Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
15 November 2006

THE NEW MEDICINE FOR DIABETES

            The lady was 60 years old and had always looked upon herself to be in excellent condition.  She took no medications for any reason, not even an aspirin.  She hadn’t been seen for several years but came to be seen for a “checkup”.  Her weight was up slightly from the past as seems to happen with age.  Routine mammography and bone mineral density tests returned within normal limits not in need of changes in management.

            But then the blood tests came back.  Her routine blood sugar check in the fasting state was normal.  But because of the weight gain, a blood test called glycosylated hemoglobin was done in addition.  The glycosylated hemoglobin (hemoglobin A-1-C) was found to be around 6.4 %, definitely higher than normal.  For practical purposes, this establishes that the lady was diabetic.  As you might imagine, this was no music to her ears.  She had always prided herself on her good health and physical conditioning and wanted to know how in the world she could be diabetic. 

            I explained that adult onset diabetes such as she had does have hereditary factors, is associated with excessive weight, and is associated with a sedentary lifestyle.  But then there is a whole bunch of people who definitely are diabetic and have no specific factors that we can identify.  For some reason, diabetics of the adult onset type become resistant to whatever amount of insulin they already have.  With time, their insulin secreting cells are overworked and fatigued.  Then their blood sugars go up high after meals at first and after several more years the blood sugars are high all of the time.

            This lady wanted to know what could be done to reverse this condition.  She was depressed to hear that the tendency to be diabetic was not going to go away.  She would have to struggle with it for the rest of her life.  But she could prevent the complications that diabetes causes by controlling her blood sugar as close to normal as possible.

            To achieve this, she needed to continue her exercise program as she always had.  But more importantly, dietary modification needed to be introduced.  Those wonderful big celebratory meals or those rich desserts or the in front-of-TV snacks needed to be cut way back.  She was instructed that she needed to do what she could to modify her diet over the next three months and then have another Hemoglobin A1C test done.  If she couldn’t get her Hemoglobin A1C down to normal in that time, then she would need to start a medication. 

            The medications available at this time include a product called Metformin which costs only $4.00 a month now but has a 20% likelihood of causing diarrhea.  Then there are the so called insulin secretors (oral insulin) that cost not much more than $4.00 a month but carry the risk of causing low blood sugars.  Thirdly, there is a new family of insulin secretors that carry less risk of causing low blood sugar but cost about $120.00 a month.  Next, there is a group of drugs that improve insulin resistance and make the person more sensitive to whatever insulin they’ve got.  These go under the horrible long name of “thiazolidindions.  They have side effect of causing fluid retention and weight gain.  But worst of all, they cost $210.00 per month or more.  Then there are a group of drugs that block of the absorption of sugar from the bowel with the claim that they prevent high blood sugars and may contribute to weight loss.  But all that sugar that is not absorbed in the small bowel reaches the large bowel where the colonic bacteria think it is wonderful.  They ferment the sugar and produce gas and diarrhea that can be very uncomfortable.  Finally, there is a new injectable medication called Byetta (exanatide) that definitely contributes to weight loss, improves diabetic control, and may help the diabetic individual regrow their lost insulin secreting cells.  Unfortunately, this medication causes nausea, needs to be injected twice a day and costs $220.00 a month. 

            But there is a new medication that has just come out that simulates this twice day injection.  The new medication is a pill taken once a day.  It too slows gastric emptying thereby decreasing hunger and at least in animals it does contribute to the regrowth of the insulin secreting cells.  It holds the potential of really reversing one of the major factors in the development of diabetes.  Specifically, diabetes comes at least partially from the loss of insulin secreting cells and thereby not enough insulin.  The new drug may contribute to the regrowth of the insulin secreting cells if it works the same in humans as it does in experimental animals.  The new drug was just approved in this last several weeks and as of the time of this dictation, the price is not established and it is not even in pharmacies yet.  But it will be something to try for people like the lady mentioned above.  The side effect profile is negligible which would be a welcome addition to the diabetic treatment programs.