On this episode of Kentucky Health, host Dr. Wayne Tuckson welcomes endocrinologist Dr. Vasdev Lohano from Baptist Health Floyd to discuss advances in treating diabetes, including devices to deliver insulin into the bloodstream and new drugs for patients.
The Many Ways Diabetes Affects Health
At its core, diabetes is a disease where glucose (sugar) levels become elevated in the bloodstream, Dr. Lohano says. While glucose is essential to provide energy to human cells, excess levels lead to a myriad of serious health problems.
“Diabetes is divided essentially into two types: Type 1 and Type 2,” Lohano says. Type 1 is far less common and usually starts in childhood. It is a lifelong condition caused by an autoimmune disorder that halts the body’s natural production of the blood sugar-regulating hormone insulin. Patients with Type 1 diabetes require constant supplements of insulin.
Type 2 diabetes affects about 93 percent of people diagnosed with the disease, Lohano says. This chronic condition develops later in life and can in most cases be prevented by eating a healthy diet and getting regular exercise. Type 2 diabetes may also require insulin injections, but other drugs have been developed to treat it.
Type 2 diabetes is “an underlying disorder of insulin resistance,” Lohano says. Complications occur throughout the body but mainly affect cardiovascular function. Persons with diabetes have higher risks of coronary artery disease, stroke, peripheral artery disease, heart failure, and other maladies.
Symptoms of Type 2 diabetes usually present over time, explains Lohano, and include fatigue, increased urination, increased thirst, and weight loss. As the condition worsens, some people may have vision loss, and any wounds they receive may take longer to heal.
“A long-term complication of uncontrolled diabetes is kidney disease,” he adds. “Chronic kidney disease can obviously lead to kidney failure, dialysis, and transplant.” Advanced diabetes can also cause diabetic retinopathy, which damages the retinas in the eyes, and neuropathy in the lower extremities.
“If (neuropathy) combines with peripheral vascular disease that becomes problematic, because then healing becomes an issue and if you develop an ulcer and don’t heal, you may need amputation,” Lohano says.
Some people have a genetic predisposition for Type 2 diabetes, and other factors come from lifestyle habits or having a cholesterol imbalance, Lohano says. Persons who have a family history of Type 2 diabetes, follow a high-calorie diet, and are sedentary have the highest risk of eventually getting the disease.
“Your lifestyle you can control – you obviously can’t control your genes,” Lohano says. “The basic thing is, live a healthy life. Now, that’s easier said than done. Your diet is foremost important. What goes in is very important, you need to pay attention to your carb(ohydrate) intake, but I would focus on starch intake rather than carb intake because fruits and vegetables have carbs, but those are good carbs.”
In addition to limiting starchy foods, Lohano says to monitor fat intake and to refrain from drinking sugary beverages.
“You need to figure out a diet that is healthy for you… and the second piece is regular, structured activity,” he advises. “You’ve got to have 15 to 20 minutes of structured physical activity, and that could be a simple as brisk walking.”
At Baptist Health Floyd in southern Indiana, patients with diabetes are treated by a team of medical workers. Diabetes specialists, dieticians, and pharmacists make up the core group, and Lohano says other specialists contribute to each patient’s care depending on his or her specific complications.
Innovative Drugs and Products Help Patients Manage Diabetes Better Than Ever Before
People with diabetes are advised to monitor the amount of glucose in their bloodstream. For decades this was done by pricking the tip of one finger and measuring the blood sample with a test strip. The late 1990s and early 2000s saw the introduction of continuous glucose monitors that measure glucose without having to draw blood via the finger-prick technique.
Continuous glucose monitors “are phenomenal,” Lohano says. “In my opinion, everybody should be using them that has diabetes.”
CGMs are small wireless sensors that attach to the back of the arm or on the abdomen. “It has a small catheter that goes in your tissue, and you can use a smartphone to basically move over (the sensor) and it will tell you what your blood sugar is,” he explains.
Lohano says insurance coverage for CGMs is expanding. For those who lack coverage, the cost of the sensors is around $100 per month.
Insulin replacement has been the standard of care for diabetes patients for decades, but that is changing according to Lohano. “(Insulin) essentially helps cells uptake glucose; glucose is obviously in the bloodstream but it has to go to the cells for it to function and add energy. Insulin is the hormone that will make that happen,” he says.
Lohano says that in addition to its role in cellular uptake, insulin helps the body store excess glucose in the liver and also prevents glucose that may be produced in the liver or the kidneys from entering the rest of the body when it is not needed.
Patients diagnosed with Type 2 diabetes are not necessarily offered insulin as first-line treatment, Lohano says. Most of them are advised to make the permanent lifestyle changes described above to manage their diabetes. “The recommendations are to use agents that not only have glucose-lowering capability but have some additional benefits,” he explains. These added benefits include helping with weight loss and both heart and kidney function.
These drugs are called SGLT2 (sodium-glucose contransporter-2) inhibitors and cause the kidneys to remove excess glucose through urine. The most widely used one is Jardiance, Lohano says. Another class of drugs, GLP-1 (glucagon receptor peptide-1) agonists, mimic a specific hormone that increases insulin production when blood glucose rises. These drugs are taken by injection and include Ozempic and Trulicity.
“We’re trying to use (these drugs) as much as we can, because as we know that as a Type 2 diabetic, you are at a high risk for heart disease,” Lohano says. “It’s not the sugar, it’s the heart that is going to be a problem at the end of the day. So if you can protect your heart and minimize interventions there, then you can have a good quality of life and a quantity of life.”
For patients that require insulin supplements, Lohano says the goal is to mimic how the body normally produces the hormone. He explains that the pancreas secretes a basal level of insulin that circulates through the body constantly as well as boosts insulin levels when a person eats. Those with diabetes may take a long-acting insulin supplement once a day, and then take short-acting insulin during meals. “It allows the patient to control their life,” Lohano says.
Most patients take insulin in pre-filled pens, Lohano says. “These are disposable pens and are very easy to use, and they are loaded with about 300 units, most of them… and pen needles come, which you can screw on top of the pen, and you basically draw the dose, and give it (to yourself).”
One of the most exciting innovations happening now, according to Lohano, is the introduction of insulin pumps that are synchronized with GCMs. These pumps are connected to the CGMs and can be programmed to release insulin into the body via the catheter when a CGM reading requires it.
At this point, only the basal insulin rate can be automatically adjusted. “We are at kind of a partial hybrid, but the goal is to go to a complete loop,” Lohano says. “We’re not there yet, there are companies working on it.”