Challenges of Managing Diabetes in the Senior Citizen

We seem to be using too much Insulin!
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One of the common medical problems senior citizens suffer from is Type 2 diabetes mellitus (maturity onset diabetes). Roughly one third of the population after the age of 65 years of age are diabetics in the USA. Indian data is not lagging behind with Kerala having 35%, Puducherry 28 %, Goa 27% and Tamil Nadu 25.5%. The figures in NCR are around 22% and in Kashmir valley around 16.6%.

Although diabetes has been known to humanity for more than 3000 years and the name Diabetes(siphon) was given to it by Araetus of Cappodocia , a city now a part of Turkey. Mellitus (Honey sweet) was added to it by Thomas Willis in 1675.

It was only in 1889 that the central causative role of Pancreas was proven by Mering and Minkowski from Austria. This finally led to the isolation of insulin and its clinical use by Banting and Best in Toronto, Canada in 1923.

Thus began the pharmacological treatment of this dreaded disease which used to consume its sufferers by way of complications like ketosis, severe infections and associated problems like heart attacks, strokes, chronic kidney disease and blindness etc. 

Blood glucose cut offs for labelling diabetes:

Fasting Blood Sugar: Blood glucose after overnight fasting is less than 100 mgs/dl. A level of 100 to 125 mgs means Pre-Diabetes and levels more than 126 mgs/dl is the cut off for diagnosing diabetes mellitus.

Random Blood Sugar: Regardless of when you last ate, a level of 200 mg/dL) or higher suggests diabetes, especially if you also have signs and symptoms of diabetes, such as frequent urination and extreme thirst.

Glycosylated Haemoglobin (HbA1C); Less than 5.7% is normal. 5.7 to 6.4% is defined as Pre-Diabetes and more than 6.4% as diabetes. This parameter gives an idea of the last 3 months average sugar values.

 

Non-Insulin drugs reducing blood sugar:

Insulin with its several injectable preparations controlling the release was the only agent available till oral drugs acting by various mechanisms started becoming available in 1955. Rapid refinement of these agents has led to several groups of oral blood sugar reducing agents becoming available. At present Metformin is the most recommended one and can reduce the Hba1c by up to 2%. Other drugs include DPP4 inhibitors also called gliptins (Sitagliptin, vildagliptin, linagliptin, Tinagliptin etc.), the new generation Sulfonylureas (Glimipieride, gliclazide etc) are again very useful drugs if used appropriately.

 

Last decade has seen emergence of 2 very important group of agents:

SGLT2 (Sodium glucose Cotransporter-2) inhibitors primarily work by preventing resorption of sugar by the kidneys and thus excreting glucose through urine. There are several other benefits of these agents in diabetics, the most important one being prevention of heart failure seen so often in these patients especially with long standing disease. Two agents which are widely available are Empagliflozin and Dapagliflozin. These reduce HbA1c by around 1. Thus, a combination of maximum dose of metformin up to 2 grams and 10 mgs of one of these agents can bring down the Hb A1c to target levels of around 7% (average sugar around 154mgs%) from 9 to 9.5% (average sugar of around 230 to 250 mgs). SGLT2 inhibitors are useful in improving the outcomes like reducing heart attacks, heart failure, strokes and chronic kidney diseases. Insulin on the other hand does not prevent these vascular events and thus not improve the much needed cardio-vascular outcomes.

GLP1(Glucagon like peptide) analogues:

Although metformin also has some GLP1 properties the newer agents like liraglutide, dulaglutide and semaglutide have been the most studied and have several beneficial properties.

These are anti-inflammatory effects, improving lipid status, reducing HbA1c up to 1 to 1.5%, appetite suppression and causing significant weight loss. All are very useful effects in obese diabetics with previous heart attacks, strokes and adverse risk factors.

The limitation of these agents of being injectable drugs has recently been overcome by semaglutide being made available as an oral tablet which has been a research feat.

 

Is Insulin being overused in the valley?

My impression after having seen a large number of patients coming from all parts of the valley during the last several years is that insulin is being used far in excess than it should be.

No doubt for Type 1 diabetes where the pancreas produces very little or no insulin, it has to be given in all. However, Type 2 diabetes (maturity onset or adult-onset diabetes) in which there is no deficiency of insulin in fact often an excess of it, is not the agent of choice.

The problem is in the cells of muscle, fat and liver to utilise insulin effectively. This is best managed by giving the oral agents of various groups which include metformin, empagliflozin or dapagliflozin, DPP4 inhibitors (Linagliptin or teneligliptin) and new generation sulfonylureas (glimepiride, Gliclazide, glipizide etc.). With the introduction of oral  GLP1 analogue semaglutide the outcomes should improve further. Many of these agents improve cardiovascular outcomes which insulin does not do.

These combined with lifestyle changes (exercise, diet rich in fruits, vegetables and salads, weight management etc.) can manage a very large number of Type 2 diabetics. Insulin in smaller doses will still be needed to control in many groups of patients.

It should be remembered that insulin promotes weight gain and promotes inflammation, an important causative factor for vascular events like heart attacks. Unrestricted use of insulin can cause hyperinsulinemia and thus increases risk of obesity, cardiovascular diseases and can decrease health span and even life expectancy. It is however to be noted that insulin is always needed in acute problems like sepsis, postoperative states and acute illnesses like diabetic keto-acidosis. 

The major multinational companies producing insulin are; Eli Lilly, Novo Nordisk, and Sanofi. Their marketing strategies need to have more science into it and be balanced and toned down. They should promote insulin only for indications where it is meant for.

Chronic adult onset of diabetes especially overweight individuals are best managed without insulin with a plethora of agents. It is also the duty of the teachers in clinical medicine, endocrinology and cardiologists to propagate the modern treatment of diabetes. We have crossed several bridges in the management of diabetes since 1923 when insulin became available.

Prof U Kaul, Founder Director Gauri Kaul Foundation. Recipient of Padma Shri and DR B C Roy Award

DISCLAIMER: The views and opinions expressed in this article are the personal opinions of the author.

The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.

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