by Gerti Tashko, M.D.
Diabetes epidemic has reached unprecedented scale; about 9% of all Americans (30 million people) have diabetes, and the trend continues to rise. At the same time, it is estimated that 85 million individuals have prediabetes. These are staggering statistics with tremendous cost to patients and society. Ninety five percent of all patients have type 2 diabetes, which is due to excessive body weight, especially abdominal adiposity or fat.
Unlike individuals with type 1 diabetes who have full insulin deficiency, type 2 diabetes patients produce plenty of insulin. But due to excess adiposity insulin does not work well and so blood sugars rise. Surprisingly, insulin is one of the main therapies for type 2 diabetes. Yet insulin is a powerful ‘building’ hormone that can cause significant weight gain, an undesirable consequence in someone who is already overweight or obese. In addition, insulin can also trigger unwanted hypoglycemia (low blood sugars) manifestation of which could vary from feeling hungry to becoming unconscious or developing seizures.
So it is reasonable for patients to use other medications that promote weight loss rather than weight gain in type 2 diabetes. Such two drug classes are ‘GLP-1 agonists’ and ‘SGLT-2 inhibitors’; which both can cause 5-15 lbs weight loss. Individuals with type 2 diabetes could therefore benefit greatly from these therapies compared to insulin. Metformin is a frequently prescribed medication that can also cause weight loss in certain patients, in addition to being inexpensive and having few adverse effects.
Presently there are five FDA approved ‘GLP-1 agonists’; Bydureon, Byetta, Tanzeum, Trulicity and Victoza. These medications have several benefits such as appetite suppression, eating smaller food portions, increasing insulin formation, and lowering production of a ‘bad’ hormone called glucagon; all of which can lead to weight loss and sugar control. In addition they do not trigger hypoglycemia. Side effects from ‘GLP-1 agonists’ are infrequent and mainly related to the gastro-intestinal system such as nausea, reflux, and bloating, and in severe cases diarrhea and vomiting. Besides cost, an important shortcoming is their route of delivery; they are all injectable medications administered twice daily, once daily or once weekly.
‘SGLT-2 inhibitors’ are a newer class of medication composed of Farxiga, Invokana and Jardiance. Their main advantage is weight loss and blood glucose reduction, and to a lesser degree blood pressure improvement. ‘SGLT-2 inhibitors’ work by expelling excessive glucose from blood to urine, which can lead to excessive urination and in turn to dehydration. Thus patients are advised to drink plenty of fluids daily. Urinary glucose can also lead to genital mycotic infection, which can be treated easily with an antifungal agent. If infection is severe or persistent, drug discontinuation is warranted. ‘SGLT-2 inhibitors’ are orally delivered and thus more convenient to patients.
In summary, type 2 diabetes is prevalent and a common cause of other conditions such as kidney failure (nephropathy), nerve damage (neuropathy), eye disease (retinopathy), bone infection (osteomyelitis) and heart illness (coronary artery disease). It is primarily due to excessive body weight or obesity. So it is natural to look for medications that can help not only with glucose control but also targeting the root problem, obesity. In the diabetes world, there are two such drug classes ‘GLP-1 agonists’ and ‘SGLT-2 inhibitors’. Both can assist patients to lose significant body weight. These medications could be expensive, but if covered by health insurance they would be viable options for type 2 diabetes. Of course, side effects and contraindications need to be discussed with the physician.