Enters now a new conceptual type of medication.  It seems that in addition to insulin the pancreas also secretes another family of hormones called amylins.  These are naturally occurring hormones secreted by the pancreas that slow stomach emptying and thereby slow the rate at which sugar enters the blood stream.  This has the effect of lowering blood sugars.  This family of hormones also enhances the effectiveness of insulin.  Thus insulin doses can generally be cut in half in individuals that initiate use of this injectable hormone.

            The new medication is called pramlintide (Symlin).  It is an injection that is taken prior to a major meal.  It is probably more useful in people with type II diabetes as opposed to the juvenile onset type I diabetes.  It is relatively short acting and thus must be injected three times a day prior to large meals.  It has the effect of stopping the large increases in blood glucose that occur after a meal.  In trials of a large number of diabetics, the Hemoglobin A1C was decreased about ½% lower than it had been prior to the use of the drug.  It does not have a block-buster effect but for some individuals it can be important.  The cost will be about $160.00 a month for individuals who use the drug three times a day.  What its long term role will be in the control of diabetics in the future is yet to be determined for this drug was only recently released to the market.

         A person who might use this medication is someone who is struggling with obtaining adequate control of blood sugars in spite of insulin and oral medications.  Pramlintide is recommended for individuals already using insulin but inadequately controlled.  We have learned in the past 20 years that checking a blood sugar in the early morning hours prior to breakfast is not a good monitor of how well blood sugars are controlled.  Most diabetics have a sharp rise in their blood sugar after they eat and this may not come back to normal for 3-5 hours.  Thus, diabetics often spend 12-15 hours a day with blood sugars in the abnormal range.  Pramlintide would be a medication to decrease those high daytime blood sugars and get the glycosylated hemoglobin back towards the normal range.

            As an additional impetus to consider a drug such as this, a recent study characterized a number of 40-60 year old patients.  The question asked was what the markers are for those individuals who will develop Alzheimer’s dementia in later life.  The best marker of all was uncontrolled diabetes.  Compared to the non diabetic individuals in the study, there was a 50% increase in the likelihood of the patient developing dementia if they were diabetic 20 years before. This says that the control of diabetes and keeping blood sugars in the normal range does not just protect the kidneys, the eyes and the feet; it protects your brain, too.

            The healthcare providers at your local clinics are well aware and well versed in the appropriate care of diabetes.  Diabetic control is well worth the effort that a person puts into it.