Below is part of a more lengthy article written by Dr Chao on some considerations for an example patient that had an increase in HbA1C despite taking Metformin and implementing exercise and slight weight loss. The author points out that there is much yet to learn about diabetes treatment and notes the most recent progress of a multicenter GRADE study taking place with several agents over 4-7 years to determine a second line agent to Metformin for situations like this.
He cites downsides of sulfonylureas of weight gain and hypoglycemia as had been seen in the previous double blinded placebo controlled study where Sucanon outperformed Glyburide. Further he gives some consideration to factors that determine a choice of alternate medications in treating the chronic progressive disease of diabetes.
It should be noted that in Dr Rojas study of Sucanon in prediabetics presented at the 2013 EASD annual meeting and included in their peer reviewed journal Diabetologica, a 12 week course of Sucanon resulted in normalization of HbA1C values in 81% of subjects and showed no adverse side effects and resulted in a desirable effect of mild weight loss. That was consistent with weight loss observed with Sucanon in the above study compared to weight gain and lesser blood sugar and HbA1C control with Glyburide.
Yet another reason I’m so confident in the past and ongoing study results of Sucanon.
The latter part of the article is below and is verbatim (that is unedited)
Refer to the American Diabetes Association1 (ADA) and American Association of Clinical Endocrinologists’ 2(AACE) clinical guidelines—there are many treatment options when patients fail metformin alone. What your patient and you decide upon via a shared decision-making approach, will result from multiple factors, including: the extent of HbA1c increase, formulary coverage, cost, patient preference, potential AEs. For instance, avoiding weight gain and hypoglycemia may steer you way from a sulfonylurea or a thiazolidinedione, and towards a GLP-1 receptor agonist, a DPP-IV inhibitor, or an SGLT2-inhibitor. Insulin is an option, though there is a stigma and many misconceptions attached to this agent. We do have more options than ever before, yet, the greater number of choices can leave both physician and patient feeling overwhelmed.
No clinical studies had been done to investigate the question of whether there’s an optimal second-line agent for those with T2DM, after metformin alone is no longer effective—until May 2013. That’s when The Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE) began. GRADE is examining which of 4 FDA-approved medications for T2DM—glimepiride (sulfonylurea), sitagliptin (DPP-4 inhibitor), liraglutide (GLP-1 agonist), and basal insulin glargine—when added to metformin is most effective and has the fewest adverse effects.4
Funded by the National Institute of Health's National Institute of Diabetes and Digestive and Kidney Diseases, GRADE was closed to enrollment last summer. There are 5,047 individuals participating at 45 sites across the US, and they will be followed over the next 4 to 7 years.
We have so much yet to learn. What clinical pearls and insights have served you well in your approach to patients with T2DM? Ms M deserves no less than our continued best efforts as her partner, helping her to continue to live well with diabetes.
My recommendations for Ms M are as follows:
Ms M wants to lose more weight, and is hesitant about a daily injection of a long-acting insulin. She realizes that adding another oral medication may not be sufficient. She agrees to try a once-weekly GLP-1 receptor agonist, such as Bydureon (exenatide extended-release), and continue refining her lifestyle changes.
Dr. Chao is a sub-investigator in the GRADE Study at the University of California, San Diego/VA San Diego site.
Jacob J. Rosenblum on what every lawyer knows.
“If the facts are against you, hammer the law. If the law is against you, hammer the facts. If the fact and the law are against you, hammer opposing counsel."
AI
