What’s New in Diabetes Treatment?

Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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2013 was a year for many new treatments for type II diabetes. For healthcare workers and patients it’s hard to keep up with the newer medications for the treatment of adult onset diabetes, and treating diabetes is an art and not a “one-size fits all” algorithm. For our folks struggling with type II diabetes the outlook just got brighter because of a class of drugs known as incretin based drugs. Here is the down-low on these medications.

Here is the key. GLP-1 is a neuroendocrine peptide and these medications work to increase GLP-1 effects. Two kinds exist: injections you give yourself and pills.

What you need to know about incretin hormone physiology. The effects of GLP-1 are to lower sugars, turn off appetite, and regulate delivery of nutrients from the stomach to the small intestine (causing delayed emptying of your stomach). Also, they only work when glucose concentration is high so they don’t carry a risk of hypoglycemia.

Who will take these medications for diabetes? The first line treatment for diabetes is metformin. If you are on the maximum dose of metformin and can’t tolerate it due to diarrhea or have kidney problems, your doctor will look for a second line treatment. This is when you will look at these options. These are attractive options because they don’t have the risk of low sugars (hypoglycemia), they work well, and they are weight neutral or contribute to weight loss (the injections).

Ok so what are they? GLP-1 receptor agonists are the injections and there are three currently available: exenatide twice a day (Byetta), exenatide once a week (Bydureon) and liraglutide (Victoza) once a day.

DPP-4 Inhibitors (sometimes known as gliptins) are the oral medications, and there are four now available: sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Tradjenta), and alogliptin (Nesina). These are taken daily.

What’s the difference in the oral meds (DPP-4) vs the injections (GLP-1 receptor agonists)? The oral meds listed above have a more modest effect on GLP-1 receptors which means they are LESS effective at lowering Hgb A1C and do not help with weight loss or cause you to feel full early (early satiety) as with the injections. But, if you only need a minimal decrease in your Hgb A1c, don’t like injections or don’t really need the weight loss these meds are a good fit.

Will they lower my sugar dangerously? No. These medications will lower sugar (cause hypoglycemia) only in folks on another medication which can do that (like insulin, glyburide, glipizide, etc).

Which one is the best? It’s a personal decision and depends on how much lowering of your Hgb A1c you need, whether you are willing to do injections or not and how expensive your out of pocket costs will be. My next blog will discuss head to head comparisons of the injectable GLP-1 receptor agonists.

Dr O.

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