Medications Beyond Insulin
Insulin has to be used by every patient with type 1 diabetes for their management. However, is there any other medication which can be used to help to safely improve sugar control?
At this moment, only a synthetic analog of hormone amylin (pramlintide, trade name Symlin) is approved in patients with type 1 diabetes. That needs to be injected before each meal alongside insulin. This hormone is made by the same cells in the pancreas as insulin so it’s missing in patients with type 1 diabetes who no longer produce their own insulin.
There has been great interest in using two classes of anti-diabetic medications approved only for those with type 2 diabetes: GLP-1 receptor agonists and SGLT2 inhibitors. Why is that? Both of these classes might offer advantages for all people with diabetes such as better post-meal control, weight loss, decrease in blood pressure and possibly reduction of some of the heart and and kidney complications shown by studies in patients with type 2 diabetes.
What are those medications and what do they do?
First, the injectable GLP-1 (aka glucagon-like peptide 1) receptor agonists provide boost to the body’s deficient “incretin” effect. Incretins are hormones we normally make in response to food and GLP-1 is the main one. Its effect is diminished in those with type 2 diabetes. These medications are injected once or twice daily or once weekly (trade names Byetta, Adlyxin, Victoza, Trulicity, Bydureon, Ozempic and the no-longer marketed Tanzeum) and do several things: they tell the pancreas to make more insulin and reduce the amount of glucagon, the brain to feel full and stop eating, and the stomach to slow down food absorption. These effects together improve sugar control and lead in many patients to weight loss and drop in blood pressure. Importantly, unlike insulin, they do not cause hypoglycemia since they work only when the blood sugar is high. Their use in T1D is off label. Persons with T1D would not be able to increase insulin levels but their use might make sense if their effect on glucagon level reduction and weight loss is preserved.
SGLT2 inhibitors, in contrast, are pills, taken once in the morning, which tell the kidneys to get rid of extra blood sugar and thus can improve diabetes control. Since that extra sugar lost in the urine represents calories, weight goes down in most patients. This effect on one’s kidney is independent of insulin presence and so they could be used in all patients with diabetes. However, they are currently only approved in T2D and used in T1D off label. Several studies in T1D have been finished showing some benefits even in those patients and thus there is an ongoing effort to convince regulatory agencies to approve them for T1D, too. In addition, there is another drug, a dual SGLT1 and SGL2 inhibitor (sotagliflozin, brand name Zynquista), which also works in the gut, which is being currently considered for approval by the FDA for T1D.
reviewed by George Grunberger, MD