Getting Started with Insulin if You Have Type 2 Diabetes

This content originally appeared on diaTribe. Republished with permission.

By Frida Velcani

New to insulin? Learn about insulin dosing and timing and how often to test your blood sugar levels if you have type 2 diabetes.

If you have type 2 diabetes, it is likely that your treatment regimen will change over time as your needs change, and at some point, your healthcare professional may suggest that you start taking insulin. While this might feel scary, there are millions of others living with type 2 diabetes and taking insulin, so it’s definitely manageable.

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Why do some people with type 2 diabetes need to take insulin?

Type 2 diabetes can progress with time, which means that it gets more difficult for a person’s body to regulate glucose levels. The body’s many cells become less responsive to insulin (called increased insulin resistance), and the specific cells in the pancreas that produce insulin make less of it (called beta cell insufficiency). This is not necessarily related to a person’s diabetes management, and it is likely not possible to prevent.

For many people, adjusting lifestyle factors such as a reduced calorie diet and increased physical activity are key to keeping blood glucose levels stable and in a target range. Healthcare professionals may also recommend that people with type 2 diabetes take additional medications like metforminDPP-4 inhibitorsSGLT-2 inhibitors, or GLP-1 agonists to their treatment plan to improve glucose management, reduce A1C, lose weight, or support heart and kidney health.

When do people with type 2 diabetes start insulin?

After 10 to 20 years, many people with type 2 diabetes will begin insulin therapy, although every person’s journey with type 2 diabetes is different. This happens when lifestyle changes and medications aren’t keeping your glucose levels in your target range. It is important that you start treatment as early as possible to avoid persistent hyperglycemia (high blood sugar), which can lead to long-term health complications affecting your heart, kidneys, eyes, and other organs.

What are the different types of insulin?

The key to transitioning to insulin is knowing your options. Some people taking insulin need to use both a basal (long-acting) and a prandial (rapid-acting or “mealtime”) insulin each day, while others may only need to use basal insulin. Learn about your options here.

  • Basal (long-acting) insulins are designed to be injected once or twice daily to provide a constant background level of insulin throughout the day. Basal insulins help keep blood sugars at a consistent level when you are not eating and through the night but cannot cover carbohydrates (carbs) eaten for meals or snacks or glucose spikes after meals.
    • Some people use other medications, like GLP-1 agonists, to help cover mealtimes. GLP-1/basal combination treatments for people with type 2 diabetes combine basal insulin with GLP-1 agonist medication in one daily injection. This combination can effectively lower glucose levels while reducing weight gain and risk of hypoglycemia (low blood sugar). Learn more here.
  • Prandial (rapid-acting or “mealtime”) insulins are taken before mealtime and act quickly to cover carbohydrates eaten and bring down high sugar levels following meals. Ultra-rapid-acting prandial insulins can act even more rapidly in the body to bring down glucose levels. Rapid and ultra-rapid insulins are also taken to correct high glucose levels when they occur or are still persistent a few hours after a meal.
  • Basal and prandial insulins are both analog insulins, meaning they are slightly different in structure from the insulin naturally produced in the body. Analog insulins have certain characteristics that can be helpful for people with diabetes. Human insulins, on the other hand, were developed first and are identical to those produced by the human body. Human insulins are classified as regular (short-acting insulin) or NPH (intermediate-acting). These are generally cheaper than analog insulins and can be bought without a prescription at some pharmacies.

Although many people use both basal and prandial insulin – which is called multiple daily injections of insulin (MDI) and consists of one or two injections of basal insulin each day as well as prandial insulin at meals – people with type 2 diabetes who are beginning insulin therapy may only need basal insulin to manage their glucose levels. Basal insulin requires fewer injections and generally causes less hypoglycemia. For these reasons, many healthcare professionals recommend basal insulin when you first start insulin therapy.

How do I take and adjust my insulin doses?

It is important to learn the different methods of taking insulin and what kinds of insulin can be delivered through each method. There are several ways to take insulin – syringe, pen, pump, or inhalation – though injection with a syringe is currently the most common for people with type 2 diabetes. There are many apps that can help you calculate your insulin doses.

  • Insulin pens are considered easier and more convenient to use than a vial and syringe. There are different brands and models of insulin pens available. Smart pens are becoming increasingly common and can help people manage insulin dosing and tracking. They connect to your smartphone and help you remember when you took your last dose, how much insulin you took, and when to take your next one.
  • Insulin pumps are attached to your body and can be programmed to administer rapid-acting insulin throughout the day, to cover both basal and prandial insulin needs. When you need to take insulin for meals or to correct high glucose, calculators inside the pump can help determine the correct dosage after you’ve programmed them with your personal insulin pump settings.
  • Inhaled insulin is ultra-rapid acting insulin and can replace insulin used for mealtime and corrections of high glucose. It is taken through an inhaler and works similarly to injected prandial insulin. People with diabetes who do not want to inject prandial insulin might use this, but it’s not for people who only use basal insulin. The only approved inhaled insulin on the market is the ultra-rapid-acting mealtime insulin Afrezza.

Your insulin regimen should be tailored to fit your needs and lifestyle. Adjusting your basal insulin dosage and timing will require conversations and frequent follow-up with your healthcare team. When initiating insulin therapy, you may be advised to start with a low dose and increase the dose in small amounts once or twice a week, based on your fasting glucose levels. People with diabetes should aim to spend as much time as possible with glucose levels between 70-180 mg/dl. Insulin may be used alone or in combination with oral glucose-lowering medications, such as metformin, SGLT-2 inhibitors, or GLP-1 agonists.

One of the most important things to consider is the characteristics of different insulin types. To learn more, read “Introducing the Many Types of Insulin – Is There a Better Option for You?” and discuss with your healthcare team.

In order to dose insulin to cover meals or snacks, you have to take a few factors into consideration. Your healthcare team should help you determine what to consider when calculating an insulin dose. Prandial insulin doses will usually be adjusted based on:

  • Current blood sugar levels. You’ll aim for a “target” blood sugar, and you should know your “sensitivity” per unit of insulin to correct high blood sugar levels.
    • Insulin sensitivity factor (ISF) or correction factor:  how much one unit of insulin is expected to lower blood sugar. For example, if 1 unit of insulin will drop your blood sugar by 25 mg/dl, then your insulin sensitivity factor is 1:25. Your ISF may change throughout the day – for example, many people are more insulin resistant in the morning, which requires a stronger correction factor.
  • Carbohydrate intake. Insulin to carb ratios represent how many grams of carbohydrates are covered by one unit of insulin. You should calculate your carbohydrate consumptions for each meal.
    • Insulin to carbohydrate ratio:  the number of grams of carbs “covered” by one unit of insulin. For example, a 1:10 insulin to carbohydrate ratio means one unit of insulin will cover every 10 grams of carbohydrates that you eat. For a meal with 30 grams of carbohydrates, a bolus calculator will recommend three units of insulin.
  • Physical activity. Adjust insulin doses before, and possibly after, exercise – learn more about managing glucose levels during exercise here.

Learning to adjust your own insulin doses may be overwhelming at first, especially given the many factors that affect your glucose levels. Identifying patterns in your glucose levels throughout the day may help you optimize the timing and dosing of your insulin. Your healthcare professional, a certified diabetes care and education specialist, or insulin pump trainer (if you use a pump), can help guide you through this process. Do not adjust your insulin doses without first talking to your healthcare team.

How often should I test my blood sugar?

The frequency of testing will depend on your health status and activities during the day. Initially, you may be advised to check your blood glucose three to four times a day. As a starting point, check in with your healthcare team about how often to check your blood sugar. Many people test before meals, exercise, bedtime, and one to two hours after meals to ensure that they bolused their insulin correctly. Over time, your fasting, pre-meal, and post-meal blood glucose levels will help you figure out how to adjust your insulin doses.

Continuous glucose monitors (CGM) are particularly useful for tracking changes in glucose levels throughout the day. Some CGM devices also connect with an insulin pump to automatically adjust insulin delivery. After you start a treatment plan, the goal for most people is to spend as much time as possible in their target range. Talk with your healthcare professional about starting CGM and developing glucose targets.

What else do I need to know about taking insulin?

It’s common to experience minimal discomfort from needle injections or skin changes at the insulin injection site. You may also experience side effects of insulin therapy, which can include some weight gain and hypoglycemia. In some people, insulin increases appetite and stops the loss of glucose (and calories) in the urine, which can lead to weight gain. Hypoglycemia can occur if you are not taking the right amount of insulin to cover your carb intake, over-correcting high glucose levels, exercising, or consuming alcohol. Treating hypoglycemia also adds more calories to your daily intake and can further contribute to weight gain. Contact your healthcare professional to adjust your insulin dose if you are experiencing hypoglycemia, or call 911 if you experience more serious side effects, such as severe low blood sugar levels, serious allergic reactions, swelling, or shortness of breath.

Staying in contact with your healthcare team is the best way to make the transition to insulin therapy. Though the first few days or weeks will be challenging, with the right support, you’ll find a diabetes care plan that works for you.

If you were recently diagnosed with type 2 diabetes, check out more resources here.

Source: diabetesdaily.com

Great News: Trials Show Some Diabetes Drugs Can Actually Protect Your Kidneys

This content originally appeared on diaTribe. Republished with permission.

By Matthew Garza, Eliza Skoler, and Rhea Teng

More people with diabetes are taking drugs like Jardiance and Farxiga, originally developed to lower glucose in people with type 2 diabetes, because the latest data confirms that these drugs can protect your kidneys. A therapy still under investigation, finerenone, has been developed to protect the kidneys of people with and without diabetes

Recent research is showing that certain drugs can benefit your kidneys if you have type 2 diabetes. Diabetes is the leading cause of chronic kidney disease (CKD), and many people don’t receive adequate treatment for this condition, so advancements in therapy to treat and prevent kidney disease are important for the 800 million people worldwide who live with chronic kidney disease. We bring you some of the newest findings on finerenone, Jardiance, and Farxiga – three medications that have been shown to protect the kidneys in people with decreased kidney function, including those with diabetes and CKD.

Note: The latest results on Jardiance and Farxiga confirm earlier findings on two other SGLT-2 inhibitors – Invokana and Steglatro – which clearly show the kidney and heart benefits of this class of medication. As a result, SGLT-2 inhibitors are recommended for treating kidney disease in many people with diabetes. SGLT-2 inhibitors were a focus of the recent American Society of Nephrology’s virtual kidney conference. As research has shown an increased number of benefits of these medications – in terms of glucose levels, weight loss, hypoglycemia reduction, and heart and kidney health – new guidelines have rapidly developed (since 2013) for the use of these drugs in people with type 2 diabetes. And, in the case of Farxiga, SGLT-2s can also protect the kidneys in people without diabetes.

Finerenone

Finerenone is currently being tested to treat CKD in people with type 2 diabetes – it’s a new type of drug (called a non-steroidal MR antagonist) that interferes with the receptors that cause kidney cells to retain, or hold onto, excess salt and water. In the FIDELIO-DKD trial, almost 6,000 people with type 2 diabetes and kidney disease received either finerenone or placebo (a “nothing” pill) and were enrolled in the study for over two and a half years. The results from the trial demonstrated the benefits of finerenone:

  • Finerenone significantly reduced the risk of severe kidney outcomes by 18% over two and a half years.
  • Finerenone reduced the risk of severe heart outcomes by 14%, compared to the placebo.

The FIDELIO-DKD trial showed this medication to be helpful for people with type 2 diabetes. Given these positive results, finerenone has been submitted to the FDA and the European Medicines Agency for approval as a CKD treatment option for people with type 2 diabetes.

Jardiance

New findings from the EMPEROR-Reduced trial showed that Jardiance, an SGLT-2 inhibitor, improved heart and kidney outcomes in adults with heart failure with reduced ejection fraction (HFrEF, or a reduced ability to pump blood out of the heart), regardless of whether they had chronic kidney disease at the start of the trial. Of the 3,730 people enrolled in the trial – with or without type 2 diabetes – participants taking Jardiance showed:

  • A 22% reduced risk for severe heart outcomes among people with CKD, and a 28% reduced risk in those without CKD.
  • A 47% reduced risk for severe kidney outcomes in those with CKD, and a 54% reduced risk in those without CKD.

The variation in risk reduction was determined to be due to chance, rather than a difference in health outcomes between people with and without CKD. These results show that even though CKD increases a person’s risk for heart issues, Jardiance lowered that risk to the level of people without CKD.

Farxiga

New analysis of the DAPA-CKD trial found that Farxiga, another SGLT-2 inhibitor, protects the kidneys regardless of the cause of kidney disease, in people with or without type 2 diabetes. This builds on the positive results presented earlier this year on Farxiga’s ability to treat people with heart disease and CKD.

Why is this important?

More than 800 million people around the world live with chronic kidney disease, including 45 million people in the US (almost 14% of the US population). The need for effective medications that work for everyone, including those with or without diabetes, is high. Treatment with SGLT-2 inhibitors – or non-steroidal MR antagonists – could be key to helping these people.

Organizations like the American Diabetes Association and the European Association for the Study of Diabetes now recommend that people with type 2 diabetes and kidney issues be treated with SGLT-2 inhibitors or GLP-1 agonist medications. If you have diabetes or kidney disease, talk with your healthcare team about which of these treatment options may be helpful for you.

It’s important to catch kidney disease early so that it can be treated. If you have diabetes, ask your healthcare team to test your kidney function every year. To learn more about preventing kidney disease, view diaTribe’s helpful infographic. You can also read about UACR and eGFR, the two lab tests that are commonly used to evaluate kidney health.

Source: diabetesdaily.com

The Latest Heart Health and Diabetes Guidelines from the American College of Cardiology

This content originally appeared on diaTribe. Republished with permission.

By Joseph Bell

New SGLT-2 inhibitor and GLP-1 agonist diabetes medication recommendations for people with type 2 diabetes

The American College of Cardiology (ACC) updated its guidance in mid-August for heart health in people with type 2 diabetes. These recommendations are supported by the American Diabetes Association (ADA), and ACC similarly supported ADA’s 2020 Standards of Care for heart disease.

What’s New?

Compared to the 2018 ACC guidelines, the 2020 update gives more attention to preventing diabetes complications, rather than treating them once they have already developed. If a person with type 2 diabetes has heart disease, kidney disease, or heart failure – or is at high risk of heart disease – the ACC recommends discussing SGLT-2 inhibitor or GLP-1 agonist medications with their healthcare professional. Unlike the 2019 European Society of Cardiology guidelines, however, the ACC does not make a specific recommendation about SGLT-2 inhibitors or GLP-1 agonists as first-line drug therapies.

Additionally, in 2018, the ACC recommended Victoza as the preferred GLP-1 agonist and Jardiance as the preferred SGLT-2 inhibitor. However, with abundant clinical research since then, the ACC now recommends additional therapies, all equally:

  • For GLP-1 receptor agonists: TrulicityOzempic (injectable once-weekly GLP-1), and Victoza (once-daily GLP-1). Of these, only Trulicity is recommended for people with multiple risk factors for heart disease. The ACC also suggested that Rybelsus (oral GLP-1) may be included in these recommendations after more research is completed.
  • For SGLT-2 inhibitors: FarxigaInvokana, and Jardiance. The ACC also mentioned the potential heart and kidney benefits of Steglatro, given results from the VERTIS CV study.

Importantly, the ACC noted that starting either an SGLT-2 inhibitor or GLP-1 agonist medication should not be dependent on a person’s A1C levels; rather, it should be based on whether they would benefit from the drugs’ heart and kidney benefits. Many people with diabetes on an SGLT-2 or GLP-1 medication also see weight loss, reduced hypoglycemia, and lower A1C – even though heart health and kidney health are the reason that the therapies are prescribed. The ACC also recommended either drug class on top of existing metformin therapy. We look forward to a future stance on SGLT-2/GLP-1 combination therapy, although no guidance has been provided so far.

The American Heart Association (AHA) just made its own statement on SGTL-2 and GLP-1 inhibitors here – it’s technical language but check out the “Conclusion and Next Steps” section at the end.

Source: diabetesdaily.com

What Are SGLT-2 Inhibitors and How Can They Help Your Heart?

This content originally appeared on diaTribe. Republished with permission.

By Mary Barna Bridgeman

SGLT-2 inhibitors can protect your heart! This type of medicine is recommended for people with type 2 diabetes who have heart disease or risk factors related to heart disease. Learn about the use of these medicines, including side effects, their effect on A1C, and their role in supporting heart health

Diabetes is a risk factor for heart disease: people with diabetes are twice as likely to have heart disease or a stroke compared to those without diabetes. Heart disease is often a “silent” condition, meaning that symptoms are not necessarily present until a heart attack or a stroke actually happens. It is important for people with diabetes to realize they may be at risk – click to read more about the link between diabetes and heart disease from Know Diabetes By Heart.

There are many ways to take care of your heart and to reduce the risk of heart disease while living with diabetes. New medicines, including sodium-glucose cotransport 2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) agonists, have been shown to protect the heart and reduce the risk of many specific heart-related outcomes. This article will focus on SGLT-2 medications, and our next article will focus on GLP-1 medications.

Heart diseases

Image source: diaTribe

Click to view and download diaTribe’s helpful infographic on preventing heart disease.

What are SGLT-2 inhibitors?

There are currently four medicines that are categorized as SGLT-2 inhibitors:

These medicines help people with type 2 diabetes manage their glucose levels: they work in the kidneys to lower sugar levels by increasing the amount of sugar that is passed in the urine. SGLT-2s increase time in range and reduce A1C levels while also lowering blood pressure and supporting weight loss. For people with diabetes who have had a heart attack or are at high risk of heart disease, or who have kidney disease or heart failure, these medicines could be considered regardless of A1C level. While SGLT-2 medications are expensive, some assistance programs are available to help with cost – see one of diaTribe’s most popular articles, “How to Get Diabetes Drugs For Free.”

What do you need to know about SGLT-2 inhibitors?

SGLT-2s have a low risk of causing hypoglycemia (low blood sugar levels). Because they increase sugar in the urine, side effects can include urinary tract infections and genital yeast infections in men and women. Dehydration (loss of fluid) and low blood pressure can also occur. Symptoms of dehydration or low blood pressure may include feeling faint, lightheaded, dizzy, or weak, especially upon standing.

Before starting an SGLT-2 inhibitor, here are some things to discuss with your healthcare team if you have type 2 diabetes:

  • How much water to drink each day
  • Ways to prevent dehydration and what to do if you cannot eat or you experience vomiting or diarrhea (these are conditions that may increase your risk of developing dehydration)
  • Any medicines you take to treat high blood pressure

When prescribed for people with type 2 diabetes, SGLT-2s rarely cause diabetic ketoacidosis (DKA), a serious and potentially life-threatening condition. For people with type 1 diabetes, DKA is a well-known risk when SGLT-2s are prescribed. Call your healthcare professional if you have warning signs of DKA: high levels of ketones in your blood or urine, nausea, vomiting, lack of appetite, abdominal pain, difficulty breathing, confusion, unusual fatigue, or sleepiness. When you are sick, vomiting, have diarrhea, or cannot drink enough fluids, you should follow a sick day plan – see Dr. Fran Kaufman’s article on developing your sick day management plan. Your healthcare professional may instruct you to test your urine or blood ketones and stop taking your medication until symptoms go away.

If you have type 1 diabetes or chronic kidney disease, depending on your level of kidney function, these medicines may not be for you. Additionally, SGLT-2s are associated with increased risk of lower limb amputation.

SGLT-2 inhibitors are usually taken as a pill once a day – often in the morning before breakfast – and can be taken with or without food.

What do SGLT-2 inhibitors have to do with heart health?

Results from clinical studies suggest SGLT-2 inhibitors may play an important role in lowering heart disease risks.

Jardiance was the first SGLT-2 inhibitor to show positive effects on heart health in the EMPA-REG OUTCOME trial. In this study, more than 7,020 adults with type 2 diabetes and a history of heart disease were followed. Participants received standard treatment for reducing heart disease risk – including statin medications, blood pressure-lowering drugs, aspirin, and other medicines – and diabetes care, plus treatment with Jardiance. Over a four-year period, results from the study showed that, compared to placebo (a “nothing” pill), Jardiance led to:

  • a 14% reduction in total cardiovascular events (heart attacks, strokes, heart-related deaths)
  • a 38% reduction in risk of heart-related death
  • a 32% reduction in overall death
  • a 35% reduction in hospitalizations from heart failure

Read diaTribe’s article on the results here.

Similarly, the heart protective effects of Invokana have been shown in two clinical studies, CANVAS and CANVAS-R. These two studies enrolled more than 10,140 adults with type 2 diabetes and a high risk of heart disease, randomly assigned to receive either Invokana or placebo treatment. In the CANVAS studies, treatment with Invokana led to the following:

  • a 14% reduction in total cardiovascular events (heart attacks, strokes, heart-related deaths)
  • a 13% reduction in risk of heart-related death
  • a 13% reduction in overall death
  • a 33% reduction in hospitalizations from heart failure

Read diaTribe’s article on the results here.

Farxiga may also reduce heart disease risks. In the DECLARE-TIMI 58 study, more than 17,000 people with type 2 diabetes received Farxiga; 40% of participants had known heart disease and 60% had risk factors for heart disease. Importantly, more than half of the people included in this study did not have existing heart disease. While Farxiga was not found to significantly reduce total cardiovascular events (heart attacks, strokes, heart-related deaths) compared with placebo, its use did lead to a 17% lower rate of heart-related death or hospitalization for heart failure. Read diaTribe’s article about the results here.

More recently, the DAPA-HF study evaluated the use of Farxiga for treating heart failure or death from heart disease in people with or without type 2 diabetes. The study included more than 4,700 people with heart failure; about 42% of those enrolled had type 2 diabetes. Farxiga was shown to reduce heart-related death or worsening heart failure by 26% compared to placebo, both in people with type 2 diabetes or without diabetes. Learn more about these results here.

All of the available SGLT-2 inhibitors have evidence suggesting benefits of this class of medications for people with established heart failure. Click to read diaTribe’s article on SGLT-2 Steglatro and heart health.

Other possible benefits of SGLT-2 inhibitors

InvokanaFarxiga, and Jardiance have also been shown to reduce the progression of kidney disease. Learn more about diabetes and kidney disease here.

SGLT-2s have been studied in people with type 1 diabetes, but are not yet approved for use by the FDA – you can learn about SGLT-2s for people with type 1 diabetes here.

What’s the bottom line?

You can reduce your risk of heart disease and promote heart health while living with diabetes. You and your healthcare team should develop a personalized plan to determine what ways are best for reducing your risk of heart disease. According to the latest evidence and treatment recommendations, SGLT-2 inhibitors may be most useful for people with type 2 diabetes and heart disease or at high risk of heart disease.

About Mary

Mary Barna Bridgeman, PharmD, BCPS, BCGP is a Clinical Professor at the Ernest Mario School of Pharmacy at Rutgers University. She practices as an Internal Medicine Clinical Pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.

This article is part of a series to help people with diabetes learn how to support heart health, made possible in part by the American Heart Association and American Diabetes Association’s Know Diabetes by Heart initiative.

Source: diabetesdaily.com

Rybelsus, the First GLP-1 Pill, Approved for Type 2 Diabetes in Europe

This content originally appeared on diaTribe. Republished with permission.

By Frida Velcani

Rybelsus, a GLP-1 agonist pill already approved in the US, received positive feedback from the European Medicines Agency (EMA) in January and was just approved on Saturday!

In exciting news for the type 2 diabetes community, the first GLP-1 agonist pill for type 2 diabetes has not only been recommended for approval in Europe, it has just been approved by the European Medicines Agency (EMA)! Rybelsus (formerly known as oral semaglutide in clinical trials) is a pill version of Ozempic, a GLP-1 agonist injection for type 2 diabetes. Rybelsus was approved in the US in September 2019, and was met with incredible enthusiasm from the diabetes community, particularly due to its availability and accessibility in the US. For a Rybelsus savings card, text READY to 21848, or go to saveonr.com.

Rybelsus, a once-daily pill, can be taken alone or in combination with other treatments for type 2 diabetes. Currently, GLP-1 agonists in Europe are available only as injections (which, depending on the medication, are taken twice-daily, once-daily, or once-weekly). This approval provides more options for people interested in starting GLP-1 treatment. The EMA approval was great news for giving people more options – the once-weekly injections have also been widely embraced.

The EMA added data to the Rybelsus label confirming that it lowers blood glucose and improves heart health – although it doesn’t say “primary prevention,” the label indicates that heart attacks are prevented in people with and without established heart disease. Clinical trials show that both Rybelsus and Ozempic reduce the risk of heart attack, stroke, and heart-related death. This is important because people with type 2 diabetes are at substantially higher risk of heart disease than those without diabetes. Click here to learn more about the benefits of Rybelsus.

Novo Nordisk has not released information about pricing for Rybelsus in Europe. Our hope is that everyone who can benefit from a GLP-1 agonist will be able to access it as early as possible.

There are more social safety nets in the EU than in the US, and many parts of the EU are more focused on prevention and preparedness than the US, so we have high hopes for accessibility in the EU. The European Society of Cardiology recommends that those with type 2 diabetes begin taking GLP-1 or SGLT-2 medications directly after diagnosis. This is good news for people with type 2 diabetes, as the recommendation should enable greater awareness among healthcare professionals. It will also help the field get less caught up in what has previously been called “clinical inertia.”

If you have type 2 and would like to learn more about a pill that has the benefits of GLP-1 – heart disease prevention, weight loss, lower A1C, and less hypoglycemia (and many experts associate also associate improved time in range with GLP-1) – chat with your doctor or a member of your healthcare team. If you like the idea of a pill, mention Rybelsus, or if you like the idea of a once-weekly injection, mention BydureonOzempic, or Trulicity.

Source: diabetesdaily.com

Diabetes Isn’t “One Size Fits All”

I love the diabetes online community for everything that it offers: advice in times of need, hope in times of despair, helpful anecdotes and inspiring stories, and friendships formed across time zones and many miles.

One of the things that the diabetes online community sometimes does, though, is to try and prescribe how everyone with diabetes should live. One day, it’s the Dr. Bernstein diet, the next, it’s high-carb, low-fat. The Mastering Diabetes (mostly) fruit diet is so popular now that their book has even made the NYTimes Bestsellers list. People are jumping on diet and exercise bandwagons before they figure out what they truly need (and want!) in terms of their diabetes management, and what it should look like, day-to-day.

Parents are often left feeling guilty if they can’t “hack” their child’s insulin pump, and individuals with diabetes feel bad when they don’t (or can’t?) do CrossFit or maintain a super low-carb lifestyle. A once seemingly supportive community now raises an eyebrow if they spot you eyeing over a cookie during a meet-up group, or (god forbid) a sugar-sweetened beverage. But I’m here to say one thing: diabetes isn’t a “one size fits all” disease.

You are not a “bad diabetic” if you don’t have a DIY looping system, or if you don’t want to sit down and try to figure it out. You’re fine just the way you are if MDI or insulin pens work better for you, if you dislike skin adhesives, or feel claustrophobic always having something attached to you.

It’s okay if you spike every morning, without fail, due to dawn phenomenon, and if you don’t ever post your CGM graphs to social media. It’s okay if you don’t have a CGM (really, it’s fine). Or if you don’t take an SGLT2-inhibitor off-label. Or even want to try. There’s no perfect low snack. There’s no perfect meal.

Figure out what your body needs, and honor that. It’s okay if you don’t want to eat low-carb, high-carb, or in-between. Or if you’ve lived with type 1 for 15 years, enjoy your weekly ice cream treat, and don’t want to give it up. Figure out what you need and want, and do that. 

It’s okay if you don’t own a Myabetic bag, or can’t afford one, or think they’re ugly. It’s alright if you’ve never been to diabetes camp or don’t want to go. It’s alright if you don’t want to jump all into advocacy and chant, and rally, and cheer. It’s okay if self-care for you is sitting in a quiet room, and coming to a place of acceptance.

It’s okay if you don’t join any Facebook diabetes support groups, or seek out diabuddies in real life. It’s okay if diabetes is only a very small part of your life. It’s okay if it’s your whole life.

It’s okay if you don’t like going to the endocrinologist, or have to force yourself to see your eye doctor. It’s okay if you don’t like talking about your diabetes with others. Diabetes is not one size fits all.

It’s okay if sometimes you’re feeling overwhelmed, over-stimulated, and need to turn inwards, for yourself and rest sometimes.

There is no perfect way to (micro)manage, eat, exercise, handle stress, socialize (or not!), dose, count, or bolus. There is only the way that will work for you and your body. Find what works for you, and embrace that. 

Have you ever been pressured to manage your diabetes a certain way? Eat a certain diet? Exercise in a specific way? How did you deal with the pressure? Share this post and comment below; we would love to hear your stories!

Source: diabetesdaily.com

Advancements in Treatment: The Use of Adjunctive Therapies in Type 1 Diabetes

This content originally appeared on diaTribe. Republished with permission.

By Paresh Dandona and Megan Johnson

Read on to learn about the research around GLP-1, SGLT-2, and combination therapy use in type 1 diabetes. Dr. Paresh Dandona is a Distinguished Professor and Chief of Endocrinology at the University of Buffalo, and Megan Johnson is a fellow on his team

For people living with type 1 diabetes, new treatments are finally on the horizon. The University at Buffalo (UB) Endocrinology Research Center is helping to revolutionize the treatment of this condition. Among the most promising new therapies are two non-insulin medications currently used in type 2 diabetes, SGLT-2 inhibitors and GLP-1 receptor agonists.

SGLT-2 inhibitors, such as Farxiga, act the kidney to help the body excrete more glucose in the urine. Meanwhile, GLP-1 receptor agonists like Victoza work in several different ways: increasing the body’s natural insulin production, decreasing the release of the glucose-raising hormone glucagon, slowing the emptying of the stomach, and curbing excess appetite. Some people with type 1 diabetes take these medications as an addition to insulin treatment as an “off-label” drug. To learn more about off-label, check out the article: Can “Off Label” Drugs and Technology Help You? Ask Your Doctor.

Why consider these medications?

In people without diabetes, the body is constantly releasing more or less insulin to match the body’s energy needs.  People with type 1 diabetes do not make enough insulin on their own and have to try to mimic this process by taking insulin replacement – but it isn’t easy.

People with type 1 diabetes often have fluctuations in their blood sugars, putting them at risk for both low blood sugars (hypoglycemia) and high blood sugars (hyperglycemia). Many individuals are unable to manage their blood sugars in a healthy glucose range with insulin alone. In fact, less than 30% of people with type 1 diabetes currently have an A1C at the target of less than 7%.

Can GLP-1 agonists be safely used in type 1 diabetes?

Over the past decade, the endocrinologists at the University at Buffalo and other research groups have been conducting studies to see whether GLP-1-receptor agonists can safely be used in type 1 diabetes.

  • The first of these was published in 2011 and showed a decrease in A1C within just four weeks of GLP-1 agonist treatment. Importantly, people given GLP-1 agonists plus insulin also had much less variation in their blood sugars, as measured by continuous glucose monitors (CGM).
  • Another study involved 72 people with type 1 diabetes who took GLP-1 agonist or placebo (a “nothing” pil) in addition to insulin for 12 weeks. The GLP-1 group had decreases in A1C, insulin requirements, blood sugar fluctuations, and body weight. People in this group did report more nausea – a common side effect of GLP-1 agonists.
  • Since then, multiple studies, some involving over 1000 people and lasting up to 52 weeks, have shown that GLP-1 treatment in people with type 1 diabetes can reduce A1C and body weight, along with insulin dosages.

Many of these studies, but not all, have suggested that GLP-1 agonists can do this without increasing the risk for hypoglycemia or diabetic ketoacidosis (DKA). There is also some evidence that GLP-1 agonists can improve quality of life in type 1 diabetes.

Who should consider GLP-1’s?

The effects of GLP-1 agonists seem to be especially strong in individuals who are still able to make some insulin on their own, although it also works in people who do not.

In one notable study, researchers gave a GLP-1 agonist to 11 people with type 1 diabetes who were still able to produce some insulin. To get an estimate of insulin production, they measured levels of a molecule called C-peptide, which is produced at the same time as insulin. In these 11 individuals, C-peptide concentrations increased after GLP-1 treatment. By the 12-week mark, they had decreased their insulin dosage by over 60%. Incredibly, five people were not requiring any insulin at all. Even though the study was very small, the results were exciting, because it was the first study to suggest that some people with type 1 diabetes had sufficient insulin reserve and thus, could – at least temporarily – be treated without insulin.

Can SGLT-2 inhibitors be used in type 1 diabetes?

SGLT-2 inhibitors like Farxiga have also shown tremendous potential. In two large studies called DEPICT-1 and DEPICT-2, adults with type 1 diabetes were randomly assigned to take either placebo or SGLT-2 inhibitor in combination with insulin. Over 700 people from 17 different countries participated in DEPICT-1, and over 800 people with type 1 diabetes participated in DEPICT-2. At the end of 24 weeks, people taking dapaglifozin had a percent A1C that was lower, on average, by 0.4 compared to people who had received placebo, and it was still lower, by over 0.3, at 52 weeks. The number of hypoglycemic events was similar in both groups.

As with GLP-1 agonists, people taking SGLT-2 inhibitors had weight loss and decreased insulin requirements. People taking SGLT-2 inhibitor, however, did have an increased risk of diabetic ketoacidosis (DKA). If individuals consider this therapy, they should be cautious about not missing meals or insulin, and not drinking large amounts of alcohol, as these behaviors can lead to increased ketone production.

Several other research groups, in trials recruiting up to 1000 individuals, have seen similar results when using this class of medications.  Researchers have been conducting additional studies to try to determine how best to minimize the risks associated with them. Farxiga (called Forxiga in Europe) has now been approved as the first oral agent as an adjunct treatment for type 1 diabetes in Europe and Japan.

Promising Combination Therapy

Now, endocrinologists are also looking at whether GLP-1 agonist and SGLT-2 inhibitor combination therapy could increase the benefits of each of these treatments. A study conducted on a small number of people showed that GLP-1 agonists can help prevent ketone production, so it is theoretically possible that this medication could reduce the risk of DKA that was seen with SGLT-2 inhibitors.

In an early study involving 30 people with type 1 diabetes who were already on GLP-agonist and insulin were randomly assigned to take SGLT-2 inhibitor or placebo, as well. People who received both drugs saw an 0.7% reduction in A1C values after 12 weeks, without any additional hypoglycemia. People on the SGLT-2 inhibitor did make more ketones, though, and two individuals in the combination group experienced DKA. Larger studies are now being conducted to expand on these results and learn more about how to give these drugs safely. The hope is that non-insulin therapies will soon be approved for type 1 diabetes. By unlocking the potential of these therapies, we can do more than manage blood glucose levels – we can improve people’s lives.

Source: diabetesdaily.com

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