Health
Slowing a diabetic's decline (American College of Physicians annual meeting)
■ With more diabetes patients living longer, a greater number need more intensive glucose-controlling regimens and help with managing complications.
By Victoria Stagg Elliott — Posted June 4, 2007
A handful of newly approved therapies for patients with diabetes have very different profiles from those previously available -- complicating questions about what to do as the disease progresses, according to presentations at Internal Medicine 2007, the American College of Physicians' annual meeting, in April in San Diego.
"The choices have exploded," said Irl B. Hirsch, MD, professor of metabolism, endocrinology and nutrition at the University of Washington School of Medicine.
The Food and Drug Administration approved exenatide, the first drug to affect incretin hormones, in April 2005. Sitagliptin, by itself and in a pill combined with metformin, was approved within the past year.
Both of these new treatments have been proven to improve control, but it's not entirely clear how they will work alongside the many other medicines that diabetics frequently take.
"We're going to need more data to know how these drugs fit into our armamentarium," said Janet A. Schlechte, MD, professor of internal medicine at the University of Iowa College of Medicine in Iowa City.
For instance, patient response to exenatide has been mixed. The drug needs to be injected, and many physicians consider the needle to be a barrier to getting patients to accept it. Some are now reporting that patients have been able to get past that issue primarily because exenatide has been shown to cause weight loss. Still, experts caution that insulin is still preferred as early as appropriate.
"Exenatide is not going to take the place of insulin. If someone needs insulin, they have got to be given insulin," said Jason C. Baker, MD, assistant professor of medicine and endocrinology at New York Presbyterian/Weill Cornell Medical Center.
But insulin has also experienced technological improvements, and there are many more versions from which to choose. An inhaled version was FDA-approved in January 2006, although doctors say its use has been limited by the size of the delivery device needed to administer it. The associated need for pulmonary testing is also an impediment.
Nonetheless, many physicians say it could be a viable option for moving patients to mealtime insulin, especially those who are resistant to administering injections. This transition is particularly critical, since experts do not believe that diabetics with very high A1c levels -- despite treatment with several oral agents -- will get their blood glucose under control only with a bedtime basal insulin shot. In addition, evidence suggests that pre-meal insulin by itself may be an effective strategy.
"Some may find the inhaled insulin more acceptable. Three injections of very short-acting insulin works really well, but that's not acceptable to a lot of people," said Dr. David S. H. Bell, an endocrinologist in Birmingham, Ala.
Experts also said that the new delivery means for insulin as well as the drugs affecting incretin were first-generation attempts. Improvements on these as well as more novel ways to treat this disease are to come. With A1c targets expected to be lowered as data is released from large diabetes trials, these options will become even more important. Diabetes experts say, however, the central issue is the need to change regimens in response to these developments and the progress of the patient's disease.
"What the problem is in real life is that we often start these patients on whatever therapy you pick and then they stay on it, and we don't do a very good job as a group, myself included, in pushing the therapy as the guidelines suggest we should," said Dr. Hirsch.
Important interventions
While the overall emphasis of diabetes treatment continues to be the prevention of complications from ever developing, some sessions focused on managing them when they do occur. Diabetes has become a significant cause of heart disease, limb loss, visual impairment and kidney damage, and experts say it is very possible to interfere with their progress after they start appearing.
"These numbers are increasing because our number of people with diabetes is increasing, but we are doing something right," said Mark E. Molitch, MD, professor of endocrinology, metabolism and molecular medicine at Northwestern University's Feinberg School of Medicine in Chicago. "We can make a difference."
Blood glucose control, of course, is the first priority. Other strategies include inspection by physicians of the bottom of diabetic patients' feet -- something many who are obese cannot do themselves. Doctors should also assess any loss of sensation. Patients should be strongly encouraged to receive regular eye exams. And medications can be prescribed to lower cholesterol, control blood pressure and protect the kidneys.
"The diabetic patient is exquisitely sensitive to blood pressure lowering," said Dr. Bell. "We need to be looking at their lipids as much as we can look at the glucose. We need to look at their feet, especially if they have neuropathy, and we need to be looking for albuminuria."
In order to improve outcomes for these patients, the college launched the ACP Diabetes Care Guide, which includes a printed manual and a CD-ROM, and the Web-based Diabetes Portal diabetes.acponline.org/. The guide is intended to be used by multidisciplinary teams to improve collaboration, and the portal provides the latest evidence-based guidance for patients and physicians.
