Duration of disease, life expectancy, co-morbidity should be considered before prescribing new drugs-Hamid Farooqi


 New Era in GLP1 Therapy

Duration of disease, life expectancy,
co-morbidity should be considered
before prescribing new drugs-Hamid Farooqi

Effective antidiabetic therapy should offer glycaemic control,
no weight gain, no hypoglycaemia, tolerability
and ease of administration

One can reduce complications by early initiation
of therapy in diabetics-Zaman Sheikh

KARACHI: Type 2 diabetes is a progressive disease. It starts much before it is diagnosed. Most often the people suffer from diabetes for almost five years before they are diagnosed. It is a multifactorial disease. People are reluctant to start insulin therapy for various reasons. This was stated by Dr. Hamid Farooqi a noted Diabetologist and Endocrinologist from UAE. He was making a presentation on a new era in GLP1 Therapy at the International Diabetes and Endocrinology conference held here from September 1-2, 2018.

Prof. Bilal Bin Younis and Dr. Samad Shera alongwith Prof.A.H.Amar chairing the session
while on extreme left is Dr. Musarrat Riaz who moderated this session.

He discussed in detail the evolving pathogenesis of Type 2 diabetes, physiology of incretin, actions of GLP1, gut incretin hormone which promotes satiety which then leads to reduction in appetite. People with T2DM have impaired GLP1 secretions. Studies have shown that many people with diabetes are uncontrolled for over six years before they are put on insulin therapy. Mostly 40% of T2DM patients are uncontrolled. We wish to avoid or reduce the complications of diabetes which include retinopathy, nephropathy, and peripheral neuropathy. Metformin is the first drug of choice but what next if the patients don’t achieve glycaemic control. Recommendations by the American Diabetic Association, Dr. Hamid Farooqi said says that start treatment with Metformin and life style modifications. If after three months, still they are not controlled, add another oral agent. Dual therapy including Metformin is recommended along with life style modifications and if still not controlled, one needs to add another agent. Once the patient fails to achieve glycaemic control after three months, one should take next step and add those drugs which are effective in atherosclerotic cardiovascular disease. Triple therapy with Insulin is then recommended. He further pointed out that no single agent will be effective in all the patients.

 He then discussed the safety and efficacy of GLP1 RA, SGLT2 and emphasized that one will have to individualize the treatment of diabetes. Duration of disease, life expectancy, and co-morbidity should be taken into account before prescribing a new drug. Dulaglutide offers once a week injection of insulin. It is important to motivate the patient. They are concerned about weight gain, have high HbA1c and they are reluctant to start insulin injections. Timing of starting the first insulin injection is important. There are several factors which affect the decision to start insulin therapy. An ideal agent should offer glycaemic control, no weight gain, should have no hypogylcaemic episodes, should be well tolerated and offer ease of administration. Head to head trial of Dulaglutide with Liraglutide has shown that HbA1c reduction is better with Dulaglutide which lowers fasting glucose within two weeks. Weight comes down but with insulin it goes up. Adverse effects noted with this agent include mild to moderate nausea. He suggested the physicians treating these patients to advise them to drink plenty of fluids and if need be use antacids. Dulaglutide, Dr. Hamid Farooqui said, has been designed keeping the patient in mind. The needle is not visible. It is a disposable pen, offers once a week dose, ready to use pen, offer better HbA1c reduction and also has less hypoglycemic episodes.

Sir Syed Institute of Diabetes and Endocrinology in collaboration with College of Family
Medicine organized an International Conference at Karachi from September 1-2, 2018.
Picture shows Prof. Abdul Basit Prof. Zaman
Sheikh (Chairman Organizing Committee),
Prof. Hamid Farooqui, Prof. Najmul Islam, Dr. Mesbah Sayed Kamel, Prof. A.H. Aamir,
Dr. Adrian Heald, Prof. Tasnim Ahsan, Prof. Jamal Raza, Prof. Shabeen Naz Masood,
Dr. Shehla Naseem and Dr. Farah Naz Farooq speaking on this occasion

Prof. Zaman Sheikh was the other speaker in this mini-symposium. His presentation was on Treating to Success: Changing face of Diabetes Mellitus. He highlighted the efficacy of DPP4 inhibitors. He pointed out that complications of diabetes start in pre-diabetes stage. He also talked about hyperglycemia induced complications which affect all organs of the body. UKPDS has shown that even 1% reduction in HbA1c results in reduction of lot of complications. Family physicians are usually reluctant to increase the dose with the result that damage occurs which leads to metabolic disorders. He suggested intensification of drug therapy and early treatment to reduce complications. HbA1c may not be well controlled with one drug. Both hypoglycaemia and hyperglycemia leads to tissue damage. He was of the view that one should not rely too much on HbA1c as there are hypo and hyper situations during the day. MAGE is a risk factor for peripheral neuropathy. Use those drugs which control the episodes of Hypo and Hyperglycemia. One should select those drugs which minimize the glycaemic variability. DPP4 inhibitors are quite safe and effective. They lead to significant reduction in variability of glycaemic control. DPP4 inhibitors have good effect in mild to moderate renal impairment and they are considered quite safe. After two years these DPP4 inhibitors reduce MAGE, he added.

Prof. Bikaram Vice Chancellor of Liaquat University of Medical and Health Sciences who was chairing the session in his concluding remarks said that many new developments are taking place in management of diabetes. Once a week insulin injection of Dulagltide now available is a much better option. Though at present it is a bit expensive but it is hoped that in the days to come its price will be reduced and many diabetics will be able to afford it.

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