November 28, 2006
LADA and MODY, Pills for Diabetes
Question from Raleigh, North Carolina, USA:
Is it unusual for a person with type 1.5 or LADA diabetes to be able to achieve control through diet and exercise for over five and a half years? My initial A1c was 9.9 with a blood sugar of 297 mg/dl [16.5 mmol/L] in 2001, over five years ago. My latest A1c was 6.7. Previous ones, over the last two years, have been 6.1, 6.3, and 6.5 so the control is slipping, though I have relaxed in my eating and exercising habits more than I should have. My fasting blood sugars now usually range from 120 mg/dl [6.7 mmol/L] to 150 mg/d. [8.3 mmol/L], although before dinner and after exercising, I will be anywhere from 70 mg/dl [3.9 mmol/L] to 100 mg/dl [5.6 mmol/L]. I am due to go back for a follow-up in December and feel I will probably need to add some type of medication to my regimen to try and get my A1c back under 6.5 and preferably under 6.
I have read many places that most patients with LADA should be started on insulin therapy, but there is no real proof that this really rests or protects the beta cells. There is obvious great expense, difficulty, and risk of hypoglycemia with the initiation of insulin therapy, though I don’t know if I would be started with just Lantus or just NovoLog with meals.
I have also read differing opinions that Actos may be appropriate as well due to its apparent anti-inflammatory properties and potential protection of the remaining beta cells. Will the newer drugs such as Januvia be appropriate or helpful for patient with LADA who is still producing significant amounts of insulin? Would metformin or acarbose be appropriate?
Have there been any recent studies that have proven the best treatment for LADA patients? I read of one that was comparing Actos with a glyburide and adding metformin or acarbose if the initial glycemic goal of an A1c under 7.0 was achieved. The study is being done by University of Washington Seattle Institute for Biomedical and Clinical Research and GlaxoSmithKline entitled “Preferred Treatment of Type 1.5 Diabetes.” This study did not mention the use of insulin and I don’t know if any results have been published.
Answer:
It sounds as if you are a well informed person about this form of diabetes. I agree with you that there is definitive information regarding the best way to treat LADA. It is really the A1c that guides care for these patients at present. It is also true that insulin may have some hypothetical benefit by resting the beta cells and making them less subject to immune system destruction. It is also true that work done in patients with type 2 diabetes suggest that drugs like Actos and Avandia have suggested beta cell preservation. Actos and metformin both have the ability to improve insulin sensitivity. This makes hypoglycemia less likely. Metformin was also used in the diabetes prevention study in the U.S. Although this is not diabetes prevention, it is preservation of function. I think a trial to look at the best form of therapy is a great idea. Sulfonylurea therapy or insulin in this setting is more problematic because of the risk of hypoglycemia. Without medications, you clearly are still able to make insulin. In conjunction with your doctor, you may want to give more consideration to a trial of metformin or a TZD (Actos or Avandia) as a means of normalizing the A1c. Metformin may be easier to use, less weight gain, cheaper, and without hypoglycemia, compared to the TZDs.
JTL
