What type of diabetes medications are available today?
Dr. Larry Ellingson: I think the good news that's happened over the last several years are many, many more choices for patients today with their medications and diet and nutrition and so forth. The Sulfonylureas where one class of drugs that came out in the late 50's and early 60's, and these drugs are very efficient at stimulating the pancreas to produce more insulin so that you can utilize a sugar that you are eating in your meals.
Over time they tend to wear the pancreas out sometimes and newer drugs such as the Biguanides or Metformin have come out and they work on the liver. So each of these oral drugs work on different parts of the body and the system, one on the pancreas, Sulfonylureas. Metformin works on the liver to suppress glucose output.
The new class of drug called Thiazolidinediones or TZDs work on muscle sensitivity or increasing sensitivity to the utilization of glucose. So, the good news about all that is that you've got different therapeutic approaches, and often times, doctors can use one, two, or sometimes three, combination of all those drugs to help reduce the blood sugar in people, and if necessary, move on to a combination of an oral plus insulin. So, many more choices today than we ever had before.
Richard Rubin: Most people with Type II diabetes now are on more than oral medication. I think the average is something like two of those medications.
Dr. Larry Ellingson: There are different types of insulin. If you go back 100 years, almost 80 years now, I guess, 1922 when it was discovered by Banting and Best at the University of Toronto, it was one type of insulin what we call today Regular Insulin, that was all that was available.
People took four-five shots a day, usually around meal time to suppress the glucose from the food you are eating. About 15 or 20 years after that, they modified the insulins with protamine to extend the time action and you produced NPH insulin, which is a little longer, lasts 8-12 hours.
In recent years, the last decade or so, they have introduced, what we would call Designer Molecules or Insulin Analogs, which really act -- really short acting insulin, sort of mimics what your body produces. When you eat something, your body spikes blood sugar, because of the food you've been taking.
As a result of that, your pancreas squirts out some insulin to suppress that glucose. The new insulin, short acting analogs actually work much like your body does, very quickly, 15-30 minutes reach a peak, drive the sugars down, which is very good, which allows some patients to actually eat, and then dose their insulin, much more flexible.
The old insulins, you had to give 30-45 minutes ahead of time, wait till they peak, hope the food came so the blood sugar in the peak of insulin match the same time. And then there are some new longer acting insulins, basal insulins we call them. Your body actually produces about a-half to one unit of insulin per hour round the clock to maintain a body -- a level to suppress your glucose, as your brain needs the sugar for energy and for working.
That basal level, the old insulins, animal insulins and sometimes NPH or Ultralente were used had a slight peak, so people would take one shot, and during the night, because of the peak, their sugars would drop low, and sometimes they'd wake up sweating and it was very uncomfortable.
The new basal insulins get to a flat peak, there is no real peak, they stay leveled all the time. So they work much like an insulin pump where it's delivering like your pancreas does, a certain amount of insulin each hour flat. Then when you eat, you program your pump to spike or you give a short acting insulin to suppress your glucose.
So those designer insulins have added tremendous flexibility, I think, for the patients' regimen and as we're dealing with behavior and adjusting lifestyle, they've afforded, I think, the patients a lot of flexibility, both on the oral side and the insulin side.
Are there devices to better help manage their disease?
Dr. Larry Ellingson: You wouldn't have to look very far back, but 25 years ago is about when we started with blood glucose monitoring and monitoring equipment. The only way to get insulin in the body was an injection. All of these technologies that have evolved have allowed them to be more user-friendly.
If you just take a look at the monitoring side of it today, where you have to prick your finger to get some blood samples. Today, there are many different types of devices and lancets that you don't have to only go to your finger, you can go to your arm, your abdomen to other sources of blood, to measure your blood sugar, which gives the patent a lot of flexibility.
Richard Rubin: When we're talking about improved devices, we're talking about insulin delivery systems. Since pills, you just take by your mouth and that's always been the way, and probably always will be the way. Insulin now is delivered not just through a syringe, where you draw up the -- use the syringe to draw up insulin from the vial, there are also devices called insulin pens, which basically store the insulin and to make this administration easier, you don't have to draw up the insulin.
And insulin pumps, which are these little devices, they look like pagers these days, that deliver the insulin electronically when you push buttons to say how much insulin to take. That gives you insulin little drip through the day that corresponds to the long acting insulin that someone might take by injection or using a pen.
And also, you can probe them to give you little bits of insulin when you eat food, and that's corresponding to the fast acting insulin that people take by injection or by using the pen.
Dr. Larry Ellingson: The insulin that's delivered today can come in a pre-filled syringe. They can come in a reusable syringe. They can come in an insulin pump.
Richard Rubin: Pumps are now being used not only by people who have Type I diabetes, but by people who have Type II diabetes as well. In fact, one of my colleagues, Chris Saudek at Hopkins did a study several years ago, in which he showed the efficacy of pump therapy for people with Type II diabetes in a veterans administration study.
So there are more-and-more people using pumps who have Type II diabetes. In fact, I was on a plane recently talking to the person who was sitting next to me, and he said that his mom had finally talked to the doctor into putting her own pump. It had taken her six years to do this, but finally at the age of 76 she gotten the doctor to agree to put her on the pump and her control was fantastic and she was doing great. So pumps are not just for people with Type I or for young people.
Dr. Larry Ellingson: Tomorrow, we are looking at inhaled possibilities for pulmonary or buccal delivery of these medications. So the patient gets a lot of flexibility, depending on his or her needs for treatment. So, I think, there are some very encouraging signs, both on the oral side, with new medications and combinations with the delivery devices that are being used for insulin, with the monitoring devices that are out there today.
Richard Rubin: As recently as probably seven years ago, there were no more than 10,000 people or so in the United States using insulin pumps. Now the numbers up there are over 200,000 or 300,000 and growing everyday. It's become a much, much more popular device. Though interestingly, almost exclusively in this country.
Dr. Larry Ellingson: Who knows in the future we may see technology that's noninvasive so that you don't have to have a needle or a device injected into, you might be able to measure it through the skin, infrared technology or something like that.
Transcription by:
Scribe4you Transcription Services