Saturday, February 11, 2012

Better Drugs for Type 2 Diabetes


Not all treatments for Type 2 Diabetes are the same. A recent study again  demonstrated the problems that can arise with drugs called sulfonylureas. These drugs  are commonly used for treating Type 2 Diabetes. They are also one of the class of drugs most commonly causing emergency hospitalizations. 

The best thing about this class of drugs is that they are cheap. But there are better drugs for Type 2 Diabetes.

There are many drugs in the sulfonylurea class. The most commonly used in the U.S. are glyburide, glimepiride and glipizide.

Notice they all end in “ide”. Although that happens to rhyme with “died” sulfonylureas are not that bad. That is if they are used with caution.

But as shown in this recent study, this class of drugs called sulfonylureas, is a frequent cause of emergency admissions to the hospital.

Why?

Because sulfonylurea drugs can cause low blood glucose called hypoglycemia.
In too many cases,  this hypoglycemia is so severe the person may lose consciousness.
After all, your brain (and mine) needs glucose to function.

The risk of hypoglycemia is especially a problem with glyburide for those persons who have reduced kidney function. As we all get older, we lose kidney function.
Loss of kidney function from kidney damage is more likely over time in those with diabetes especially if they have had poor glucose control.

Glyburide and its breakdown products, called metabolites, are eliminated by the kidneys. So that means, in people with reduced kidney function, glyburide hangs around longer to lower the blood glucose. Hypoglycemia is even more of a  problem in people who might miss a meal or not eat enough.

These facts explain why many of those having a medical emergency because of sulfonylureas were the elderly.
Glyburide is the worst drug among the 3 listed above in this class.
In general, I stay away from glyburide for my patients.

Sulfonylureas also tend to cause weight gain. And sulfonylureas also do not seem to keep the glucose under control for a long period of time. In other words, in many people, sulfonylureas seem to lose their effect over time.
There are better drugs for Type 2 Diabetes.

Metformin is also low cost but does not tend to cause hypoglycemia or weight gain. Some doctors stop metformin when it is not necessary. See my previous post on this topic.

About 10-15 percent of people cannot tolerate metformin because of diarrhea. In general, the slow release or XR,  formulation of metformin is better tolerated.

But even when people are taking  metformin, many need more than just metformin to control their blood glucose.

Fortunately, there are now many options.
But these other options cost more. Many though have advantages over the  sulfonylureas.

The GLP-1 mimetics are superb choices. They do not cause low blood sugar and tend to be as effective as the sulfonylureas and they promote modest weight loss, not weight gain. Of the GLP-1 mimetics, Victoza is a once a day drug. Newly available,  Bydureon is once a week. Byetta is twice daily.

In another class is Actos. Actos remains an excellent choice for many patients and it should be generic and therefore lower cost by the fall of this year. Like any drug, Actos has its pluses and minuses but it does tend to maintain glucose control over a long period of time and does not cause hypoglycemia.

And there are 3, soon to be 4, drugs called DPP 4 inhibitors. These drugs are less effective than the GLP-1 mimetics and, unlike the GLP-1 mimetics do not tend to promote weight loss. Currently the 3 available drugs in the U.S. are marketed as Januvia, Onglyza and Tradjenta. None of these causes hypoglycemia.

Cycloset and Welchol are two very different drugs for Type 2 Diabetes. Cycloset has unique properties. See a previous post.
WelChol lowers cholesterol and glucose.

All these drugs are in many ways better drugs for Type 2 Diabetes than those sulfonylureas: glimepiride and glipizide and surely glyburide. Glyburide, I think should be avoided.

Then there’s insulin. When used skillfully, insulin is great medicine.

All medicine needs to be tailored to the individual.
No one medication or dosage is best for everyone.
I am pleased that we have increasing options and better drugs for those suffering with Type 2 Diabetes.
If the all goes well, more are coming.
But remember, healthy eating and exercise can be highly effective.

Your Diabetes Endocrine Nutrition Group

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