Friday, July 20, 2012

"New Strategies for treating Diabetes" continued

"New Strategies for treating Diabetes" 
 Wall street journal July 10,2012


Bariatric surgery 
Bariatric surgery ( gastric bypass ) has been around for years . I have seen some of the benefits and I have helped take care of patients with serious complications from the surgery. Improved techniques have made the surgery much safer and it is now gaining wider acceptance.  One of my most rewarding patients was a young women whose was very obese with uncontrollable glucose and multiple  other risk factors . Bariatric surgery was discussed as an option for her to consider. The deciding factor for her was the day she could no longer reach the steering wheel in her car because of obesity. She had an excellent result from the surgery.


Stepped approach to the treatment of type 2 diabetes 
The stepped approach to the treatment of type 2 diabetes has been around for years.  This approach typically started with diet and exercise , metformin would be added initially or later and then additional medications added eventially leading to insulin. This approach usually failed to keep up with progressive process of type 2 diabetes and leads to some thing called treatment inertia and prolonged exposure to the damaging effects of high glucose levels


Newer Ideas
New medications and increasing data show that early aggressive correction of glucose levels can preserve the life of insulin producing cells and slow the progression of type 2 diabetes .


I recall a discussion with a diabetes doctor years ago who was well ahead of his time. He started every new patient with type 2 diabetes on insulin the first day he saw them. He helped them gain control of their glucose with insulin , diet and exercise and then waited for the patient to ask about other treatment options before adding oral medications. He was then  often able to wean them off of insulin and maintain control of their glucose levels.


 I have attached my discussion of an article supporting the benefits of early aggressive treatment of type 2 diabetes.


Preserve your Beta Cells, Its hard to find new ones

Diabetes Care -  July 2012 volume 35 Page 1406-1412
Beta cell Function Preserved after 3.5 years of intensive Diabetes Therapy

This study demonstrates  Beta cell function can be preserved with early aggressive therapy for patients with type 2 Diabetes
Current approaches to Diabetes management usually go in a step wise method starting with one drug metformin and then adding other medications as needed depending on the progression of the disease.This approach leads to some thing called treatment inertia and a continuous progression of Beta cell failure. The progressive Beta Cell failure was best demonstrated in a classic study, UK Prospective Study ( UKPDS ) , one of the first studies to demonstrate that achieving an A1c of 7 reduced the risk of developing Eye , nerve and kidney damage.

Study design
Patients were 21 to 70 years old treatment Naive type 2 Diabetes diagnosed within the previous 2 months.
All patients were initially treated with metformin and insulin  ( Novolog mix/ their protocal )for 3 months  and then divided into 2 groups and followed for 3.5 years

Group 1 continue Metformin and Insulin
Group 2  switched to Triple therapy Metformin , Glyburide and pioglitzone

The medications in both groups were adjusted to attain excellent A1c results
Group 1 average A1c  6.3 at the end of the study
Group 2 average A1c  6.59 at the end of the study

Results 
 Beta cell function was preserved for 3.5 years in both groups

Conclusion:
 This study demonstrated that intensive therapy with insulin and metformin at the time of diagnosis of Type 2 Diabetes  followed by multiple oral agents or insulin can preserve Beta cell function. Treatment inertia fostered by by the stepwise approach to glucose control may not be the best thing for your Beta cells.

Have fun , Be smart , Avoid treatment inertia and preserve your Beta Cells
David Calder, MD

1 comment:

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Your comments and questions are appreciated. David Calder,MD