Five Treatments Turning the Tide on Diabetes

Individuals diagnosed with diabetes incur an average of $7,900 more in medical expenses annually, the American Diabetes Association (ADA) reports. Diabetes costs add up to a whopping $245 billion in direct medical costs and $69 billion in reduced productivity annually, according to an ADA study based on 2012 numbers. The largest components of medical expenditures are hospital inpatient care (43% of the total medical cost), prescription medications to treat the complications of diabetes (18%), antidiabetic agents and diabetes supplies (12%), physician office visits (9%), and nursing/residential facility stays (8%).

Given the large amount of people who have diabetes and the high costs associated with it, finding better ways to treat it are vital. Here are five new advances in disease management—including promising treatments in the pipeline.

Double-duty medications

Poorly controlled diabetes is associated with an increased risk of heart disease, says Roger Kulstad, MD, associate clinical professor of medicine, Division of Endocrinology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. A study published in British Medical Journal estimated that every 1% increase in HbA1c above 6% is associated with a 14% increase in risk of heart attack.

Two classes of diabetes medications (SGLT2 inhibitors and GLP-1 receptor antagonist) show cardiovascular benefits for patients with diabetes at high risk for heart disease. The hope is that the medications may also help prevent or delay cardiovascular disease, says Anders L. Carlson, MD, medical director, International Diabetes Center.

One SGLT-2 inhibitor, empagliflozin (Jardiance), for instance, makes patients excrete sugar, salt, and water, says Robert S. Busch, MD, director of clinical research, Albany Med: The Endocrine Group, Albany, New York. It has been shown to lower cardiac death by 38% and heart failure by 35%. A GLP-1 antagonist, liraglutide (Victoza), a daily GLP-1, has been shown to lower cardiac death by 22%.

Furthermore, several GLP-1 therapies that only need to be administered weekly with a simplified pen are now on the market. Another advantage is that they do not cause hypoglycemia (low blood glucose) when used alone or with other drugs that don’t cause hypoglycemia. “This is a big concern when using insulin or other standard pills for diabetes (e.g., sulfonylureas) which may cause hypoglycemia and weight gain,” Busch says. These drugs facilitate weight loss as well as lower blood sugar by a variety of mechanisms including increasing insulin from the pancreas only if sugar is high, decreasing appetite, and delaying stomach emptying.

More effective insulin

Insulin therapies, another type of diabetes treatment, are undergoing an era of rapid change. New forms of insulin can now be two to five times as concentrated as conventional insulin. “This allows for higher doses to be used in patients who require them or those who want fewer injections,” Carlson says.

New combinations of injectable forms of insulin with another non-insulin hormone are now available. “These drugs have the potential to reduce the number of injections patients need every day,” he says.

Newer insulins under development can also act faster to lower blood glucose and may even be taken after a meal. “The new options aim to more closely mimic the body’s natural insulin response, which helps to prevent complications of wide swings in blood glucose levels,” says Carlson.

Busch says some concentrated insulins have a smoother, or “peakless,” mechanism of action. “Because of this, they are less likely to cause hypoglycemia than traditional basal insulins,” he says. “Hypoglycemia is one of the biggest obstacles in treating patients with diabetes because of the risks of fainting and negative effects on the heart. A higher concentrated form of insulin, glargine (Toujeo), was FDA approved in March 2017 and is more effective than standard basal insulin, Lantus, he says. A higher concentrated form of insulin from Novo Nordisk, degludec (Tresiba), was redesigned to last longer, keep glucose levels more stable, and prevent hypoglycemia from occurring.

Promising cell-based therapies

On another front, researchers are starting to conduct testing in humans for stem cells that act as pancreas cells. “They are put into ‘capsules,’ placed in the body, and start to secrete insulin,” says Susan Renda, DNP, assistant professor, Johns Hopkins School of Nursing, Baltimore. “Although much more studying needs to be done, it could be a promising treatment for type 1 diabetes.”

More effective glucose monitors

Glucose monitoring devices continue to evolve. Abbott’s FreeStyle Libre is now available in the United States for personal use. This device, which has a factory-calibrated glucose sensor, can be worn up to 10 days and provides nearly real-time blood glucose levels right to the patient. Because it is factory calibrated, no routine fingerstick blood glucose tests are required—unlike most other glucose monitoring devices. “This is a major advantage to many patients who do not like to stick their fingers, and has been a goal among the diabetes community for decades,” Carlson says. “Glucose monitoring devices will continue to get smaller, more accurate, and more integrated into smart devices.”

Glucose sensors, a type of glucose monitoring device, can provide vital information to patients about their glucose levels, Kulstad says. A small electrode goes under the skin and measures glucose levels in skin tissue. A computer calculates estimated serum glucose.

The sensor can notify patients if their glucose levels are dropping rapidly or if their glucose levels decline while sleeping, Kulstad says. A glucose sensor can also alert patients that their glucose is rising too rapidly and the patient can administer extra insulin before it gets too high.

The most recent sensors are much more precise and require less frequent recalibration. In 2016, the FDA expanded the indication for continuous glucose monitoring systems. Kulstad says it’s safe for patients to use sensor data to make diabetes treatment decisions without the need for a confirmatory fingerstick glucose as long as certain precautions are taken, such as training patients on how to use the device and understand its limitations. Sensors also require less-frequent recalibration, with some devices requiring a fingerstick recalibration only twice a day.

Release of the artificial pancreas

Medtronic released its MiniMed 670G automated insulin delivery pump in 2017, a major step toward a fully automated insulin delivery system (also known as the artificial pancreas), for type 1 diabetes patients. “This is the first commercially available device to use continuous glucose monitoring information to adjust insulin doses,” Carlson says. “Using an algorithm inside the insulin pump, the system adjusts insulin doses up or down accordingly to target a healthy glucose level.”

Data show improved average diabetes control, more time spent in a more ideal blood glucose range, and fewer blood glucose readings in the low range. “This is important because both high and low glucoses are associated with significant complications and costs,” Carlson says. Hypoglycemia hospital admissions from the emergency department, for instance, cost an average of $1.2 billion per year, so any technology that prevents levels from going too low is a major advancement.

Carlson says the next step would be to create a fully “closed loop” device, rather than a “hybrid closed loop” device, that is smart enough to give a quick burst of insulin when the patient eats without having to tell the device that they are going to eat something. Currently, patients must enter their blood glucose and amount of carbohydrates they estimate are in a meal. Then, based on programed settings, the pump delivers an appropriate burst of insulin. To close the loop, the device would need to be able to handle that rapid increase in blood glucose following a meal or snack. Several groups are working on this, and newer systems may involve other hormones in addition to insulin being placed in the insulin pump.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.