American College of Physicians: Internal Medicine — Doctors for Adults ®

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New drugs should improve management of diabetes

From the May 1995 ACP Observer, copyright 1995 by the American College of Physicians.

By Bob Keaton

Do your diabetic patients forget to take their insulin 30 minutes before a meal? One of the four new drugs or drug classes for diabetics about to come on the market may make that requirement unnecessary, according to Arthur H. Rubenstein, MACP, professor and chairman of the department of medicine at the University of Chicago's Pritzker School of Medicine.

Patients will be able to take the novel insulin analogues at mealtime and still prevent the rise in blood glucose, Dr. Rubenstein said. Insulin now in use requires about 30 minutes to take effect. The new drug, produced by Eli Lilly, is under FDA review.

Other new drugs are metformin and thiazolidine-diones, which decrease the body's resistance to insulin; and glucagon-like peptide-I, which enhances the body's secretion of insulin and will initially be available only as an injectable.

Metformin has been available in Canada and Europe for about 15 years, and is expected to be on the U.S. market this spring. Investigational studies are under way on the thiazolidine-diones (ciglitazone, troglitazone and pioglitazone), which are available in Japan, but probably won't be available here for about a year.

Many advances have been made in diabetes management in the past decade, Dr. Rubenstein said during his Meet the Professor session on new strategies for treating diabetics.

He said physicians "shouldn't underestimate the wonderful advances" of home glucose measuring methods, which allow patients to monitor and adjust the control of their therapy, and the hemoglobin A 1C test, which complements blood sugar measures by reflecting the glucose level over a period of eight to 12 weeks.

These two approaches to blood glucose measurement underpinned the Diabetes Control and Complications Trial, Dr. Rubenstein said. Results of the trial, published in 1993, concluded that diabetic complications are dependent on the blood glucose levels in the years preceding the onset of complications. It proved that maintaining the blood glucose level as close as possible to normal can prevent or ameliorate future complications. "Generally speaking, the worse the control, the worse the complications," Dr. Rubenstein said.

Although that trial involved only Type I diabetic patients, there is no reason to believe that it is not applicable to the treatment of Type II patients, Dr. Rubenstein said. Nearly all of the studies on Type II patients support the results of this trial, although those studies have been criticized for various reasons.

"The goal in treating diabetes should always be to prevent the blood sugar from becoming elevated, rather than to treat it once it has already risen to high levels," Dr. Rubenstein reminded the audience.

Bob Keaton is an Atlanta-based freelance writer specializing in medical issues.

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