Diabetics should strive to keep their blood sugar within a target range through drug therapy. Oral drugs and injections are used for drug therapy, and treatment drugs are selected in consideration of the type of diabetes mellitus, the presence or absence of complications, and the patient’s condition. We took a closer look at the important drug therapy for diabetic patients with Dr. Hyejin Yoon (Dunsan Endo Internal Medicine Clinic).
Hyejin Yoon, Director of Dunsan Endo Internal Medicine Clinic｜Source: Hidak
Q. What is the typical chronic disease, diabetes?
Insulin is a hormone made by the pancreas. Inside the pancreas, there is a tissue called ‘Langerhans islet’, and insulin is secreted from beta cells inside this tissue.
Insulin plays an important role in storing nutrients. Insulin is needed for the glucose absorbed from the small intestine to be transported into the cells, and only when insulin acts on the insulin receptors on the muscle cell membrane can glucose be absorbed into the cells.
Insulin also prevents the breakdown of triglycerides into fatty acids in adipose tissue. When insulin stops working, triglycerides are broken down into fatty acids and fatty acids increase in the blood, which can lead to complications such as hyperlipidemia and fatty liver in the process.
Diabetes mellitus is a metabolic disease in which the secretion of insulin is insufficient or normal function is not achieved. In other words, diabetes is a disease that occurs when insulin does not work properly, glucose accumulates in the blood, the blood sugar balance in the body is broken and blood sugar rises.
Q. When is insulin treatment necessary?
Insulin treatment is recommended in cases of severe hyperglycemia of 9% or more of glycated hemoglobin at the time of diagnosis. In particular, when hyperglycemia is accompanied by symptoms such as polyuria, polydipsia, and polydipsia, or when clinical manifestations of catabolic effects such as weight loss and ketoacidosis appear, the initial treatment with insulin must be started.
In addition, insulin treatment is required in patients with autoimmune type 1 diabetes in which insulin is not secreted by the pancreas, patients who develop diabetes following surgical removal of the pancreas, and pregnant women who cannot use oral medications. Insulin treatment may be considered if the glycated hemoglobin remains above 7.5% even with combination therapy or if the blood sugar continues to rise. Insulin can be safely used in patients with impaired liver and renal function, and insulin therapy is sometimes considered to control blood sugar in patients who have undergone surgery such as myocardial infarction or stroke.
Q. You mentioned that there are cases in which patients with type 2 diabetes need insulin treatment.
Type 2 diabetes patients initially manage their blood sugar with ‘lifestyle changes and oral medications’. In the case of oral drugs, if you start with one drug and do not achieve the target glycated hemoglobin, a two-drug combination therapy or a three-drug combination therapy will be considered. In some cases, four-drug combination therapy is used, but if fasting blood glucose level is 150 mg/dL or higher and glycated hemoglobin level is 7% or higher, oral drug and Insulin combination therapy should be actively considered together.
Prolonged hyperglycemia further reduces the pancreas’ ability to secrete insulin. Therefore, in patients with type 2 diabetes who do not reach their target blood sugar level with oral medications and progress to hyperglycemia, active insulin treatment is required. There is also a study result that in patients with hyperglycemia of 9% or more at the time of diagnosis of diabetes mellitus, active insulin treatment for 3 months can prevent the decrease in insulin secretion for at least 3.5 years.
Q. Can I switch to oral medications following starting insulin treatment?
There is a study in which 275 patients with type 2 diabetes mellitus with a glycated hemoglobin level of 9% or higher at the time of diagnosis of diabetes used insulin as the initial treatment and followed up for 33 months. In this study, depending on the degree of blood sugar control, some patients discontinued insulin and switched to oral medication to maintain treatment. Of the participants, 63% of patients stopped insulin and took only oral medications, and 37% continued their insulin treatment. In other words, even with insulin treatment as the initial treatment, 6-7 out of 10 people can stop insulin and switch to oral medications. In addition, this treatment can better preserve the pancreatic insulin-secreting ability.
Diabetes｜Source: Getty Images Bank
Q I know that diabetes injections include ‘GLP-1RA’ in addition to insulin.
When blood sugar is not controlled with oral medications and injection is required, the use of GLP-1RA along with insulin may be considered. Glucagon-like peptide-1 (GLP-1) is secreted by L-cells in the intestine. It regulates blood sugar in our body by promoting insulin secretion by pancreatic beta cells and suppressing glucagon secretion by alpha cells.
GLP-1RA is an injection formulation made by making structural changes to GLP-1. In patients with type 2 diabetes, if the target blood sugar cannot be reached with the oral drug combination therapy, or if the postprandial blood sugar is high due to poor snack control, the use of GLP-1RA should be considered before insulin. It is known that, when using this injection, an average weight loss of 2 kg through diet control is effective.
Q Please explain in more detail when GLP-1RA treatment is required.
If you look at the diabetes treatment guidelines for 2021, when choosing an oral diabetes drug for a patient diagnosed with diabetes, it is recommended that the drug be selected according to the patient’s risk factors, that is, the underlying disease. If you have a history of atherosclerosis or cardiovascular disease such as myocardial infarction or stroke, or if you are at high risk of developing these diseases, it is recommended to use GLP-1RA injection first.
In addition, if the glycated hemoglobin is not controlled to less than 7.5% under the condition of improving lifestyle and using metformin as the first-line agent, GLP-1RA for patients who find it difficult to combine second-line drugs or use metformin as the first-line agent The use of is recommended first. In addition, if basal insulin needs to be added due to the failure of oral drug combination therapy, the use of GLP-1RA may be considered before insulin addition.
Q. Can I switch to oral medicine following using GLP-1RA?
If blood sugar control is good while using GLP-1RA, you can change to oral medication. However, if you have trouble controlling your appetite, or if you are taking oral medications, including high-dose sulfonylureas, while using GLP-1RA, you need to be careful as blood sugar may rise if you stop injecting.
Help = Director Yoon Hye-jin (Internal Medicine Specialist at Dunsan Endo Internal Medicine Clinic)