Study Eases Concern That Common Diabetes Med Might Harm Bones

THURSDAY, Jan. 3, 2019 (HealthDay News) — If you have type 2 diabetes and you’re taking canagliflozin to help control your blood sugar, a new study has some good news for you: The drug doesn’t appear to raise the risk of bone fractures.

Previously, research had suggested this might be the case.

“We were interested in doing this study because there was one randomized trial that said there was an increased risk of bone fractures and another that said there wasn’t. So, we conducted a real-world study with almost 200,000 people with type 2 diabetes,” said study author Dr. Michael Fralick.

“I hope these findings are reassuring to patients and physicians because these are blockbuster medications for type 2 diabetes. This class of medicines can improve blood sugar levels and help reduce heart disease risk,” he said. Fralick is from the division of pharmacoepidemiology and pharmacoeconomics at Brigham and Women’s Hospital in Boston, and a general internist at the University of Toronto.

Canagliflozin (Invokana, Invokamet) is one drug in a class of medications called SGLT-2 inhibitors. Other drugs in this class include dapagliflozin (Farxiga) and empagliflozin (Jardiance).

These drugs cause the kidneys to remove excess sugar from the blood and excrete it through urine, which lowers blood sugar levels, according to the U.S. Food and Drug Administration. This class of drugs has been linked to a number of complications, including kidney injury and serious genital infections.

Fralick said one way these drugs could potentially increase fracture risk is by lowering bone mineral density.

Dr. William Leslie, author of an editorial accompanying the study, suggested that dehydration may be another way these drugs might be linked to fracture risk. Leslie is a professor of medicine and radiology at the University of Manitoba in Canada.

For the new report, Fralick and his team reviewed data from two U.S. commercial health care databases. They found information on about 200,000 people with type 2 diabetes who were just starting to take one of two different type 2 diabetes medications — canagliflozin or a medication in a class of drugs called GLP-1 agonists, which includes Victoza, Trulicity and Byetta. These drugs haven’t been linked to an increased risk of fractures.

The researchers looked for fractures in the upper and lower arms, as well as the hips and pelvis.

In the end, the study team compared approximately 80,000 people on canagliflozin to about 80,000 treated with GLP-1 agonists. The patients’ average age was 55, and about 48 percent were female.

The study showed a similar risk of fractures in these low-risk, middle-aged populations.

Both Fralick and Leslie said the jury is still out for people who are at a higher risk of fractures, such as elderly people.

This study is “a relatively low-risk population. But, it begs the question, what about higher-risk populations? We need additional safety data,” Leslie said.

The U.S. Food and Drug Administration currently requires canagliflozin labels to carry a warning about the potential fracture risk, and Fralick said it may be too soon to change the labeling, particularly for people at high risk. Both experts said more research is needed.

In the meantime, if you’re concerned about taking canagliflozin, Fralick recommended having a conversation with your health care provider. But, he added, “For people without a high baseline risk, the risk of fracture is very small and the clear benefits to SGLT-2s outweigh that potential risk.”

The findings were published online Jan. 1 in the Annals of Internal Medicine.

More information

Learn more about oral diabetes medications from the American Diabetes Association.

Some Diabetes Drugs Linked to Higher Heart Risks

FRIDAY, Dec. 21, 2018 (HealthDay News) — Two common classes of type 2 diabetes drugs may lower blood sugar levels, but new research suggests those same drugs might boost the risk of heart attack, stroke and heart failure.

The drug classes in question are sulfonylureas and basal insulin. Sulfonylureas cause the body to release more insulin. They’re taken orally and have been used since the 1950s. Basal insulin is given as an injection, and it’s engineered to be released slowly throughout the day.

Meanwhile, the study found that newer — and typically more expensive — drugs appear to lower the risk of heart disease and stroke.

Study author Dr. Matthew O’Brien said the new findings call for a “paradigm shift in how we’re treating diabetes.”

Currently, people with type 2 diabetes are given metformin, and if they need a second treatment, they’re often given sulfonylureas or basal insulin. But these findings call that practice into question.

“People who started taking sulfonylureas and basal insulin have a much higher incidence of cardiovascular disease. So, if all the new drugs lower cardiovascular disease risk, that’s where we should go first to treat type 2 diabetes,” O’Brien explained. He is an assistant professor of general internal medicine, geriatrics and preventive medicine at Northwestern University Feinberg School of Medicine in Chicago.

But that doesn’t seem to be what’s happening in practice. Endocrinologist Dr. Joel Zonszein, director of the Clinical Diabetes Center at Montefiore Medical Center in New York City, said that only 10 percent to 15 percent of patients are being treated with the newer diabetes medications.

“Most patients are getting medications that are less effective and may be causing cardiovascular problems,” Zonszein said.

There are about a dozen different classes of diabetes medications, according to information from the American Diabetes Association (ADA). O’Brien and his colleagues began the study because there isn’t a strong consensus on which of these many drugs to use if the standard first-line treatment doesn’t work.

“When we diagnose people with type 2 diabetes, we give them metformin because that’s what the expert groups all recommend. But if metformin is no longer effective or a patient has gastrointestinal intolerance, it’s kind of a dealer’s choice for what to treat with next. No one knows which is best. We wanted to get some clarity on what the next best medication is,” O’Brien said.

The study looked at more than 130,000 insured adults with type 2 diabetes who were starting therapy with a second-line anti-diabetes medication. The information came from U.S. insurance claims data from 2011 to 2015.

The study participants were aged 45 to 64, and the average follow-up time was 1.3 years.

Treatment with the medication classes known as DPP-4 inhibitors (Januvia, Tradjenta, Onglyza), SGLT-2 inhibitors (Invokana, Farxiga, Jardiance) and GLP-1 agonists (Byetta, Trulicity, Victoza) were all associated with approximately a 20 percent reduction in the risk of complications, such as heart disease and stroke.

Sulfonylureas were associated with 36 percent higher odds of complications, while basal insulin was associated with nearly twice the risk of heart disease and stroke complications, the investigators found.

O’Brien said because the study is observational, it cannot prove whether it’s the medications or an issue with the people taking them that causes the increased cardiovascular risk. He said that people taking insulin tended to be sicker, which may have influenced those findings. However, the researchers controlled the data to account for a number of factors, such as age, blood sugar control and other illnesses.

O’Brien thinks there should be a change in practice now. “I think we have enough evidence from our study and others that sulfonylureas and basal insulin should no longer be the default for a second choice,” he said.

Zonszein agreed, and noting the benefits of newer medications, he suggested that they should be used sooner rather than later.

“I think the newer diabetes medications should be used with metformin from the beginning. These newer drugs help with weight loss, they don’t really cause hypoglycemia [low blood sugar] and they help prevent cardiovascular disease,” Zonszein said.

O’Brien stressed, however, that no one should stop taking medication without talking to their doctor. Instead, he said to have a conversation with your doctor and ask whether or not your current medication is the best choice for you. If it’s a matter of insurance payment, he said your doctor may be able to work with your insurance company to get you a newer diabetes medication, if that’s the best choice for you.

Examples of sulfonylureas include chlorpropamide (Diabinese), glimepiride (Amaryl), glipizide (Glucotrol) and glyburide (Micronase, Glynase, and Diabeta). Examples of basal insulins include glargine (Lantus, Toujeo), detemir (Levemir) and degludec (Tresiba).

The findings were published online Dec. 21 in JAMA Network Open.

More information

Learn more about diabetes medication options from the American Diabetes Association.

Diabetes Can Make Weight-Loss Harder. Here's Help

SUNDAY, Oct. 14, 2018 (HealthDay News) — Because of the medications they take, losing weight can be difficult for people with diabetes.

Diabetes medications are a major roadblock to weight loss, according to a paper from the American Association of Diabetes Educators.

“Diabetes medications are vital in helping manage blood sugar, so you shouldn’t stop taking them. Instead, ask (your doctor) about alternative medications and treatment strategies,” co-author Patricia Davidson said in an association news release. She’s an assistant professor at
West Chester University in Pennsylvania.

There are other things that could be holding you back, too. “Everyone needs an individualized strategy for managing diabetes and losing weight. A diabetes educator can help,” said co-author Katherine O’Neal, of the University of Oklahoma College of Pharmacy.

The paper outlines ways for people to manage their diabetes and lose weight. The tips might also help others avoid or delay getting type 2 diabetes, especially those with prediabetes.

Get at least 150 minutes a week (about 22 minutes a day) of physical activity. The more the better, so try to work toward 300 minutes of activity a week (about 43 minutes a day).

This might be easier to achieve if you do things you enjoy, such as dancing at home or at a club, walking the dog, or going for a stroll after dinner. Work activity into your daily routines, such as walking around the grocery store before loading up your cart, parking in the farthest spot when running errands, or sprinting up and down the stairs when doing laundry.

Watch your diet. High-fiber foods can lower your blood sugar, help you lose weight, and decrease the amount of medication you need. Try to get 25 to 30 grams of fiber a day.

At least 10 grams of your daily fiber intake should come from fruits and vegetables. Aim for five servings a day: ideally, one or two fruits and three or four veggies. Whole grains are another important source of fiber.

A food and/or activity tracking mobile app can help keep you motivated. It’s also a good idea to seek online and in-person support groups of people in the same situation.

Weight-loss surgery may be an option, but is typically limited to people who are very obese. It also carries significant risks.

More information

The American Diabetes Association has more on weight loss.

Type 1 Diabetes Often Misdiagnosed in Adults

TUESDAY, Oct. 9, 2018 (HealthDay News) — It’s not always easy — even for doctors — to tell if someone has type 1 or type 2 diabetes when they’re diagnosed as an adult.

And a new study finds mistakes are common.

That’s what happened to British Prime Minister Theresa May when she was diagnosed with type 2 diabetes in 2012. She was in her 50s at the time. Despite having all of the symptoms common to type 1 diabetes, including rapid weight loss, her doctor initially said she had type 2 diabetes.

After the prescribed medications didn’t help, May’s doctor ran more tests and realized she had type 1 diabetes. Her daily regimen was quickly changed from oral medications to injections of the hormone insulin.

“My very first reaction was that it’s impossible because at my age you don’t get it,” May told Diabetes U.K. “But then my reaction was: ‘Oh no, I’m going to have to inject’ and thinking about what that would mean in practical terms.”

So, how do doctors mix up the two conditions?

It’s really hard to tell the difference in adults, study author Dr. Nick Thomas said.

“In childhood, almost all diabetes is as a result of type 1 diabetes. After 30 years of age [there’s] a dramatic increase in type 2 diabetes, and type 1 represents less than 5 percent of all cases of diabetes, so trying to identify cases is like finding a needle in a haystack,” Thomas said. He’s a clinical academic fellow at the University of Exeter in England.

There’s also a common misconception that type 1 diabetes can only occur in children. But that’s not the case.

“Type 1 diabetes can occur at any age. Doctors need to be alert to the possibility of type 1 diabetes in situations where patients rapidly fail oral therapies,” Thomas added.

Type 1 diabetes is an autoimmune disease that leads the immune system to attack the insulin-producing cells in the pancreas, according to the U.S. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Insulin plays a key role in metabolism by ushering sugars into the body’s cells to be used as fuel.

But the autoimmune attack leaves people unable to produce enough insulin. Without insulin injections — using shots or an insulin pump — type 1 diabetics couldn’t survive.

The exact cause of type 2 diabetes is still unknown, but excess weight and genetics are known to play a role, NIDDK says.

People with type 2 diabetes don’t use insulin properly. This makes the body produce more and more insulin. Eventually, the pancreas is unable to keep up, and people with type 2 may need insulin injections. However, type 2 can often be managed with lifestyle changes and oral medications.

The current study looked at almost 600 people diagnosed with diabetes after age 30 who needed to take insulin. They were diagnosed between 2007 and 2017. The researchers also looked at a group of 220 people diagnosed before 30.

Twenty-one percent of those diagnosed after age 30 were found to have severe insulin deficiency, which researchers said confirmed a diagnosis of type 1. In this group, nearly 40 percent weren’t given insulin when they were first diagnosed. Almost half of the type 1 group said they had type 2 diabetes.

“Managing type 1 diabetes as type 2 diabetes can result in rapid deterioration of a patient’s health and development of a potentially life-threatening condition called diabetic ketoacidosis,” Thomas said.

Dr. Joel Zonszein, director of the clinical diabetes center at Montefiore Medical Center in New York City, wasn’t surprised that some people were being diagnosed incorrectly.

“Years ago, we used to see type 1 only in the young, and now we’re starting to see younger people with type 2. And type 1s are heavier than they used to be,” he said.

Plus, “diabetes classification is very generic, and not very good. Even a good endocrinologist can miss a diagnosis,” Zonszein said.

The number of incorrect diagnoses in the British study surprised him, however.

“They found 20 percent, and I thought it would be around 10 percent,” Zonszein said, adding that it could have something to do with the population differences between the United Kingdom and the United States.

The study was presented last week at a meeting of the European Association for the Study of Diabetes, in Berlin, Germany. Studies presented at meetings are usually considered preliminary until published in a peer-reviewed journal.

More information

Learn more about the different types of diabetes from the U.S. National Institute of Diabetes and Digestive and Kidney Diseases.