How I Crushed Type 2 Diabetes in Only Weeks and Completely Changed My Outlook on Life

Editor’s note: We found Rey’s remarkable story in the diabetes online community, and asked him if he would share it with us. Rey experienced extraordinary rapid success by following a precise diet and medication regimen immediately after diagnosis with type 2 diabetes. His improvement was incredible, but others making the same changes may not experience the same success. Please speak to your doctor or caregiver before enacting any major health changes of your own.

I’m Rey, and I’m a 44-year old male with a history of high blood pressure and being overweight, but until recently I had no major health issues. Only this past summer I learned that I had dangerously uncontrolled diabetes. Within the span of just a couple of months, I completely changed my diet, started and then stopped glucose-lowering medications, and got my blood sugar back into the normal, healthy range. Here’s my story.

My First Health Scare

My story is ultimately a diabetes story, but there were some bumps along the way that I think are worth including before I jump into the diabetes.

My adventure really began in the summer of 2020. After some stressful life events, I developed a rather constant state of anxiety, which seemed to be preventing me from getting good sleep. Even while using a sedative, I was up at least 4-5 times during the night, every night. I didn’t have a previous history of mental health problems, so this was all new to me. The especially challenging part was that as time passed, lying in bed became a trigger for the anxiety, which made the sleep even harder to come by. I felt like I was just going through the motions to get through life.

Fortunately, after months of stubbornness and sucking it up the best I could, I finally got to the bottom of things. I discovered it was sleep apnea, and started CPAP treatment. The result was truly life-changing, sleep returned to normal, and my anxiety went away 100%.

Life was great and I’d survived and handled my major mid-life health crisis…. or so I thought! Little did I know, but that relief would prove to be short-lived as in the coming months I started to experience a new set of symptoms.

I was at my highest weight yet and my BMI was creeping towards 30. Some reading this will scoff and think “30 is nothing, I’m well above that,” but everyone’s body is a little different and apparently 30 was my personal breaking point.

My fasting blood sugar was over 100 mg/dL, and my doctor said something about pre-diabetes, but she didn’t sound too concerned about it.

The Symptoms

I was again experiencing sleeplessness. Now I was finding that instead of sleep apnea waking me up during the night, my bladder was sure filling up and I was getting up to pee several times a night. Also, I was quite thirsty when this would happen. I did notice it was nights that I’d eat pizza or pasta for dinner that were the worst. Some combination of stubbornness and perhaps denial kept me from taking this too seriously, so I just kept on with things. Besides, this was March 2021 and you didn’t dare go into a medical clinic unless you were on your covid deathbed. Surely, this was no big deal, and getting checked out could wait.

Still, I sensed something was wrong and I reduced the amount of pizza and pasta I was eating for dinner (maybe twice a week instead of five nights a week), eating beans with rice and veggies for dinner instead. In hindsight, not great, but a minor improvement.

The next major symptom arrived in April: blurry vision. At first, I wasn’t worried. I’d gotten LASIK eye surgery done 12 years earlier, and this change seemed like a mild return of my nearsightedness. I was also in my mid-40s, which I’m told is a time where focusing becomes harder and your vision changes.

Then it got really bad: I was on a trip to Florida when I couldn’t read a menu board that was 8 feet in front of me. I had to resort to taking a picture of it with my phone and then looking at that picture to read the menu. Something was majorly wrong!

When I got back from Florida (after some real nerve-wracking and likely dangerous driving), I went in to get my vision checked and received a -2.0 diopters prescription. The optometrist was shocked that I had let my vision get that bad before getting glasses and made a comment about diabetes, but was also of the impression that my vision would change throughout the day as my blood sugar changed. That clearly wasn’t happening to me (turns out it’s more complicated than that).

The last major symptom was that I had been losing weight at a pretty decent clip (5-10 pounds a month). Obviously, this must have been due to cutting back on pizza and pasta, right? Curiously, past attempts at eating better had never been quite this effective, but why question such great progress when you’re on a roll! At this point, it was late April and the earliest I could get in for a check-up was mid-June, so why not ride out another month of weight loss and see how great my labs come back then?

My Diagnosis

A little over a week before the appointment I started researching diabetes online, since I was starting to wonder about what my doctor and optometrist had said. But surely that takes years to develop, right?

Obviously, my “diet” was working since I had now lost 25 pounds this year and weighed less than I did in my 30s. Who knew eating healthy was so easy!

After a little light reading, I quickly realized how wrong I was, that everything that had happened in the last few months was explained perfectly by diabetes, and that the weight loss might have been diabetes rather than my new diet. This was hard to process.

I picked up a blood sugar meter, and on a Friday night fumbled with the thing enough to figure out how to get a reading. I was shocked when the meter read 567 mg/dL. That can’t possibly be right! My girlfriend tried the meter and her result came in at 77 mg/dL. I tested mine again and this time it registered 596 mg/dL!

At this point, it was 11 PM on a Friday night, and my safest course of action would have been to go to the ER, but I figured if high blood sugar hadn’t killed me in the last 3-4 months, it probably wasn’t going to kill me that weekend. I decided to read more about diabetes, give myself a couple of days to get my wits about me, and go into urgent care on Monday. I also continued to test my blood sugar and it seemed to stay in the 300 to 450 mg/dL range that weekend, regardless of what I ate or whether I was eating.

At urgent care my A1c came in at 13.7%, and my fasting blood sugar was 449 mg/dL. Based on my history, I was more likely to have type 2 diabetes (and additional testing would later confirm that). I was prescribed metformin, and advised to take insulin, advice that I wasn’t ready to take.

Rey kept track of his blood sugar measurements from the moment he began testing, before he was diagnosed with diabetes. You can see his girlfriend’s healthy reading, 77 mg/dL, on the first day.

A New Diet

I now understood that the reason I had lost so much weight so quickly was my uncontrolled diabetes, at least 3 months of it!

I immediately cut most high-carb foods out of my diet and subsisted largely on a diet of full-fat cottage cheese, full-fat plain Greek yogurt, hard cheese, nuts, avocadoes, and canned beans with olive oil. I also kept some fruit and berries in my diet initially. Throughout the day I ate random combinations of these foods. I didn’t really prepare them or fancy them up at all with cooking (other than heating the beans in the microwave so they’d be warm).

I knew I had screwed things up, and if there was going to be any hope of reversing the damage I feared I had done to my body I needed to focus. Maybe I would be able to go back to eating pizza, pasta, and all those delicious carb-filled foods that I loved someday, but it was clear now wasn’t the time for that.

I’d certainly thrown in the towel on diets plenty of times before and gone back to eating like crap, but this time it felt like there was a gun held to my head, and quitting wasn’t an option. Perhaps I’m being overly dramatic about this, and perhaps it wasn’t the healthiest outlook, but it’s how I saw things and it got me through the first weeks where I was at my highest level of motivation.

I wasn’t using a particular diet system I had found on the internet or in a book, it was just me trying to think of all the foods (as a vegetarian) that I normally ate that were lower on the glycemic index, and sticking to those. Frustratingly, there seemed to be a lot of disagreement online in regards to what the “best” diet was for a diabetic, but I’ll come back to that later.

The Right Medications

With this diet and metformin, my blood sugar still ranged from about 250 to 400 mg/dL that first week. My blood sugar really needed to come down since the longer it remained elevated, the greater my risk for diabetes-related complications. Clearly, a week of my new diet and metformin wasn’t enough, and I was more open to exploring what else could be done.

When I saw my primary doctor after that week, she wanted to put me on insulin too, in order to stabilize my blood sugar. Although I knew that insulin would have rapidly brought my blood sugar down to normal levels, using it would have made it difficult for me to gauge if my dietary changes were getting the job done.

Through my research, I had become convinced that SGLT2 inhibitors were the only class of drugs that made any sense for a person with new uncontrolled type 2 diabetes to take (in addition to metformin). Normally in uncontrolled diabetes, your kidneys excrete sugar to your urine as a means of keeping your blood sugar from getting dangerously high, but that effect doesn’t really kick in until your blood sugar levels are way up there. With an SGLT2 inhibitor, your kidneys are just doing that all the time, keeping your blood sugar down in the process. The real beauty of this is instead of insulin, which causes your body to store that excess sugar (only delaying the problem), once you pee out the excess sugar, it’s gone forever.

I asked my doctor for a referral to an endocrinologist and a prescription for an SGLT2 inhibitor instead. She didn’t have much experience with SGLT2s and started talking about other drugs, but she could see I had a pile of notes with me on different drug classes, the research I had done on them. I think she also realized that although she was the one to write the prescription, that I was ready to argue my case.

As soon as I started taking the SGLT2 inhibitor my blood sugar came down almost immediately.

On Farxiga, within days my blood sugar dropped to the 100 to 150 mg/dL range. I had to pee a little more at first too, which suggested the drug was doing exactly what it was supposed to. After a few days, I found I wasn’t peeing any more than normal, which was probably due to my fairly low-carb diet.

[Editor’s note: Rey had an incredibly positive experience with SGLT2 inhibitors, but they are not for everyone, and do carry side effects and risks, especially when combined with low-carbohydrate diets. Please speak to your doctor about changing your medication.]

This was a great improvement over where I was before, but like every newly-minted diabetic I had dreams of reversing my diabetes and getting my blood sugar back to “normal.” I obviously wasn’t there yet and just because you want something doesn’t mean it’s possible or realistic, but I was holding onto that dream.

Remission is a very controversial topic. Most ADA and official-looking literature I found said that diabetes was a progressive disease. As time passes, more drugs are required to maintain the same degree of control, and some pretty awful complications occur as it gets worse and worse. That was a rather depressing outlook. If it all falls apart in the end, why not just go back to enjoying all those carb-rich foods that I love and enjoy whatever time I’ve got left? Fortunately, I didn’t fall into that trap, but I have to imagine many do.

Intermittent Fasting

I was aware of internet doctors out there on the fringes saying type 2 diabetes can be reversed and people can manage through diet alone, without drugs. Are they selling false hope, similar to new-age healers selling energy crystals to cure cancer? Most of them are talking about low-carb and “keto,” which I’d previously assumed to be just another random fad diet. “They’re obviously quacks,” I thought. I figured that American Diabetes Association was most certainly correct about diabetes being progressive, just giving me the cold hard truth. But just for the sake of argument, I decided to hear the quacks out first.

Of the doctors on Youtube, the first to really suck me in was Dr. Jason Fung, a Canadian nephrologist. He had a very intuitive model for explaining type 2 diabetes, and used research on treating the condition with gastric bypass surgery (which has been highly successful) as a starting point. He suggested a low-carb diet combined with fasting in various forms. Hey, I’m already doing the low-carb thing and it seems to be helping. Maybe fasting would be the next nudge I needed.

I started with 3 set meals a day (eating between 7:30 AM and 7:30 PM, and then fasting from 7:30 PM until 7:30 AM the next morning). Around the time I started Farxiga, I moved into the next phase of fasting, which was to skip breakfast and then eat only lunch and dinner (eat at 12 PM and then 8 PM). To my surprise, I no longer felt hunger when I wasn’t eating. I now know that’s a common benefit to the keto diet, but if someone had tried to tell me about that a year earlier, I would have thought they were crazy. Also, I didn’t really know I was doing keto. I was just doing a tighter version of the diet I’d explained earlier, with less fruit and no beans.

I completed my first full-day fast the weekend after starting Farxiga. I didn’t eat anything at all starting Friday after dinner until around 1 PM on Sunday, for a 40+ hour fast. Again, Farxiga had gotten my blood sugar down to under 150 mg/dL on a regular basis, but this was the kick that finally got me back under 100 mg/dL. Throughout Friday it was testing 130 to 150 mg/dL, Saturday morning I was at 144 mg/dL, but as Saturday dragged on and my fast continued I started getting multiple readings under 100 mg/dL. My Sunday morning fasting result was 96 mg/dL and, it got as low as 79 mg/dL on Sunday afternoon before I finally broke my fast. To my surprise, breaking my fast only bumped me to 119 mg/dL and 5 hours later my blood sugar was back down to 82 mg/dL. Seeing this progress felt truly amazing and it was only 16 days after finding out I had diabetes!

Maintenance

Rey’s blood sugars improved rapidly and remarkably with the right combination of diet and medication.

Of course, you don’t eat your way to diabetes in two weeks and you don’t undo your diabetes in two weeks either. I was taking 2,000 mg of metformin a day as well as the SGLT2 inhibitor. The week after my big fast, my fasting blood sugar readings would go back over 100 mg/dL, but I kept plugging away, only eating two larger meals a day during a narrow set of eating hours. I also tested the high-carb waters with a 6-inch Subway sandwich – it spiked my blood sugar to 190 mg/dL, which is much higher than a non-diabetic would likely hit from that meal. That helped knock me back down a peg and remind me that I still had diabetes, after all.

The next weekend I noticed that my blood sugar numbers were starting to come down to under 100 mg/dL without extended fasting. I also noticed that foods that previously spiked my blood sugar a great deal were now spiking it much less. On June 28th (day 24 of knowing I had diabetes and 13 days after starting my SGLT2) I decided to stop taking Farxiga and see what effect it would have. This was not a responsible decision, as you should always consult with your doctor before discontinuing medication, but with my improved blood sugar levels, I questioned if Farxiga was still doing anything for me. It turned out my guess was correct. There was no significant change in fasting or post-meal blood sugar readings in the days that followed, and my type 2 diabetes was now well-controlled via just diet and metformin!

About a week later I started wearing a Freestyle Libre 2 to get a broader picture of my blood sugar trends, and for convenience. My readings were still in the 80-90 mg/dL range throughout the day, with small bumps up over 100 mg/dL after a meal. When I finally was due for my appointment with an endocrinologist to discuss my diabetes treatment, the feel of the visit could best be summed up as “why are you here?” My data showed that my average blood sugar in the previous 10 days had been 95 mg/dL, which would extrapolate to a 4.9% A1C (compared to the 13.7% result when first tested). This is, of course, only an estimate. And my blood sugar had only been well controlled for 2-3 weeks at this point.

Blood sugar wasn’t the only improvement either over last year’s numbers: total cholesterol dropped from 238 mg/dL to 172 mg/dL, with HDL (“good cholesterol”) fairly steady from 64 to 62 mg/dL. LDL (calculated) dropped from 141 to 90 mg/dL. Triglycerides dropped from 165 to 102 mg/dL. The endocrinologist agreed that I no longer needed Farxiga and indicated there really wasn’t a reason for me to see her again, but that I was free to set up another appointment if things changed.

My Best Path Forward

Since then, I’ve done more reading on the keto diet and feel that’s my best path forward to continue to maintain my health, both in terms of diabetes and beyond. I’ve improved enough that I no longer wear a CGM or perform finger sticks to check blood sugar on a regular basis, only checking maybe once a week “just to be sure.” Although I’ve tested out eating some of my old high-carb favorites and been impressed by how much less they spike my blood sugar now, I’m no longer interested in eating them on a regular basis, which is surprising to me. I’ve also found I can sleep through the night just fine without my CPAP machine due to the 35 pounds of weight I have lost from my peak of 215 lbs. The sleep apnea isn’t completely gone, so I still wear the mask most nights, but it appears to be dialed back from severe to mild.

It’s a very weird feeling: when I first found out I had diabetes I wanted nothing more than to continue eating the foods I loved and found comfort in. I felt like something had been stolen from me and feared that my body was permanently broken. Why should other people be able to eat what they want to, and I can’t? It felt very unfair and I really wanted there to be a drug or a treatment that would let me eat how I wanted to. Now that I’ve immersed myself in a better understanding of just how bad those foods were for me, I view things very differently.

I share my story not to lord my results over you if you’ve been less successful with your diabetes. I got really lucky, finding good dietary advice quickly after my diagnosis. Sadly, much of the official guidance out there seems sure to fail. I was also lucky with my uncontrolled diabetes “helping” with the first 25-30 pounds of weight loss.

I no longer have aches and pains when I get up out of bed or have to roll a certain way to avoid them, my memory has improved quite a bit and I’m no longer struggling to recall things I was just told, as I did with high blood sugar levels. I have so much more energy and stamina rather than feeling lethargic or struggling to complete physical activities. It’s like I’m in my 20s all over again (except for a little gray hair)! The downside is I now know if I go back to a lifestyle of enjoying carbohydrate-rich foods, things will go poorly for me, but as long as I don’t, I get to enjoy life so much more than I had before. And there are plenty of delicious foods that aren’t packed with carbs that I’m free to enjoy.

I think diabetes has been a net positive for me, as strange as that sounds. The me of today is very different than the me of a year ago.

Source: diabetesdaily.com

Diabetes Community Survey Shows Drug Costs Still Ranks Highest Access Concern

This content originally appeared on Beyond Type 1. Republished with permission.

By Beyond Type 1 Team

In early 2021, Beyond Type 1’s advocacy division surveyed almost two thousand people living with or caring for someone with diabetes to determine key healthcare access issues faced by members of the Beyond Type 1 community throughout 2020. While other surveys on access have been conducted within the diabetes community, it was important to Beyond Type 1 to hear directly from the community they serve on issues faced, both throughout the COVID-19 pandemic and generally.

The survey follows ongoing advocacy work from Beyond Type 1 addressing the rising cost of insulin and other healthcare access issues such as implicit bias and equitable technology access, Medicare and Medicaid access, drug pricing and rebate reform, and more.

The survey ran in English and Spanish, was anonymous, and included survey respondents both within and outside of the United States. The survey was run independently by Beyond Type 1 and specific methodology can be found at the bottom of this article.

Key Learnings

Access + Cost

A majority of respondents (56%) ranked access to affordable insulin and diabetes drugs as their most important access issue. This aligns with data reported from studies such as the 2018 Yale report showing that one in four insulin-dependent people ration insulin due to cost, while also nodding toward the high cost of other diabetes medications like SGLT2 inhibitors and GLP-1 receptor agonists.

Almost half of respondents (40%) ranked access to diabetes supplies as the second most important access issue (8.5% of respondents ranked access to supplies as their most important access issue), while nearly the same amount of respondents (36%) ranked access to affordable healthcare coverage as their third most important access issue. Just 6% of respondents ranked access to new therapies that cure, treat, or prevent diabetes as their top access issue (75% of respondents ranked it as their least important access issue).

Health Insurance

In the United States, 66.4% of respondents indicated they used employer-based health insurance to access healthcare in 2020. This is slightly higher than the 2019 U.S. population health insurance coverage data provided by the Current Population Survey Annual and Social Economic Supplement (CPS ASEC) and the American Community Survey (ACS), which calculated 55.4%.

Of the remaining third of respondents:

  • 8.1% received 2020 health coverage through Medicaid
  • 7.7% through Healthcare.gov / State Marketplace
  • 5.8% through Medicare
  • 5% reported no insurance coverage in 2020,
  • and 4.6% indicated ‘other’, which could include either a combination of coverage options, catastrophic care plans, COBRA, and/or other temporary plans

While two-thirds of respondents reporting employer-based health insurance could be seen as a positive—that access to healthcare is the norm rather than the exception—40.4% of respondents indicated they incur a deductible of more than $1500 per person for their insurance coverage. This indicates that over a third of respondents are covered by High-Deductible Healthcare Plans (HDHPs), a rising trend across American healthcare that, for those with chronic health needs, creates excessive financial burden.

HDHPs create a scenario in which a person often must pay full price for medications or supplies until the healthcare plan’s deductible is met, creating a significant out-of-pocket cost at the start of every calendar year. For people living with chronic conditions such as diabetes, this economic burden can create avoidance of healthcare treatment, unaffordability of life-essential medications, and inability to purchase or utilize supplies needed.

Out of Pocket Costs

Survey respondents reported excessive out of pocket expenses not only for medications, but for diabetes supplies (such as insulin pump or glucose monitoring supplies).

  • 55% of respondents stated they have paid more than $100 out-of-pocket in any month for any diabetes medication
  • 64% of respondents paid more than $100 out-of-pocket in any month for diabetes supplies

Global Issues

While the American healthcare system often creates an undue financial burden for people living with diabetes, access abroad remains a major issue as well.

  • 55% of respondents could not get supplies
  • 18.3% of respondents had run out of medications or rationed due to cost
  • 23% of respondents made a decision between bills and diabetes supplies

The Impact of COVID-19

Of course, the COVID-19 pandemic exacerbated healthcare issues across the globe. For those living with diabetes or caring for individuals with diabetes,

  • 30.7% of respondents did not see a healthcare professional or have lab work completed in 2020 due to fear of contracting COVID-19
  • 38.4% of respondents experienced mental health issues related to the COVID-19 pandemic
  • 7.8% of respondents experienced employment discrimination due to COVID-19 in relation to diabetes during 2020

The Bottom Line

Living with diabetes creates a major financial burden for many—the added medical cost of living with diabetes in the United States has been estimated at an average of $9,071 annually per individual—and the financial decisions that many are forced into making create short- and long-term consequences. Among survey respondents:

  • 21.6% ran out of medications or rationed due to cost
  • 15.0% skipped specialist visits or other healthcare to pay for diabetes care or supplies
  • 16.8% did not see a medical professional due to cost
  • 14.1% “borrowed” insulin or other diabetes supplies because of cost
  • 20.1% utilized a copay card for any diabetes medication
  • 22.8% made a decision between bills and diabetes supplies

These survey responses will continue to shape ongoing work being done by Beyond Type 1 ensuring everyone impacted by diabetes — type 1, type 2, and beyond — has a right to the best care possible for their unique situation. To learn more about Beyond Type 1’s advocacy work and to lend your voice to legislative actions, click here.

Details on Methodology

The Beyond Type 1 Diabetes Experiences Survey was created on Formsite, a secure platform for processing and hosting sensitive survey data in both English and Spanish versions. Both versions were identical in ranking questions, response offers, and language. The survey was logic mapped to offer additional questions for those who identified as individuals living outside the United States.

Questions were created by employees of Beyond Type 1 living with diabetes, with careful attention paid to plain, inclusive language in demographic self-identification inquiries.

The Beyond Type 1 Diabetes Experiences Survey was shared online through different avenues from mid-January to mid-February in English and mid-January to mid-March in Spanish through the Beyond Type 1 website (English and Spanish), the Beyond Type 2 website (English and Spanish), a targeted email from Beyond Type 1, and both organic and paid posts on Twitter, Facebook, and Instagram. There was no paper version available to print out; it was online responses only.

Respondents self-identified as people living with diabetes or caring for an individual living with diabetes.

The survey was completely voluntary; no one was paid to provide responses. All responses were mandatory for a survey to be deemed complete. If an individual did not click submit at the bottom of the survey, no results were recorded. A statement before the beginning explained that the survey results were anonymized, and only aggregate data and key learnings would be shared publicly.

1924 individuals fully completed the survey, with 1850 identifying as living in the United States.

Noted Limitations

The sample size of 1924 individuals is a small section of the global diabetes population, although larger than many similar surveys in the space. Additionally, respondents cannot be assumed as indicative of all people living with diabetes – 93% of respondents lived with or were caretakers of someone with type 1 diabetes, 91% lived in the United States, 85% were white, and 83% were female. Just 3.2% were 65+. All respondents had access to the internet and were either already following or in some way connected to Beyond Type 1 channels.

Source: diabetesdaily.com

Insulin at 100, Part 3: Insulin’s Uncertain Future

This content originally appeared on diaTribe. Republished with permission.

This is Part 3 of James S. Hirsch’s exploration of the riveting history of insulin, on the occasion of its 100th birthday.

Part 1: The Discovery

Part 2: Failed Promises, Bold Breakthroughs

Insulin’s Uncertain Future

Insulin

Image source: Emily Ye, Diabetes Daily

As further refinements in insulin occurred, the insulin narrative should have become even more powerful – that insulin not only saves people, but in reaching new pharmacological heights, it is allowing patients to live healthier, better, and more productive lives. These should be insulin’s glory days – as well as days of unprecedented commercial opportunity. According to the International Diabetes Federation, in 2019, the global population of people with diabetes had increased a staggering 63 percent in just nine years – to 463 million patients.

Insulin sales should be booming, with a new generation of Elizabeth Evans Hughes and Eva Saxls to tell the story. In fact, insulin sales are declining, and insulin has no spokespeople. Reasons vary for these developments, but one fact is undeniable: insulin has lost its halo.

Insulin is still essential for any person with type 1 diabetes, though even with type 1 patients, insulin is sometimes under-prescribed as doctors fear getting sued over a severe hypoglycemic incident. The belief is that patients are responsible for high blood sugars, doctors for low blood sugars.

Where insulin has lost its appeal is with type 2 patients, which has driven the diabetes epidemic in the U.S and abroad. According to the CDC, from 2000 to 2018, America’s diabetes population surged 185 percent, from 12 million to 34.2 million, and an estimated 90 percent to 95 percent of that cohort has type 2. (The global percentage is similar.) These patients have long had options other than insulin – metformin, introduced in 1995, remains the ADA’s recommended first-line agent. But as a progressive disease, type 2 diabetes, in most cases, will eventually require a more intensive glucose-lowering therapy. Nothing achieves that objective better than insulin, but insulin is delayed or spurned entirely by many type 2 patients.

Some concerns are longstanding; namely, that insulin can lead to weight gain because patients now retain their nutrients. Some type 2 patients wrongly associate insulin with personal failure surrounding diet or exercise, so they want to avoid the perceived stigma of insulin. Some people just don’t like injections. Meanwhile, other patients associate insulin with the medication that an ailing patient takes shortly before they die: insulin as a precursor to death. Some clinicians who care for Hispanic patients refer to insulin pens as las plumas to avoid using a word that carries so much baggage.

What’s striking is how dramatically the cultural narrative has changed, from insulin the miracle drug to insulin the medical curse. And where are the commercials, the movies, the documentaries, and the splashy publicity campaigns about the wonders of insulin? They don’t exist.

The greatest impact on insulin use in type 2 diabetes has been the emergence of a dozen new classes of diabetic drugs. These include incretin-based therapies known as GLP-1 agonists and DPP-4 inhibitors (introduced in the 2000s) as well as SGLT-2 inhibitors (introduced in 2014). diaTribe has covered these therapies extensively, and their brands are all over TV: Trulicity, Jardiance, Invokana, and more. They all seem to have funky names, and like insulin, they can all lower blood sugars but – depending on which one is used – some have other potential advantages, such as weight loss. (Some have possible disadvantages as well, including nausea.)

The expectations for these drugs were always high, but what no one predicted was that GLP-1 agonists and SGLT-2 inhibitors have been shown to reduce the risk of both heart and kidney disease – findings that are a boon to type 2 patients, who are at higher risk of these diseases. These findings, however, were completely accidental to the original mission of these therapies.

Insulin, the miracle drug, has been eclipsed by drugs that are even more miraculous!

Consider Eli Lilly, whose Humalog is the market-leading insulin in the United States. In 2020, Humalog sales fell 7 percent, to $2.6 billion, while Trulicity, its GLP-1 agonist, saw its sales increase by 23 percent, to $5 billion.

That’s consistent with the global insulin market. Worldwide insulin sales in 2020 declined by 4 percent, to $19.4 billion, marking the first time since 2012 that global insulin sales fell below $20 billion.

It’s quite stunning. Amid a global diabetes epidemic, and with the purity, stability, and quality of insulin better than ever, insulin sales are falling. (Pricing pressures from insurers and government payers have also taken a revenue toll.) In 2019, Sanofi announced that it was going to discontinue its research into diabetes, even though its Lantus insulin had been a blockbuster for years. More lucrative opportunities now lay elsewhere.

Falling sales may not be the insulin companies’ biggest problem. Public scorn is. Though the insulins kept getting better, the prices kept rising, forcing many patients to ration their supplies, seek cheaper alternatives in Canada or Mexico, or settle for inferior insulins. Some patients have died for lack of insulin. According to a 2019 study from the nonprofit Health Care Cost Institute, the cost of insulin nearly doubled for type 1 patients in the United States between 2012 and 2016 – they paid, on average, $5,705 a year for insulin in 2016, compared to $2,864 in 2012.

Many patients are outraged and have used social media to rally support – one trending hashtag was #makeinsulinaffordable. Patient advocates have traveled to Eli Lilly’s headquarters to protest. In March of this year, nine Congressional Democrats demanded that the Federal Trade Commission investigate insulin price collusion among Eli Lilly, Novo Nordisk, and Sanofi, asserting they “are using their stranglehold on the market to drive up costs.” The letter notes that as many as one in four Americans who need insulin cannot afford it, and at least 13 Americans have died in recent years because of insulin rationing.

The criticism has been unsparing. In April 2019, in a hearing for the U.S. House of Representatives on insulin affordability, Democrats and Republicans alike pilloried the insulin executives. At one point, Rep. Jan Schakowsky (D-Illinois) said to them, “I don’t know how you people sleep at night.”

Insulin is hardly the only drug whose price has soared, but as the Washington Post noted last year, insulin is “a natural poster child of pharmaceutical greed.”

In response, the insulin companies have adopted payment assistance programs to help financially strapped consumers. They also blame the middlemen in the system – the PBMs, or the Pharmaceutical Benefit Managers – for high insulin prices, who in turn blame the insulin companies, and everyone blames the insurers, who point the finger at the companies and the PBMs.

Drug pricing in America is so convoluted it’s impossible for any patient to accurately apportion blame, but the history of insulin explains in part why the companies have come under such attack. When Banting made his discovery, he sold the patent to the University of Toronto for $1. He said that insulin was a gift to humankind and should be made available to anyone who needs it. Insulin was always profitable for Eli Lilly and the few other companies who made it, and critics have complained that the companies found ways to protect their patents by making incremental improvements in the drug.

But for years, those complaints were easily dismissed. The companies were revered for their ability to mass produce – and improve – a lifesaving drug that symbolized the pinnacle of scientific discovery while doing so at prices that were affordable.

When prices became unaffordable – and regardless of blame – the companies were seen as betraying the very spirit in which insulin was discovered and produced, and their fall from grace has few equivalents in corporate history.

Is the criticism fair?

Hard to say, but even the companies would acknowledge that they’ve squandered much good will. Personally, I’m the last person to bash the insulin companies – they’ve kept me and members of family alive for quite some time. Collectively, my brother, my son, and I have been taking insulin for 117 years, so I feel more regret than anger: regret that at least one insulin executive didn’t stand up and say loudly and clearly:

“Insulin is a public good. No one who needs it will be without it. And we will make it easy for you.”

Insulin

Image source: Emily Ye, Diabetes Daily

Whatever that would cost in dollars would be made up for in good will – and such a public commitment would honor the many anonymous men, women, and children, before 1921 and after, who gave their lives to this disease.

The next chapter for insulin? It will almost certainly include continued improvements. Both Eli Lilly and Novo Nordisk are trying to develop a once-a-week basal insulin to replace the current once-a-day options – that would be a major advance is reducing the hassle factor in care. Research also continues on a glucose-sensitive insulin, in which the insulin would only take effect when your blood sugar rises. That would be a breakthrough, but investigators have spent decades trying to make it work.

Since its discovery, the ultimate goal of insulin has been to make it disappear, as that would mean diabetes has been cured. It turns out that insulin therapy may indeed disappear someday, even if no cure is found. Since its discovery, the ultimate goal of insulin has been to make it disappear, as that would mean diabetes has been cured. It turns out that insulin therapy may indeed disappear someday, even if no cure is found.

Stem-cell therapy has long held promise in diabetes – specifically, making insulin-producing beta cells from stem cells, which the body would either tolerate on its own (perhaps by encapsulating the cells) or through immunosuppressant drugs. Progress has been halting but is now evident. Douglas Melton began his research in this area in 1991, and in 2014, he reported that his lab was able to turn human stem cells into functional pancreatic beta cells. The company that Melton created for the effort was acquired by Vertex Pharmaceuticals, and earlier this year, Vertex announced that it had received approval to begin a clinical trial on a “stem-cell derived, fully differentiated pancreatic islet cell therapy” to treat type 1 diabetes. Another company, ViaCyte, also announced this year that it will begin phase 2 of a clinical trial using encapsulated cells in hopes that they will mature into insulin-secreting beta cells.

It may take 10 to 15 years, but leaders in the field are cautiously optimistic that a cell-based therapy will someday provide a better option than insulin.

Diabetes would survive, but the therapy once touted as its cure would be dead.

Because I have a soft spot for happy endings – and because so much of own life has been intertwined with insulin – I have my own vision for insulin’s last hurrah.

A group of researchers in Europe are conducting a clinical trial to prevent type 1 diabetes. Called the Global Platform for the Prevention of Autoimmune Diabetes, the initiative began in 2015, and researchers are testing newborns who are at risk of developing type 1 to see if prevention is possible.

And what treatment are they using?

Oral insulin.

Like the discovery of insulin itself, this effort is a longshot, but if it works, insulin will have eradicated diabetes – a fitting coda for a medical miracle.

I want to acknowledge the following people who helped me with this article: Dr. Mark Atkinson, Dr. David Harlan, Dr. Irl Hirsch, Dr. David Nathan, Dr. Jay Skyler, and Dr. Bernard Zinman. Some material in this article came from my book, “Cheating Destiny: Living with Diabetes.”

About James

James S. Hirsch, a former reporter for The New York Times and The Wall Street Journal, is a best-selling author who has written 10 nonfiction books. They include biographies of Willie Mays and Rubin “Hurricane” Carter; an investigation into the Tulsa race riot of 1921; and an examination of our diabetes epidemic. Hirsch has an undergraduate degree from the University of Missouri School of Journalism and a graduate degree from the LBJ School of Public Policy at the University of Texas. He lives in the Boston area with his wife, Sheryl, and they have two children, Amanda and Garrett. Jim has worked as a senior editor and columnist for diaTribe since 2006.

Source: diabetesdaily.com

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.

Click to jump down:

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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