New, more effective anti-diabetic drugs, insulin pumps and inhalants may improve the lives of more than 240 million diabetics worldwide. While vigourous preventative steps are needed to stem the rising tide of obesity and diabetes, more effective diabetes drugs will go a long way to help prevent some of the 3 million deaths caused by the disease every year.
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Dr Liesel Rademan, Department of Endocrinology, Tygerberg Hospital, compiled this special report for Health24 on the 19th World Diabetes Congress.
Huge global impact
The global impact of diabetes has been gaining considerable media attention. Most recent figures reveal that there are currently 240 million people with diabetes worldwide and that over 3 million deaths are attributable to the disease each year.
The hottest topics of discussion at the congress included metabolic syndrome and six promising new anti-diabetic treatments.
Six promising treatments
There have been many advances in the treatment of type 2 diabetes. Initially healthcare practitioners were limited in what they could offer type 2 diabetics – exercise and nutrition being the cornerstone of treatment.
Following failure on regular oral diabetic agents (i.e. biguanides and sulphonylureas), insulin therapy would be added.
Now healthcare professionals can select from newer agents that not only improve glycaemic control, but in some cases have also been shown to be effective in the prevention of type 2 diabetes.
1. An example of an agent that not only improves glycaemic control, but in some cases has also been shown to be effective in the prevention of type 2 diabetes: the Thiazolidinediones e.g. Rosiglitazone.
Thiazolidinediones are a class of insulin sensitising antidiabetic drugs that work on the PPAR-gamma nuclear receptor. They were initially used as add-on treatment to conventional treatment regimes, but have now been shown to be effective as monotherapy (ADOPT trial) in the treatment of type 2 diabetes. They have also shown to be effective in the prevention of type 2 diabetes in high risk individuals (DREAM trial) and to slow the progression of type 2 diabetes.
2. The Incretin mimetics are another exciting new class of drugs that can be used in the treatment of type 2 diabetes.
Incretins are hormones produced by the gut that stimulate insulin secretion after a carbohydrate-rich meal. Exenatide is one example. It has been shown to be successful in significantly reducing HbA1c, improving fasting and postprandial glucose, and is effective in weight reduction in type 2 diabetics. DPP-IV inhibitors inhibit the breakdown of incretin hormones and are currently undergoing clinical testing for use in type 2 diabetes.
3. Cannabinoid receptor antagonists were yet another class of drugs discussed that can be employed in the treatment of type 2 diabetes.
The RIO-Diabetes study was presented. This study showed that Rimonabant 20mg, a drug already registered for the treatment of obesity, not only significantly improved weight, but also glycaemic control and other cardio-metabolic risk factors in people with type 2 diabetes.
There is gathering evidence for the superiority of newer insulin analogues above conventional insulins in the treatment of insulin dependent diabetics (both type 1 and type 2).
4. Also of great interest is the emergence of inhaled insulins in the treatment of insulin dependent diabetics. The main disadvantage of inhaled insulins is limited absorption and therefore the need for much higher and more costly doses for the same effect as injected insulins.
Exubera® is an inhaled form of insulin registered for use in both type 1 and type 2 diabetics. It is inhaled 10 minutes before a meal and has been shown to be effective in controlling blood glucose levels. Other insulin inhaler devices are currently being developed.
5. Insulin analogues are modifications of human insulin to either increase or delay absorption of insulin into the blood from the injection site. They are made by modifying the chemical structure of human insulin and in so doing create a compound that has different chemical properties to that of human insulin.
The greatest benefit thereof is the ‘time to action’ profile. In other words, compared to conventional insulin these insulins either work faster and for shorter periods (e.g. Insulin Aspart, Insulin Lispro and Insulin Glulisine), or have a more prolonged course of action for 24 hours (Insulin Glargine and Insulin Detemir).
The short-acting analogues do not have to be injected half an hour before meals but are given immediately before the meal. There is a reduced incidence of hypoglycaemia (especially nocturnal hypoglycaemia) with both short-acting and long-acting analogues.
6. The advent of insulin pumps has brought greater freedom to the lives of many people diabetics. Insulin pumps deliver short-acting insulin 24 hours a day through a catheter which is placed under the skin with the aid of a small needle.
In the newer pumps the needle is removed and only a soft catheter remains in place.
Currently a large percentage of insulin-dependent diabetics in the United States are using insulin pumps; it is expected that the rest of the world will follow this trend. One of the disadvantages is cost – not only the cost of the actual pump but also the monthly cost of expendable items. The use of algorithms to calculate the carbohydrate content of meals and calculating the correct insulin dose can also prove difficult initially.
Some of the newest insulin pump systems are fitted with their own monitoring devices. The MiniMed Paradigm REAL-Time System is an example of such a pump. It is the world's first system to integrate an insulin pump with REAL-Time continuous glucose monitoring.
Treatment for all
One of the IDF’s main aims is to ensure that poverty does not exclude anyone from receiving treatment. The congress provided a platform to address important issues pertaining to treatment of diabetics worldwide. The congress was successful in presenting delegates with the latest advances in diabetes care and management and equipped many with education tools to take back to their respective countries in order to further educate diabetics and their families.
The next World Diabetes Congress will be held in Montreal, Canada, in 2009.
Special report on the 19th World Diabetes Congress, compiled for Health24 by Dr Liesel Rademan, Department of Endocrinology, Tygerberg Hospital. December 2006.
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