Diabetes Mellitus type 2 (adult onset diabetes) is a common disease, afflicting approximately 425 million people worldwide. In the United States, about 8.5% of the adult population have diabetes. The elevated glucose or blood sugar seen with the disease can cause many symptoms including the desire to drink a lot of fluids and urinate frequently, blurry vision, increased appetite, and fatigue. The long-term complications include vision loss, kidney damage, nerve damage, and damage to the blood vessels leading to amputations, heart attacks, and strokes. People with diabetes may die at a younger age due to these complications.
Traditionally, treatment strategies have aimed to reduce blood sugar levels to control the acute symptoms related to high blood sugar. This can often be accomplished using oral medications such as sulfonylureas and metformin and when necessary injectable insulin can be utilized. These treatments have been shown to be very effective in controlling the blood glucose levels. If the glucose remains well controlled, studies have also shown decreased rates of diabetic eye damage, nerve damage and kidney damage. The downside to the sulfonylureas and insulin, but not metformin, includes weight gain and an increased risk of hypoglycemia (low blood sugar levels) which can be dangerous.
Recently, physicians have been excited to have two new classes of medicine to utilize which do not cause hypoglycemia and may actually induce weight loss. The first is a class called SGLT-2 inhibitors. These medicines work in the kidneys to block reabsorption of glucose filtered from the blood. These medicines bring down the blood sugar level without causing hypoglycemia. Different pills in this class have also been shown to lower the risk of heart attacks, congestive heart failure, strokes and death from cardiovascular causes. They may also lower blood pressure slightly and induce some weight loss. Risks of theses medicines include a higher rate of urinary tract infections and yeast infections. There have been some reports of serious genital area skin infections. They may also cause dehydration which may affect kidney function. In some studies, but not all studies of one drug in this class, there also was an increased risk of amputations.
Another new class of medicines available for the treatment of diabetes is the GLP-1 agonists.These medicines work by altering gut hormone activity after eating. They also slow gastric emptying after meals and work in the hypothalamus of the brain to decrease hunger. The biggest side-effect seen with these medicines is nausea and diarrhea. They also should not be used in people with a personal or family history of certain endocrine tumors. Research has shown that this class of medicine can help lower the risk of heart attacks, strokes, kidney failure and death from cardiovascular causes. It works well to reduce blood sugar without causing hypoglycemia. It also is quite effective in causing weight loss. It has been only available as an injectable agent (ranging from twice daily to weekly depending on the drug). This fall, the first oral formulation has been approved so now this type of medicine can be given as a daily pill.
These two new classes of medicine have become game changers for physicians and patients. With these agents, we can not only decrease the acute symptoms of diabetes, but we can prevent some of the dreaded long-term complications such as kidney failure, strokes, and heart attacks. Unfortunately, all of these medications are rather expensive, which, depending on insurance coverage, may limit their use. But we now have new and better tools for treating diabetes more safely and with better long-term results.
Erik Meidl, M.D., F.A.C.P.
Board Certified American Board of Internal Medicine
Board Certified American Board of Obesity Medicine