UAB Medicine News
All About Diabetes: Treatment Now and for the Future
Just over 14% of adults age 18-76 in Alabama have type 2 diabetes. That’s the second highest percentage in the United States, where more than 30 million people suffer from the disease, according to the Centers for Disease Control and Prevention (CDC).
In fact, nine of the 10 states with the highest type 2 diabetes rates are in the South. CDC data about diabetes and pre-diabetic conditions suggest that, should current trends continue, the disease will reach a global crisis point by 2040.
What is Diabetes?
Diabetes is a broad term for a condition that causes the body’s blood glucose (sugar) levels to rise higher than normal. There are two major and well-known types of diabetes. The most common form of the disease, type 2 diabetes, occurs when the body fails to produce enough insulin to offset the body’s level of insulin resistance. Insulin is a hormone needed to convert sugar, starches, and other food into energy. At first, the pancreas makes extra insulin to make up for the resistance. But over time, the pancreas often can’t maintain normal blood glucose levels.
Type 1 diabetes, previously known as juvenile diabetes, usually is diagnosed in children and young adults, though it can develop at any age. Type 1 diabetes occurs when the immune system attacks beta cells in the pancreas that produce insulin. The destruction of beta cells prevents the production of any insulin. Roughly 5-10% of people with diabetes have this form of the disease. Those with type 1 generally must take daily insulin injections and regularly monitor blood sugar levels.
Another form, known as gestational diabetes, sometimes occurs during pregnancy in women who didn’t previously have diabetes. It may require varying degrees of treatment and/or lifestyle and dietary changes, similar to those recommended for type 2 diabetes. Gestational diabetes gradually goes away after delivery. If the condition remains after delivery, it may be diagnosed as type 2 diabetes.
Type 1 diabetes requires insulin injections several times during the day, including with meals. Insulin also may be administered using an insulin pump, which gives small, steady doses throughout the day.
Gestational diabetes often may be managed through healthy food choices and getting regular physical activity. If diet changes do not reduce glucose levels, medications such as insulin or the diabetes drug metformin may be taken during pregnancy.
The treatment for type 2 diabetes varies depending on age, the severity of the condition, medical history, and even personal preferences. They can include physical activity and weight loss, nutritional changes, and either oral or injected medications and/or insulin. Patients also may need medication for other health problems, such as high blood pressure or high cholesterol, as part of their diabetes care plan.
The basis of all treatment, however, involves diet and exercise, says endocrinologist Fernando Ovalle, MD, director of the UAB Comprehensive Diabetes Clinic.
“We ask patients to change their diet, exercise, and lose weight,” Dr. Ovalle says. “That’s a lifestyle intervention, which is the foundation of any therapy for diabetes. Without that intervention, any other treatments may fail.”
That intervention may not be enough, depending on the patient’s medical history or ability to exercise and maintain diet adjustments over time.
“If a change in diet is not getting results, then we add medication to the treatment plan,” Dr. Ovalle says. “Metformin is the first line of defense, because it is proven to be well-tolerated and safe. If metformin at a maximum tolerated dose does not achieve the target glucose levels, then the new recommendations are to use either a DPP-4 inhibitor or sodium-glucose cotransporter-2 [SGLT2] inhibitor.”
A DPP-4 inhibitor boosts insulin levels when blood sugars are too high and tells the liver to cut back on making sugars. These drugs do not cause weight gain and may be taken alone or with metformin. An SGLT2 inhibitor increases how much glucose leaves the body through urination and blocks the kidneys from reabsorbing glucose.
Alternative and Experimental Treatments
When medicines and lifestyle changes are not enough to manage diabetes, other treatments may be an option.
Bariatric surgery (sometimes called weight-loss surgery or metabolic surgery) may help some people with obesity and type 2 diabetes lose a large amount of weight and achieve proper blood glucose levels. Also, some patients may no longer need diabetes medication after surgery. Success with this surgery varies with each patient, the type of weight-loss surgery, and the amount of weight lost. Other factors include how long the person has had diabetes and used insulin. Some research suggests that bariatric surgery can improve blood glucose control in obese patients with type 1 diabetes.
A new technology called an artificial pancreas may help certain patients. An artificial pancreas replaces manual blood glucose testing and the use of insulin shots or a pump. A single system monitors blood glucose levels around the clock and automatically provides insulin or a combination of insulin and a second hormone, glucagon.
In 2016, the FDA approved a type of artificial pancreas system called a hybrid closed-loop system. This system monitors glucose level every five minutes and automatically delivers the correct amount of insulin needed.
Pancreatic islet transplantation is an experimental treatment for poorly controlled type 1 diabetes. Pancreatic islets are clusters of cells in the pancreas that make the hormone insulin. With type 1 diabetes, the body’s immune system attacks these cells. A pancreatic islet transplant replaces destroyed islets with new ones that make and release insulin. This procedure involves taking islets from the pancreas of an organ donor and transferring them to a person with type 1 diabetes. Because researchers are still studying pancreatic islet transplantation, the procedure is available only to patients enrolled in research studies.
New Findings at UAB
Researchers at the UAB Comprehensive Diabetes Center recently discovered a safe and effective therapy to reduce insulin requirements and hypoglycemic episodes in adult subjects with recent-onset type 1 diabetes by promoting the patient’s own beta cell function and insulin production. It’s the first such discovery to target diabetes in this manner.
The findings revealed that regular oral administration of verapamil, a common blood pressure medication first approved for medical use in 1981, enabled patients to continue producing their own insulin, limiting their need for injected insulin to balance out their blood sugar levels. Dr. Ovalle was co-principal investigator of the study.
“Beyond verapamil allowing subjects with type 1 diabetes the ability to live a life with less external insulin dependence, these findings will impact the quality of life they can have,” he says. “Hopefully, by improving overall blood sugar control, it will also limit risks for heart attack, blindness, kidney disease, and other conditions.”
Dr. Ovalle says that even with the small sample group, the UAB trial results show promise that subjects with type 1 diabetes have therapy options and that researchers are nearing a more effective way to deal with diabetes.
“We are waiting for someone else to replicate our clinical trial, so clinicians may adopt the use of verapamil,” Dr. Ovalle says. “I can’t say whether we will ever see FDA approval or not. Most likely what will happen is that a drug company will develop a similar treatment that gets the same results, so they can patent that new drug.”
At the UAB Comprehensive Diabetes Clinic, people with diabetes can see several specialists and receive evaluations and recommendations to help them better manage their condition. Click here to learn more.
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