Choosing a First Injectable in Type 2 Diabetes: Try a GLP-1. February 15, 2019

Choosing a First Injectable in Type 2 Diabetes: Try a GLP-1
by Jay H. Shubrook, DO; Neil S. Skolnik, MD
Reallly, why take any injectable but not insulin? Is there some reason for that?

GLP-1s that used to be given as twice-a-day injectables and then daily injectables have now become available as once-weekly injectables, making the idea of injectable therapy a lot more tolerable for our patients.

       It is good to take one shot weekly rather then  four shots daily. Why do I take four shots daily? Because of my diabetes is so advanced that dose of insulin I have to take is very high, so I have to divide it for four portion, at least keep injections under 100 units. Now, when it is said that medication to treat diabetes must be taken once weekly, what does it mean? Simple, it is mean-less. In the Standards of Care for people with diabetes ADA suggest to provide individualized care, and now what? One dose - fit- all ? It is diabetes type 2. Dose of insulin is not only different for every diabetic type 2, but even for the same diabetic it is different day from day.

Shubrook: Absolutely. I know that when I tell my patients that there are injections that can help them lose weight, I see a big change in the acceptance of injections. Now that we can administer them less frequently, they are even more attractive to our patients.

      I think that Mr.  Shubrook has no one idea that diabetes type 2 never resulted by obesity. The matter of fact that 80% obese people have no diabetes. Less the 20% are obese and diabetics. Also when sugar got out from system diabetics start to lose weight. At the time of treatment many not only do not lose weight but gain it. So, what really do GLP-1 doing? Are they effective as anti-diabetic drugs? Not at all. They cannot be.

 Skolnik: That is one of the important reasons why GLP-1s, not insulin, are now recommended as the first injectable for our patients with type 2 diabetes who have not reached their A1c goals with two or three oral agents. This is not an unusual scenario.

       So, when diabetic takes two or three oral agents and did not reach A1c goal, what does it mean? Should diabetic add-on injectable GLP-1? Should diabetic drop all oral agents and take only GLP-1? We can speculate about effect of any anti-diabetic agents or injectables, but still, they are not effective. It is said right above, two or three oral agents taken by diabetic type 2 and still A1c is higher then goal. To add drama the goal is not as it is non-diabetics level of sugar, healthy level, but  recommended for diabetics as a goal by ADA.  Normal A1c =4.5% ADA recommend to have A1c=7%, and sometimes even 8% considered to be acceptable. Why? because of no one anti-diabetic medicine works the same as it is oral agent or any injectables.

When you think about it, in the old days—which right now in medicine is prior to 2 months ago—we used to always start with insulin. Patients were afraid of insulin because it could cause hypoglycemic episodes and it predictably caused a good bit of weight gain, about 5-10 pounds.

The matter of fact, in past when Insulin was first line treatment for diabetes patient took it and now they live with every day injections 60+ years after being diagnosed as insulin-dependent diabetics. In contrary, those who were diagnosed with diabetes type 2 and treated with oral agents departed withing less then 10 years after treatment started.  

Now we're able to offer a GLP-1 receptor agonist as the preferred agent for the first injectable.

Good question is, what good is this medicine for?  To speed trip to Funeral Home? Or to delivery more money into someone pocket? Who you serve, Mr.Skolnik, MD?

Shubrook: I want to fine-tune it a bit. Does that apply to everyone, regardless of the person's A1c? Is that everyone, regardless of the medical history? Who are the best people for a GLP-1 receptor agonist?

Very good question.

That's a great point. We always want to be careful about blanket statements. Since our time is limited, let's say that this applies to most people. Patients with a very high A1c, over 11%, who are symptomatic and losing weight may benefit from insulin as the first injectable. They may have an insulin deficiency, which will not be addressed by a GLP-1 alone. 

Now I lost. Just above it was said that

When the GLP-1 receptor agonists have been compared with insulin in head-to-head trials, they are as good or better than insulin at lowering the A1c and controlling glucose. For those three reasons—efficacy, decreased hypoglycemia, and weight loss instead of weight gain—the new guidelines clearly recommend GLP-1 receptor agonists as the preferred first injectable for patients who have not achieved adequate control on two or three oral agents.

and just next paragraph, insulin must be used and GLP-1 alone would not effective. Am I messed something? Insulin is effective without GLP-1. GLP-1 is not effective without insulin. So, how data were collected in head-to-head trails that GLP-1 is better then insulin? LOLOLOL. At least, read what you publish. Someone able to read what you said with opened mind, and do not let spaghetti hang on from nose.

Shubrook: What I'm hearing you say is that when considering a first injectable for someone on two or three oral meds who is not at goal, following the guidelines should lead to consideration of a GLP-1 as one of our first choices, for two reasons.
First, we're potentially going to get weight loss rather than weight gain. Second, we are going to have a lower risk for hypoglycemia with an equivalent, or sometimes more effective, lowering of the A1c.
Shubrook: Now we also have evidence that GLP-1s may actually reduce cardiovascular (CV) risk. We know that insulin doesn't necessarily raise CV risk but it certainly doesn't lower CV risk, so that's icing on the cake for people who have established CV disease.

It is good to have so nice effect:
no low sugar;
weight loss;
lower CV risk.
What about lowering blood sugar?  How blood sugar lowering with GLP-1? No one word about it. How to get from A1c=11% down to 4.5%? That's right. It is all about : "I told you so!" but nothing about main point, how to control blood sugar with GLP-1? Just nothing.

Shubrook: I also want to highlight, as we mentioned earlier, that if you have someone with a very high A1c who appears to be glucose toxic, insulin may be your better first choice. As you mentioned, insulin and a GLP-1 combination may provide even more benefits by reducing glucose toxicity in addition to some of the benefits of the GLP-1.

       Insulin by itself is difficult to dose. If there are GLP-1 which as it is presented  low blood sugar and GLP-1 which also low blood sugar, then what about side effects and medicine interaction? Of cause it is just rhetorical question. In hospital no one MD will treat diabetic with this combination therapy. Why at home patient has to use medicine which no one MD can use properly?
     At least, this medicine is not for me. No Combination Therapy!

via Ravenvoron