Category Archives: Drugs for Diabetes

Sulfonylurea Drugs Linked to Heart Disease in Women

Posted on December 26, 2014 | Comments Off on Sulfonylurea Drugs Linked to Heart Disease in Women

…according to this article at Diabetes Care. The study population was the Nurses Health Study. The longer the sulfonylurea was used, the stronger the association with Coronary Heart Disease. CHD is by far the most common cause of heart attacks. On the bright side, the drugs were not linked to stroke risk. Remember, correlation is not causation, blah, blah, blah…

This report is another reason to do all you can to control blood sugars with diet and exercise, minimizing the risks—known and unknown—of long-term drugs.

I rarely start my patients on sulfonylureas these days.

Steve Parker, M.D.

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What We Don’t Know About Diabetes Drugs Could Kill You

Posted on December 21, 2014 | Comments Off on What We Don’t Know About Diabetes Drugs Could Kill You
paleobetic diet, low-carb diet, diabetic diet

How about this one?

MedPageToday has an article on the “Bittersweet Diabetes Economy” talking about the cost of treating diabetes, pharmaceutical company influence on diagnosis and treatment of diabetes and prediabetes, and the unknown long-term effectiveness of diabetes drugs. Most of the article pertains to type 2 diabetes. A quote:

Last year, sales of diabetes drugs reached $23 billion [worldwide or U.S.?], according to the data from IMS Health, a drug market research firm. That was more than the combined revenue of the National Football League, Major League Baseball, and the National Basketball Association.

But from 2004 to 2013, none of the 30 new diabetes drugs that came on the market were proven to improve key outcomes, such as reducing heart attacks or strokes, blindness, or other complications of the disease, an investigation by MedPage Today and the Milwaukee Journal Sentinel found.

The U.S. Food and Drug Administration approved all of those drugs based on a surrogate endpoint: the ability to lower blood sugar. Many of the new drugs have dubious benefit; some can be harmful.

Another key outcome we don’t know about is prevention or postponement of death in type 2 diabetes via drug therapy.

Now you have some inkling of why I exhort my patients to maximize diet and exercise interventions before resorting to drugs, increasing drug dosages, or adding more drugs. (I’m not talking about type 1 diabetes here.)

RTWT.

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Metformin: More Effective in Blacks Than Whites

Posted on October 30, 2014 | Comments Off on Metformin: More Effective in Blacks Than Whites

Diabetes Self-Management has some of the details.

The implication is that the genetically determined physiology of black diabetics is different from whites. There could be other explanations, admittedly.

 

Here’s why I bring this to your attention. You don’t see me review many scientific articles involving mice, rats, pigs, or rabbits. In fact, I hardly ever read them. I take care of human patients. I suspect there are too many genetic differences between us and them that clinically pertinent studies are rare.

If you read my blogs carefully, you’ll also note I often hesitate to generalize clinical study results from one ethnic group to others. The different black/white responses to metformin validates my approach.

Type 2 diabetes in whites and blacks may not be the same disease, and it could be different in Asians, Australian aborigines, and North American Native Americans. For that matter, Ethiopian black diabetes may not be the South Africa black diabetes.

You may also be starting to understand why there’s so much confusion about which diabetic drugs are the best. We have 12 different classes of drugs now; what’s best for me may not be best for you.

Steve Parker, M.D.

PS: Type 1 diabetes, on the other hand, is probably more homogenous across ethnic and national boundaries.

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A New Drug Treatment Option For Diabetes: Afrezza

Posted on October 4, 2014 | Comments Off on A New Drug Treatment Option For Diabetes: Afrezza
paleobetic diet, low-carb diet, diabetic diet

How about this one?

Well, it’s not really new. It’s our old friend insulin, soon to be available via inhalation with the brand name Afrezza. The U.S. Food and Drug Administration approved it in July, 2014. Click for the package insert.

Who Can Use It?

Adults with either type 1 or 2 diabetes.

Who Should Avoid It Or Not Use It?

  • those with chronic lung disease such as asthma or chronic obstructive lung disease (COPD)
  • smokers
  • pregnant or lactating women
  • those in diabetic ketoacidosis (DKA)
  • users who see a significant deterioration in lung function over time

Common Side Effects:

Hypoglycemia, cough, throat pain.

What’s the Dose?

It comes in 4 and 8 unit cartridges. See the package insert for dosing details. Afrezza is a rapid-acting insulin taken at the start of meals, so you’re looking at two or three doses a day. Type 1 diabetics still need to take a basal (long-acting) insulin once or twice daily. As far as I can tell, the type 2 diabetics in the pre-approval clinical studies were all taking one or more oral diabetic drugs in addition to the Afrezza; the inhaled insulin was an add-on drug. The average time to maximum effect of the drug is 50 minutes with the 8 unit dose; blood levels of insulin are back to baseline after three hours.

Anything Else Interesting About It?

The manufacturer recommends a test of lung function before starting the drug, to identify folks with lung disease who shouldn’t inhale insulin. The test is called spirometry or FEV-1 (forced expiratory volume in 1 second). Moreover, spirometry should be repeated six months after start of the drug, then yearly thereafter.

Another form of inhaled insulin—Exubera—was on the U.S. market in 2006 and discontinued by the manufacturer the next year. The problem may have been poor sales or a concern about lung cancer.

You can’t get it at your pharmacy yet. Maybe later this year or the next.

Steve Parker, M.D.

 

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Introducing Albiglutide (Tanzeum) for Type 2 Diabetes

Posted on June 18, 2014 | Comments Off on Introducing Albiglutide (Tanzeum) for Type 2 Diabetes
paleobetic diet, low-carb diet, diabetic diet

Is this what you want?

The U.S. Food and Drug Administration approved albiglutide for treatment of adult type 2 diabetes a few months ago. It will be sold in the U.S. as Tanzeum. It’s a once-a-week subcutaneous injection.

Albiglutide is a GLP-1 receptor agonist, joining exenatide and liraglutide in that class.

It’s not a first-line drug for diabetes. In clinical studies, it’s been used alone and with metformin, glimiperide (a sulfonylurea), pioglitazone, and insulin.

The most frequent side effects have been upper respiratory infections, diarrhea, nausea, and injection site reactions.

If I had diabetes, I’d be sure to do all I could for my condition with diet and exercise before ramping up the drugs.

Steve Parker, M.D.

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Meet the Newest T2 Diabetes Drug: Dapagliflozin (Farxiga)

Posted on March 22, 2014 | 3 comments

We have 12 classes of drugs in our armamentarium for the war on diabetes. The latest class is SGLT2 inhibitors and the newest of these is dapagliflozin. I read the manufacturer’s U.S. package insert and updated my SGLT2 inhibitor post.

Your kidneys normally filter some blood glucose into the “urine” and then reabsorb nearly all of it back into the blood. SGLT2 inhibitors interfere with reabsorption, so glucose ends up in the urine.

If you’re thinking that might cause yeast infections, you’re right.

Fun Fact: Taking 10 mg/day of dapagliflozin leads to loss of blood glucose into the urinary tract to the tune of 70 grams a day.

That’s 280 calories down the drain. I suspect that cutting 70 grams of carbohydrate from your diet would have just as much effect on diabetes as do these drugs. Without the yeast infections.

This drug class’s mechanism of action doesn’t appeal to me intellectually.

Steve Parker, M.D.

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Just What You Always Wanted: A Second SGLT2 Inhibitor (dapagliflozin or Farxiga)

Posted on March 5, 2014 | Comments Off on Just What You Always Wanted: A Second SGLT2 Inhibitor (dapagliflozin or Farxiga)
Open wide!

Open wide!

Where do they get these names?!

The trade name in the U.S. is Farxiga. (How do you pronounce that?) In Europe and Australia they call it Forxiga. Go figure.

MedPageToday has the details. Here’s the FDA press release, which misspells dapagliflozin. Here’s the Australian package insert for full prescribing information. Here’s my summary of both drugs in the class at one of my other blogs.

We how have 12 classes of drugs for treating diabetes.

If you’re eating the typical high-carb diabetic diet—200 or 300 grams of carbohydrate daily—you quite likely can reduce your drug requirement by cutting back on the carbs.

Steve Parker, M.D.

 

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Which T2 Diabetes Drugs Are Popular in the U.S.?

Posted on February 12, 2014 | 2 comments
Better living through chemistry

You may be able to avoid some of these through diet and exercise

Diabetes Care recently published results of a survey covering 1997 to 2012. The focus was on T2 diabetics age 35 or older:

“Between 1997 and 2012 biguanide [metformin] use increased, from 23% … to 53% … of treatment visits. Glitazone use grew from 6% in 1997 to 41% of all visits in 2005, but declined to 16% by 2012. Since 2005, DPP-4 inhibitor [e.g., Januvia] use increased steadily, representing 21% of treatment visits by 2012. GLP-1 agonists [e.g., Byetta] accounted for 4% of treatment visits in 2012. Visits where two or more drug compounds were used increased nearly 40% from 1997 to 2012. Between 2008 and 2012, drug expenditures increased 61%, driven primarily by use of insulin glargine [e.g., Lantus] and DPP-4 inhibitors.”

We have 12 classes of drugs for the treatment of T2 diabetes now. It’s not entirely clear which ones are the best. Since the long-term side effects of many drugs are unknown, if I had T2 diabetes I’d try to limit my need for drugs by restricting my carbohydrate consumption, maintaining a reasonable weigh, and exercising. And, no, they don’t always work.

Steve Parker, M.D.

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How Does Your Doctor Choose Your Diabetes Drugs?

Posted on December 28, 2013 | Comments Off on How Does Your Doctor Choose Your Diabetes Drugs?
paleobetic diet, low-carb diet, diabetic diet

How about this one?

We now have 12 classes of drugs for the treatment of diabetes. Choosing which ones to use is not always straightforward.

It’s easy for type 1 diabetes: insulin.

Type 2’s have more options. Metformin is the unanimous #1 pick. After that, it’s murky.

I recently reviewed the American Diabetes Association’s Standards of Medical Care in Diabetes – 2014. A type 2 treatment algorithm therein mentions only six of the 12 available classes. This gives you an idea of expert consensus on which drugs to use. The classes are biquanides (metformin), sulfonylureas, thiazolidinediones, DPP-4 inhibitors, GLP-1 agonists, and insulins. This is one reason you don’t see much use of bromocriptine and colesevelam.

The American Association of Clinical Endocrinologists also have a type 2 diabetes treatment algorithm, published in 2013. It also addresses prediabetes and overweight/obesity. You’ll see some of the other classes mentioned. It’s confusing because of abbreviations.

Believe it or not, most doctors want to do what’s right for our patients. We want positive results that reduce suffering and death. Does Big Pharma influence the production of guidelines and individual physician drug choices? If I had to guess, I’d say yes. But I don’t have the resources to investigate that in any depth. I know without a doubt that if I recommend a drug and the patient has a bad outcome, it helps me win the malpractice lawsuit if I’ve recommended a guideline-approved drug. Other docs know that, and it’s one of many factors that influence drug choice. We also consider cost (if you bring it up), convenience, patient preference, what our local colleagues are doing, what other illnesses the patient has, potential adverse drug effects, etc.

We don’t know the long-term adverse effects of many of these drugs. That’s why I favor doing as much as reasonably possible with lifestyle modification, such as diet and exercise, before stacking up multiple drugs. If you need drugs, and most with diabetes do, lifestyle modification can help you minimize drug use.

Steve Parker, M.D.

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Dr. Richard Bernstein Not a Fan of Insulin Pumps

Posted on July 17, 2013 | 5 comments

Click for details at DiabetesHealth. Dr. Bernstein is a type 1 diabetic and one of the first users of a home blood glucose monitor. He’s most famous for recommending very-low-carb eating for folks with diabetes, in his book Diabetes Solution. An excerpt from DiabetesHealth:

I spent a month in a major insulin pump center and saw several things. Many of the female patients seemed to have wings on their sides where the pump tubing was inserted and they got lipohypertrophy [overgrown fat tissue] from localized injections, but that was the least of it. None of them actually had remotely normal blood sugars.

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