TREATING TYPE 2 DIABETES Presents Jigsaw Puzzle of Options

With the number of cases increasing more than 10-fold over the past 50 years, diabetes is now the world’s most expensive endocrine disease, and it’s only getting worse. Today, almost one in 10 Americans are diabetic, rising to one in four among adults age 65-plus. Diabetes doubles the risk of death from heart disease and stroke and costs the U.S. $175 billion per year—most of it for drugs and medical devices.

These grim facts have been on my mind ever since my father was diagnosed with diabetes. Like the vast majority, he has type 2 diabetes.

Luckily, diabetes is imminently treatable. My dad takes seven different medications per day. He uses a finger-pricking computer to keep track of his glucose levels. All of this costs about $200 each month. That made me wonder, how much choice do doctors have when designing a treatment for diabetes patients? With the help of Michelle Bolek and Christopher Kelly, public affairs officers at the U.S. Food and Drug Administration, I took a virtual walk down the aisle of diabetes drugs and devices.

Abundant Meds and Devices

Various concoctions of insulin comprise a third of the 33 FDA-approved drugs for diabetes. Unlike most of the small molecular compounds in a pharmacy, insulin is a protein encoded by a human gene. Animal proteins tend to be unstable and expensive to harvest. Luckily, insulin is far more affordable, thanks to a 1982 breakthrough that allowed the insulin gene to be transplanted into bacteria and yeast for mass-production.

The next-most-important drug for type 2 diabetes is Metformin. Its target is farther upstream. It acts on the liver to reduce the rate at which glucose is released into the blood. Since its FDA approval for diabetes treatment in 1994, Metformin has become the most widely prescribed drug for diabetes.

The dozens of other drugs mostly treat the symptoms of diabetes. Lucentis helps treat damage that diabetes can cause in the back of the eye known as macular edema. The drug was already approved for treating a diff erent type of macular degeneration. Drugs for treating the core problem—glucose levels—are continually approved. Last year was Tradjenta, a new drug for controlling blood glucose levels. This year it was a long-acting version of the injectable glucose-regulating drug Byetta.

On the other side of the diabetes aisle is a mind-boggling choice of devices. The FDA approved more than 200 of them in 2012. Most are variations on a few themes: hundreds of glucose monitors, 178 gadgets for pumping insulin, and dozens of “infusion sets” for delivering the insulin to the blood. Glucose monitors are standard issue to almost every patient. Now many of these meters can even send data to your iPhone.

The newest glucose meters don’t require daily finger pricks. Instead, a tiny sensor stays just under the skin of the abdomen. The newest, made by a company called Dexcom, automatically alerts you if your blood sugar is trending toward dangerously high or low levels.

Weighty Issue

Of course, all of these drugs and devices are treatment rather than cure. Ask any overweight diabetes patient about gastric bypass surgery. The procedure is risky, like all major surgery, but it does return blood sugar levels to normal in most diabetes patients.

The tantalizing possibility of a less dangerous cure arrived last year. A British study found that seven out of 11 type 2 diabetes patients who underwent two months of radical dieting—about 600 calories per day—became free of diabetes symptoms. Longer follow-up is needed to see whether this is a permanent cure, but my dad is already planning on trying it. He is about 100 pounds overweight, so he sees it as two birds with one stone.

It shocks me that the causes of type II diabetes remain unknown. Glucose regulation is one of the most thoroughly studied systems in the body. But that is the nature of the disease, says Sue Lynn Lau, a diabetes researcher at the Garvan Institute in Sydney, Australia. “It is much harder to piece together a jigsaw puzzle than identify a single missing part. In type 2 diabetes, there are multiple contributing factors that combine to produce the final outcome of impaired glucose metabolism. Each one alone might not be enough, but it’s the interaction of all these factors wiTheach other over time that matters. Not everybody has exactly the same factors in the same amounts—the picture might look the same, but each person is a different jigsaw… Where do you start studying, and how do you know what came first?”

One thing is certain, at least. Diabetes can be prevented with nearly 100 percent success through diet and exercise. It’s too late for my dad, but the rest of us are taking a hard look at our daily routines.

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