Investigational and emerging treatments are attempting to achieve certain outcomes in order to have a “place at the table” in the management of type 2 diabetes. Some of these desired characteristics include minimal to no risk of hypoglycemia and weight loss with an effective A1C reduction.
In August 2014, a new drug was approved for the management of type 2 diabetes. Empagliflozin, also known as JARDIANCE, is the third FDA-approved agent sodium glucose co-transporter 2 (SGLT2) inhibitors. In healthy individuals, approximately 90 percent of the filtered glucose is reabsorbed by SGLT2 in the proximal renal tubule. The kidney desires to excrete excessive, filtered glucose in order to restore normal levels of glucose in the blood. In a patient with type 2 diabetes, the kidney is dysfunctional and responds to hyperglycemia through glucose reabsorption. (Defronzo RA, Diabetes 2009)
Empagliflozin is a selective SGLT2 inhibitor, which will decrease blood glucose levels secondary to the process of glucosuria in which glucose is excreted in the urine. It is similar to the other SGLT2 inhibitors – INVOKANA (canagliflozin) and FARXIGA (dapagliflozin). Empagliflozin lowers A1C by 0.7 to 1%; reduces weight by 4 to 7 pounds; and lowers blood pressure by 3 to 5 mm Hg. However, it is expensive – estimated to be $10 per day. Other disadvantages include genital yeast infections and urinary tract infections. Empagliflozin should be started as a second or third agent with other oral agents. As a certified diabetes educator, you can educate patients to take the medication in the morning due to a possible diuretic effect.
To me, this agent provides another option in this therapeutic class. However, this class may become “me-too” class as there may be minimal differences between agents. In addition, there are several emerging SGLT2 inhibitors in clinical trials. These agents will not become a common first-line agent for type 2 diabetes, as metformin remains the superior agent. However, these agents could be used as combination therapy. Remember that diabetes management should be individualized and take into consideration the drug’s efficacy, safety, cost, as well as the patient’s preference and tolerance.
Many communities have support groups for patients with diabetes or type 2 diabetes, but few have the same opportunities for folks with type 1 diabetes to come together and share experiences or listen to type 1 focused presentations. Take Control of Your Diabetes had a track for those with type 1 this year which was very well attended in our area and patients and family members appeared to be very grateful.
I have many patients who feel isolated by type 1 diabetes, and I am surprised that so many have never met another soul with type 1. So teaming up a patient with an online support group seems to be a positive step towards increasing a feeling of belonging and encouraging sharing of tips for managing and coping with diabetes. If you have not worked closely with type 1 diabetes, it truly is a fellowship.
There are many options and here are a few to consider:
Listen to your patients, if they are asking for support, provide them with some options. Type 1 diabetes is a tedious but “do-able” disease. Having someone who understands the daily tasks and can offer support whether through a face to face contact, support groups in the community or online may provide that extra something that makes the tasks seem less burdensome. What support options have you found helpful for your patients?
I recently attended an interesting presentation given by one of our dietitians on the role of microbiota and its relationship to diabetes - A fascinating angle which sparked my interest to learn more. My dear friend Google helped me find a significant number of articles published in the past 2-3 years which address this fairly new topic.
Recent studies suggest gut bacteria play a fundamental role in diseases such as obesity, diabetes and cardiovascular disease. Most authors agree that intestinal bacteria may have a greater influence on us than was previously thought. More and more data, derived from animal and human studies, suggest obesity and type 2 diabetes are associated with a profound dysbiosis.
One article states the human body contains ten times more bacteria than our usual human cells. The majority of these bacteria make up the normal gut microbiota. These huge numbers of bacterial genes in addition to the genes in our own cells are collectively known as the metagenome. Swedish researchers compared the metagenome of 145 women with diabetes, impaired glucose tolerance and healthy controls, and showed that women with type 2 diabetes have an altered gut microbiota. Researchers concluded that by examining the patient's gut microbiota they could predict which patients are at risk of developing diabetes. In fact, researchers have had better predictive value using gut microbiota than the classical predictive markers used today, such as body-mass index and waist-hip ratio.
The next challenge is to examine whether the composition of the gut microbiota promotes the onset of type 2 diabetes. If studies show this to be true, this would indicate new opportunities to prevent the disease. That would add another layer of potential medications or perhaps modifying food choices to assist in the challenges we all face to prevent and treat T2D.
Interestingly, it has been found that certain drugs such as metformin also interfere with the intestinal microbiota. With so many of our patients using metformin, it would seem important to study this further – perhaps we are making things worse for our patients with the medications we think are helping. Changes in intestinal microbiota may also explain why gastric bypass surgery is more effective in correcting diabetes than gastric banding.
As more research develops and a ‘gut signature’ becomes more evident in T2D, a better understanding of the role of the microbiota in diabetes might provide new aspects regarding its pathophysiological relevance and pave the way for new therapeutic principles.
Fascinating information in an entirely new part of the human anatomy - it will be interesting to see where this leads.
Recently we had a well-loved diabetes educator, Patti Geil pass away. She was an author of 12 books and owned Geil Nutrition. I was so shocked to hear the news. She was a leader locally in Kentucky and nationally in the field. In her obituary, the family asked for donations to go to the AADE Education and Research Foundation. I thought it was very fitting that they chose the Foundation since Patti was so involved with AADE. It made me want to share so that other educators can let their families know about such a wonderful way to give to diabetes education.
It was AADE nationally and locally as well as the Annual Meeting that really inspired me as a diabetes educator and made me proud to be in the profession. The AADE Education and Research Foundation gives several scholarships allowing educators to help cover the cost of the Annual Meeting. This can be such an amazing experience especially for a new educator. They also offer recognition awards which really inspire educators and reward them for being leaders in their field.
There are also numerous research grants focusing on improving patient health outcomes through behavior change that are also funded by the AADE Education and Research Foundation.
It is so important for your family to know your preferences in such a challenging time. For Patti, it makes my heart smile to know that her passion for diabetes education will live on through contributions to the AADE Education and Research Foundation. You can learn more here .
When prescribing exercise or physical activity for a person with diabetes (PWD), diabetes educators should be specific. Research shows that an individual is more likely to perform exercise as recommended when those recommendations are specific. We give specifics when educating about medications, meal planning and blood glucose monitoring (i.e., how much and how often). Why would it be different with exercise? An individualized exercise or physical activity plan can be made specific by using the FITT Principle where F=frequency, I=intensity, T=type and T=time.
• If the person can not only talk, but also sing, the exercise is considered light intensity. This is useful when a person is getting started with exercise or if they have health concerns making moderate exercise unsafe.
This simple talk test method for determining exercise intensity has been compared to exercise tests where heart rate is monitored and has been determined to be safe and accurate. In fact, if a person is taking a beta blocker medication, it is generally safer than monitoring of heart rate (which is blunted by the medication). Obviously, this test doesn’t work in all situations, for example when swimming. In this case, a person can determine their intensity by doing water exercise and comparing their effort to how they feel when swimming.
So, when prescribing exercise or physical activity for a PWD, let’s be specific with exercise intensity and teach the talk test.
In my next blogs, I will review the specifics of frequency, type and time of exercise so stay tuned!
Recently, I received an email from Diabetes Care about articles published ahead of print. My eye was drawn to read a position statement of the American Diabetes Association (ADA) on type 1 diabetes. In a 20-page publication, Chiang and colleagues provided background information and clinical guidance for the management of individuals with type 1 diabetes from infancy to an older age.
Here are some highlights from the article:
- Pancreatic autoantibodies should be used to confirm the diagnosis of type 1 diabetes. Since my practice site is located in a rural area, I have not recommended obtaining these laboratory tests, but most commercial laboratories do not have reliably sensitive or specific assays for certain autoantibodies.
- As recommended in the 2014 ADA guidelines, relatives of patients with type 1 diabetes should be referred to a clinical research study. You can refer to sites by the National Institute of Health and Juvenile Diabetes Research Foundation for research information and location of centers.
- There is a lot of great information about development issues (Table 2), clinical evaluation (Table 4), and DSME content (Table 6) for patients with type 1 diabetes from infancy to an older age. This section would be a great topic for discussion and presentation at the AADE15 meeting in New Orleans, LA.
- I was familiar with celiac disease among patients with type 1 diabetes, but did not know the statistics – 1-16% versus 0.3-1% in the general population, respectively.
- There has been change in desired A1C goals for the youth. Previous goals were: <8.5% for children younger than 6 years, <8% for children 6 to 12 years of age, and <7.5% for adolescents 13 to 19 years of age. In this position statement, the ADA recommended an A1C goal of <7.5% for all pediatric age groups.
- A growing area of research is beta-cell replacement therapy. On page 2047 of the position statement, recommendations of patient candidates for pancreas transplant and islet transplantation are provided.
- Pramlintide and some incretin agents have been studied as adjunctive therapy among patients with type 1 diabetes. While the studies have been small in sample size and short in length, the evidence is promising (i.e. reduction in A1C, reduction in total insulin dose, and promotion of weight loss). However, additional evidence is needed to have stronger conclusions and clinical application for patients with type 1 diabetes.
For more information, you can refer to the article: Chianga JL, Kirkman MS, Laffel LMB, Peters AL. Type 1 diabetes through the life span: a position statement of the American Diabetes Association, published in Diabetes Care on June 16, 2014 (DOI: 10.2337/dc14-1140).
A number of years ago I began to work in the hospital and was shocked at how many folks were in for foot wound debridement and amputations. Even though I have some patients in the outpatient world that have neuropathy and need medications to help them tolerate pain, and some who have lost a foot to an amputation, I was totally unprepared for the number of foot and below the knee amputations that were performed on a regular basis. And unfortunately, patients with excellent blood glucose management now, but poor control earlier in their lives with diabetes, were not immune.
Approximately 50% of patients with diabetes will develop neuropathy at some point in their lifetime, most experiencing peripheral neuropathy involving the lower extremities. Those with poor diabetes management are at highest risk.
As diabetes educators, it is important for us to include education about self-foot examinations in most of our education sessions. Visually inspecting feet should be done at most visits, with a thorough foot exam at least annually by a trained individual, be it a diabetes educator or medical provider. The annual exam should include visual examination of the feet as well as sensory assessment. In cases when problems are detected, referring to a podiatrist with a strong understanding of diabetes is a must. The new 3rd edition of The Art and Science of Diabetes Self-Management Education Desk Reference is a wonderful resource for providing information on frequency of screenings, explaining the visual foot assessment, and providing information on what should be included in a comprehensive foot exam.
In addition to screenings, prevention of complications starts with teaching patients to pay attention to their feet. Ask your patient if they wash their feet regularly? Dry between their toes? Take off their socks each night and check for any sores, dry or red areas. If the individual cannot see the bottoms of their feet, encourage the use of a mirror. Have a sample of one in your office and help them look at their feet. Remind them of the importance prompt medical attention if their assessment reveals any question about the health of their feet.
I can remember many years ago attending a session at an American Diabetes Association Annual Meeting, where the presenter showed slides of foot and leg complications of diabetes due to poor management. I was young and so surprised that something so destructive could be occurring, often undetected.
I am now no longer surprised, but saddened. Prevention is really the answer, and teaching patient to care and examine their feet, along with managing their blood glucose values, can go a long way to help reduce the risks of irreparable damage.
We as a nation have an obsession with food. Being in the diabetes arena brings it even more to the forefront as it has a significant impact on patients’ lives and glycemic control. It is a fine balance between eating properly, taking the correct medication for your food choices, and not feeling guilty if the choices were not exactly what the CDE had recommended. A major portion of each of our Diabetes Classes is spent discussing food choices – and it continues to be the part that patients find the most challenging.