February 1, 2015

Options After Insulin

This is one confusing article in Diabetes Self-Management magazine. First, there is an error in the byline, as when I contacted Will Dubois, his answer back was there is a misprint in the byline because he didn't write it. In an email to Gary Scheiner, he confirmed to me that he is the author and the article is written for people with type 1 diabetes.  The byline has now been corrected.

I have needed to reread the article several times and slowly to determine that it was written for people with type 1 diabetes. I do wish he had clearly stated that the article was written for type 1 diabetes. This can be inferred, but is far from clear in the overall context of the article. With the number of people with type 2 diabetes using insulin, this could have been written for both types. However, I should have known this as most CDEs do not deal with type 2

With the conflicts of interest that the American Association of Diabetes Educators has, I am also wondering how much of a conflict of interest is represented by the article and the medications he is promoting. The “off label” use that is being promoted is heavy and questionable at best.

Since I am a person with type 2 diabetes, none of the medications is “off label” use for me. This is the only clear reason for this being written for those with type 1 diabetes. I cannot agree with some of the medications as the potential side effects far out weigh the benefits and this is true for type 2 and type 1.

In looking at the medications recommended for type 1 there are only two that I could consider as being valid and only one that is truly “off label” and that would be metformin as it is used “off label” for prediabetes as well and has many studies to confirm its benefits. The one contraindication would be kidney problems which is true even for type 2 diabetes.

The first injectable drug other than insulin to hit the market was pramlintide (brand name Symlin), a replacement for the hormone Amylin. Amylin is normally secreted by the pancreas along with insulin. People with type 1 diabetes secrete no Amylin at all, and people with type 2 diabetes usually secrete far too little. Yet people with type 2 diabetes that use insulin therapy early often preserve their ability to produce enough Amylin to avoid needing Symlin. When insulin is the medication of last resort, then often Symlin may be needed, but is seldom prescribed.

The only drug that the author gave a warning for is the Thiazolidinediones. Both pioglitazone (Actos) and rosiglitazone (Avandia) have been linked to increased risk of congestive heart failure in people already at high risk for heart disease.

Even the newest class of type 2 oral drugs, sodium-glucose cotransporter 2 (SGLT2) inhibitors are not listed with the warning for people with kidney problems as they are for people with type 2 diabetes.

There are several DPP-4 inhibitors on the market today, as well as a few under development. The currently available drugs include sitagliptin (Januvia), linagliptin (Tradjenta), saxagliptin (Onglyza), and alogliptin (Nesina). No warning is given about causing hypoglycemia when these drugs are used with insulin.

With the lack of warnings and the overall promotion of drugs that are generally for type 2 diabetes, I would be concerned about unstated conflicts of interest.

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