Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
12 July 2006

EXANATIDE – FOLLOW-UP AND UP-DATE

             In the May 11^th issue of “The Clinical View”, I wrote about a new diabetic medication called exanatide.  There have been some new developments in the past few months and my own personal experience with the drug as described below.

            As described previously, in the 1990’s researchers worked on a hormone called “glucogon-like-peptide-1” or GLP-1 for short.  This hormone is produced by the intestine.  It turns out that this hormone stimulates the insulin secreting cells in the pancreas.  Remember that when blood sugars go up in diabetes, it is because the insulin secreting cells in the pancreas are slowly, progressively lost and not regrown.  It turns out that the type 2 diabetics have a substantial deficiency in GLP-1 and this is one of the reasons that they don’t have enough insulin.  In early studies in animals, it was found that GLP-1 helped regenerate insulin secreting cells.  To this time in humans, the data supporting this observation are sketchy but encouraging.

            In the article I wrote in May, I described the five (5) advantages of exanatide as including:

            1.  A slowing of gastric emptying thereby contributing to a decreased hunger.  This slowing of gastric emptying also slows the rate at which food gets into the blood stream and the blood sugar does not go up as high.

            2.  Exanatide use was associated with a definite weight loss.  On average, patients lost 1-2 pounds per month without personal effort.  There are now reports in the literature of individuals losing sixty pounds in the course of a year in response to this drug.

            3.  It was associated with a significant drop in the A1C indicating much better control of the person’s diabetes.

            4.  It decreased the secretion of a hormone called glucagon.  Glucagon raises blood sugars and less of it helps lower blood sugars.

            5.  I mentioned above, exanatide has an insulin secreting cell stimulatory effect.

            Since that article in May of 2005, I have now personally completed a three month use of this medication on myself.  Initially, my glycosylated hemoglobin (A1C) was around 6.8%.  Within one month, my A1C had dropped to 6.4% and by the end of three months it had dropped into the normal range at 5.9%.  The drug had relatively little effect on my resting glucose levels which were normal anyway; but it definitely cut down the increases in blood sugar that came after meals.  Initially, my after meal blood sugars were over 170 mg% two hours after eating.  With the exanatide, the values rarely exceeded 140 mg%.

            In December of 2005, I challenged one of my colleagues’ to a weight loss effort.  We were both to lose ten pounds from January 1 to April 1.  If we didn’t meet the challenge, we were to wear a badge that stated “I was too weak and too lazy to lose 10 lbs in three months and now I have to wear this silly ass badge until I do”.  As you might imagine there was no way I was going to wear a badge like that and I lost the 10 pounds.  I had figured that this would help me better control my own diabetes and my A1C would go back to normal.  There was no such effect.  My A1C stayed at about 6.8%.

            I have been reading about exanatide (Byetta) and decided it was time to try this.  Through no personal effort, I have lost an additional 4 pounds in the last three months since starting the drug.  This was a surprise to me because losing the original 10 pounds took quite an effort.

            So what is the downside?  The most objectionable thing about exanatide is the loss of appetite and slight nausea that one feels when using this medication.  Within a few days of staring the injections, the constant drive to eat seems to just disappear.  One almost has to think about getting to meals.  A very loving spouse now thinks I am wasting away and is pushing food at me, quite a difference from the past.

            The slight nausea that one feels with this medication is probably related to the slow emptying of the stomach.  If I do eat a big meal once in awhile, especially if it is a fatty meal, it feels like my stomach doesn’t empty for two days.  Spicy BBQ or garlic often gets burped for two days after it is eaten.

            The injections twice a day are hard to remember.  I have forgotten six times in the course of three months especially if we go out after work without going home.  The medication has to be refrigerated and the expense is substantial at $175.00 a month.  Fortunately, with Medicare Part D, the cost to me personally is only about $40.00 per month but that is a lot cheaper than some diabetic medications.

            This drug has now been on the market for about a year and three months.  Experience has been accumulating.  Researchers are now prescribing this medication for individuals that are already taking injectable insulin.  The insulin requirements have been dropping substantially in these patients and the weight loss benefit is definitely present.  The company that makes this medication is developing a sustained release product that will only have to be injected once a week or once every 10 days and that should be out within a year or two.

            In summary, I am still using it.  I am very pleased with the control of the diabetes and the weight control aspect is a welcome fringe benefit.  Several patients are now trying the drug and “so far, so good”.  An endocrinologist I refer to told me he has over two hundred diabetic patients using this drug and he is very pleased with it.