New drug classes have a variety of benefits

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GLP-1 agonists and SGLT-2 inhibitors

May be a game-changer for diabetics

By Robin Williams Adams

Your Health Correspondent

More than 50 brands of drugs, including different types of insulin, are on the market for the treatment of diabetes.

Waves of research have brought different classes of drugs to the fore over the years, even as the long-available metformin remains dominant as a first-line treatment for type 2 diabetes.

Their growing number shows the wide, some might say overwhelming, range of treatment options available to patients if they can afford them or have insurance to cover them.

Newer classes of drugs – GLP-1 agonists and SGLT-2 inhibitors – are the ones that are receiving increased attention, research and study.

Some consider these new drugs a game-changer because of research showing benefits beyond blood sugar control in diabetic patients taking specific drugs.

“They were a game changer,” letting some type 2 diabetics go off insulin, said Watson Clinic endocrinologist Dr. Vindya Boelke.

Dr. Jessica Castellanos

“There are many good drugs out there,” said Bond Clinic endocrinologist Dr. Jessica Castellanos, agreeing that GLP-1 agonists and SGLT-2 inhibitors are a game-changer.

“(But) they are very expensive and some patients cannot afford them.

This scenario has occurred alongside an ongoing concern about the affordability of insulin, which type 1 diabetics routinely need.

Like some type 2 diabetics.

With type 1 diabetes, the body cannot make insulin. With type 2, the body does not produce enough insulin or cannot process it properly.

As a result, people develop high blood sugar which puts their health at risk.

Competition is fierce among diabetes drug makers looking to fill these gaps. As a current example, viewers may recognize the names Ozempic and Trulicity from frequent commercials.

Ozempic, approved in 2017 for diabetes and taken as a weekly injection, and Rybelus, approved in 2019 and taken daily as a pill, are brand names of the same drug, semaglutide.

They fall into the camp of GLP-1 agonists. As do Trulicity (dulaglutide) and other drugs with tide at the end of their unbranded names.

GLP-1 agonists is an acronym for glucagon-like peptide 1 agonists.

They stimulate the body to produce more insulin. The extra insulin helps lower blood sugar levels.

They also help control appetite and slow the release of food from the stomach.

GLP-1 agonists have shown benefits in weight loss as well as blood sugar control. Research has found that some drugs in this category can reduce the risk of serious cardiovascular problems for type 2 diabetics with heart disease.

Trulicity gained Food and Drug Administration approval in 2020 to reduce cardiovascular events. Ozempic gained approval in 2020 for cardiovascular risk reduction in adults with type 2 diabetes and known heart disease.

“The only reasons I wouldn’t use GLP-1 receptor agonists are if (patients) tried and had side effects or because of cost,” Boelke said.

SGLT-2 inhibitors allow patients to quickly get rid of sugar in the urine. They reduced the weight of some patients with type 2 diabetes.

Several studies have also indicated they’re associated with a reduced risk of major cardiovascular events like heart failure, according to a meta-analysis from the Journal of the American Medical Association’s Cardiology Magazine.

SGLT-1 stands for sodium-glucose cotransporter 2.

Patients may know them by brand names like Farxiga (dapagliflozin), Invokana (canagliflozin), and Jardiance (empagliflozin).

With insulin and other medications, determining which medication to prescribe depends on each patient’s individual medical profiles, such as other medications they are taking, other medical conditions, and what they are willing to do matters of exercise and lifestyle change.

Cost is another important factor, one physician interviewed acknowledges but dislikes.

Dr Erjola Balliu

“He’s trying to figure it out with insurance — there are so many brands now — that they will cover,” said Dr. Erjola Balliu, an endocrinologist at Lakeland Regional Health.

GLP-1 agonists are usually given as weekly injections. Rybelus, taken as a daily pill, offered a new choice.

Having more oral options available for treating diabetes has helped tremendously, said Dr. Cara Nelson-James, medical director of Central Florida Health Care.

“A lot of our patients are against injectables,” she said.

“Having another medication to offer those who are on a maximum dose of metformin and a sulfonylurea (medication) is helpful while we gently guide them into the idea that they need insulin.”

Rybelsus does have some additional requirements, however, such as taking it every morning on an empty stomach and waiting 30 minutes before taking any other medication or food, said Gloria Willey, a certified diabetes care and education specialist at Watson Clinic.

Despite these promising findings for new drugs, metformin remains the first-line treatment for most diabetics, local doctors said.

Several combination medications contain metformin among their ingredients.

It is affordable and has a long track record. But, over time, it can become less effective, especially for type 2 diabetics.

The passage of the Cut Inflation Act last month brought renewed attention to the difficulties many patients face in obtaining insulin.

Physicians surveyed said they were happy with the upcoming monthly cap on the cost of insulin for Medicare patients, but were disappointed with the removal of provisions that would have capped its cost under commercial plans.

“Insured patients often have high deductibles that they must meet before coverage begins,” Nelson-James said.

Boelke said 80% of his patients report difficulty getting insulin and other medications.

Most insurance plans cover at least one GLP-1 drug and one SGLT-2 drug, Willey said.

Patients may reach the “doughnut hole” of Medicare coverage faster than they think, Balliu said.

For some, the cost becomes so prohibitive that doctors have to modify their treatment.

Food insecurity is an often overlooked area – linked to low income and high drug costs – that can cause major problems for people with diabetes.

They begin to eat more and more pasta and other carbohydrates, which are cheaper but detrimental to their health when consumed in excess.

“Not being able to afford healthy meals is a big problem for diabetic patients,” Castellanos said. “I always ask the patient, ‘What vegetables do you eat?’

Contact Robin Williams Adams at robinwad[email protected]


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