New Treatment Options for Diabetes Patients

Over the past decade, the list of type 2 diabetesmedications has grown — helping people gain better blood sugar control. But the drugs’ side effects — plus taking several pills every day — can be frustrating.

“There are two problems with diabetes,” explains Ronald Goldberg, MD, associate director of the Diabetes Research Institute at the University of Miami Medical Center. “Your body doesn’t make enough insulin. And your organs are resistant to using insulin that is produced.”

If lowering high blood sugar is the primary goal, today’s diabetes drugs do their job “but only to a limited extent,” Goldberg tells WebMD. “Even when patients respond to one drug, they will need more and more drugs over time, as the pancreas deteriorates.”

Type 2 Diabetes Treatments: New Options

Fortunately for many, advances in treatment are helping to make a difference, giving people with type 2 diabetes a growing list of options, including:

* Complex new drugs, like Byetta, which is taken by injection but is not insulin. It attacks high blood sugar from multiple angles and suppresses appetite. “Byetta is a real advance,” says Stephen Davis, MD, chief of Diabetes, Endocrinology, and Metabolism at Vanderbilt Medical Center in Nashville, Tenn.
* Januvia, which just received FDA approval, is a novel drug that works with gut hormones, natural enzymes, and the body’s own insulin to control blood glucose. A similar drug, Galvus, is expected to receive FDA approval in 2007.
* Several two-drug combination pills have been approved by the FDA in the past two years — reducing the number of pills people must take. The well-known drug metformin is now available in an extended-release, once- or twice-a-day dosage — without bothersome intestinal side effects.
* Acomplia (rimonabant) is awaiting FDA approval for the treatment of obesity, one of the leading risk factors for the development of diabetes. It shows great promise in controlling blood glucose, plus heart disease and stroke prevention, Davis tells WebMD. “That’s the direction the research is going … diabetes medications that also reduce cardiovascular risks. It is rapidly coming together.”

Metformin: Diabetes Workhorse Drug

Metformin has long been the workhorse of the oral diabetes drugs. Metformin “mostly works by preventing the liver from releasing too much sugar,” Goldberg explains.

He says metformin is good at controlling glucose. “And it’s a drug that does not cause weight gain. Also, the generic version is less expensive for patients. For all those reasons, metformin is usually the medication we start patients on.”

However, because of side effects — gas, bloating, and diarrhea – some people have trouble tolerating metformin in its standard form, says Davis.

Extended-release metformin takes care of that problem. The drug has fewer side effects, says Davis, “and is absolutely an advance … much better tolerated.”
New Combination Drugs for Diabetes

The new combination medications join metformin with other well-known diabetes drugs. Sulfonylureas like Amaryl and Glucophage help stimulate the pancreas to make more insulin. Thiazolidinediones (TZDs) like Actos and Avandia help “sensitize” fat and muscle cells, making them more responsive to the body’s natural insulin, thus overcoming insulin resistance.

Here’s the current list of FDA-approved combination drugs:

* Glucovance (metformin and glyburide, a sulfonylurea)
* Metaglic (metformin and glipizide, a sulfonylurea)
* Avandamet (metformin and rosiglitazone, a TZD)
* Avandaryl (glimepiride, a sulfonylurea and rosiglitazone, a TZD)

“The combination drugs make sense,” Davis tells WebMD. “The individual components are effective drugs, and in putting them together you get an additive effect.” For people with early to moderate diabetes, the combinations can be effective, he says. “A once-a-day pill is also easier for patients to remember to take. Plus they’re cost-effective, since patients get two medications with one co-pay.”

However, the two-in-one drugs have a downside, Davis says. “If there are side effects with one drug, you cannot change the dosage to reduce them. The patient may have to quit the drug altogether.”

Combination drugs are not appropriate for people with advanced diabetes, he adds. “Their glucose is more difficult to control, and they are less able to tolerate side effects. I would not prescribe them for those patients.”
Sophisticated New Treatment Options for Type 2 Diabetes

The two-pronged mission of Byetta — a drug derived from lizard spit — has generated lots of interest, says Goldberg. The drug stimulates insulin production after a meal, but only when blood glucose is high. It also represses glucagon, a hormone that increases blood sugars. The drug is given by injection (via a small pen-like device) before breakfast and dinner.

The drug mimics a natural blood-sugar-lowering hormone made in the gut (GLP1), Goldberg explains. “The drug does this very, very effectively. Plus, the appetite-suppressant effect and weight lossloss also helps control the diabetes.”

Prandin and Starlix (meglitinides drugs) are fast-acting drugs that — after you eat — release enough insulin to control excess blood sugar. You take the drugs before sitting down to a meal. However, the drugs “are not dependable,” says Goldberg. “The drug dosage has to be carefully calculated, and patients must watch their blood sugar carefully.”

The drugs Precose and Glyset (alpha-glucosidase inhibitors) take a very different approach. They block the digestion of starch in the intestine, so blood sugar doesn’t rise as much after a meal, Goldberg explains. “Trouble is, there are a lot of side effects with Precose, so it’s not used much at all. Mainly, the problem is flatulence.”
The Future of Diabetes Drugs: Beyond Blood Sugar Control

Side effects may not always present a problem. For example, research has revealed positive “side effects” of Precose and many other already-available diabetes drugs:

* Metformin and Precose can reduce the risk of developing type 2 diabetes in at-risk individuals, when combined with a healthy diet and exercise.
* Actos can reduce the risk of heart attack, stroke, and premature death among people with type 2 diabetes.

“We now think of diabetes as than more than just managing glucose. To manage a patient with diabetes effectively, you need to control blood pressure, lipids, glucose, and even inflammation,” Davis tells WebMD.

Diabetes: Drugs Coming Soon?

“One of most promising and exciting new drugs,” is Acomplia (rimonabant), Davis tells WebMD. “It’s what’s called a CB-1 blocker — it blocks the endocannabinoid system.” That system is important in the body’s regulation of internal processes involved in diabetes, heart disease, and stroke, he explains.

Four very large trials have shown that 20 milligrams of rimonabant can significantly reduce weight, increase HDL “good” cholesterol, lower triglyceride levels, lower blood glucose, and improve blood pressure. The drug is currently under FDA investigation, and will likely be approved in 2007.

Januvia (sitagliptin) and Galvus (vildagliptin) are in a novel class of diabetes drugs called DPP-4 inhibitors. By inhibiting this natural enzyme, Januvia significantly increases the levels of incretin-a hormone, which helps regulate blood sugars. It also increases the synthesis and release of insulin. Januvia has just received the FDA’s blessing. Galvus is expected to be approved in 2007.
Don’t Forget: Treatment With Exercise, Healthy Diet

To get the most benefit from any diabetes medications, you must stick to a healthy lifestyle, Davis says. He doesn’t advise patients to follow extreme diets, like low-carb or vegan diets – even though one study by the American Diabetes Association found that a vegan diet can reduce the need for diabetes medications.

“I certainly wouldn’t recommend a vegan diet. You can get nutritional deficiencies,” Davis tells WebMD. “I advise a well-balanced, nutritious diet that includes protein, fat, and carbohydrates.”

Exercise prompts your body to use insulin efficiently — if you eat a sensibly-sized meal, Davis says. “However, if you eat a very large meal, the medications may not be able to cope with the excess blood sugar. So yes, diet and exercise are important. Exercise controls insulin, blood pressure, weight, and well-being.”