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Your Guide to Treating Diabetes

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Who Is the Best Candidate for Non-Insulin Injectables?


The number of diabetes cases is growing, but so are therapeutic options for treating this life-long illness. Physicians can now present patients with a much broader range of treatment choices that can be tailored to their needs. Over the last 10 years, non-insulin injectable drugs have been shown to be effective therapeutic options in the continuum of diabetes care. As a physician, I’ve seen many of my diabetes patients improve significantly using this class of drugs.

What is a "non-insulin injectable"?

‘Non-insulin injectable’ is a generic term that encompasses any medication injected to treat diabetes aside from insulin. The term typically refers to two main drug categories glucagon-like peptide 1 (GLP-1) receptor agonist class and another is considered an “amylin analog.” These medications have been approved by the Food and Drug Administration (FDA) to treat diabetes. The GLP-1 drugs mimic the body’s native hormone that tells the brain to prepare for the arrival of food and to stop eating when full. The GLP-1 class also helps stimulate insulin production, needed to regulate your blood sugar level, decrease production of glucagon, the hormone which asks the liver to produce more of your own sugar, and store energy from the food you eat. Currently, the FDA has approved the following GLP-1 drugs for diabetes: exenatide (Byetta), exenatide extended release (Bydureon), dulaglutide (Trulicity), liraglutide (Victoza), lixisenatide (Adlyxine), semaglutide (Ozempic).

The amylin analog, or pramlintide, is an injectable drug (Symlin), that works similarly. Diabetes impairs the production of the hormone amylin, which assists insulin in controlling post-meal glucose, or blood sugar, levels. The amylin analog works by telling your brain to curb your appetite and slow the exit of food from your stomach.

While the amylin analog is approved to treat type 1 and type 2 diabetes, the GLP-1 drugs were developed only for people with type 2 diabetes, a disease in which your body doesn’t use insulin properly, leading to what’s called ‘insulin resistance.’ Unless a person has certain conditions that might prevent him or her from using the drugs, I consider almost any patient with type 2 diabetes a potential candidate for the GLP-1 class if lifestyle changes alone don’t control their blood sugar levels. The drugs in this class can be taken in combination with other medications, at any stage in your diabetes, and they work through multiple mechanisms in the body to achieve results. The amylin analog, on the other hand, is only approved to be taken together with insulin injections prior to all meals.

How they work

In addition to genetic and environmental factors, weight gain is a contributing factor to type 2 diabetes, and the GLP-1 injectables directly target this issue, causing a sense of fullness and other factors that can lead to weight loss. They also help to slightly lower blood pressure, particularly if a patient has high blood pressure, which is a common issue in people with diabetes. For this reason, I recommend these agents be used in the beginning of a patient’s diabetes treatment course, especially for patients that struggle to lose weight and keep their blood pressure down. The amylin analog also targets factors that lead to weight loss by fine tuning a patient’s response to food intake and by lowering glucose levels. Unlike the GLP1-class this drug can only be used with insulin in a treatment plan.  

Depending on which drug and dosage your doctor prescribes, you might inject the medicine once a day or once a week. Taking injections may sound off-putting, but because these drugs are so effective, I rarely have patients stop taking these injections. That’s why initial education on the part of the physician is important. These injections are relatively easy to do, almost painless, and can be injected in less-sensitive parts of the body like the abdomen, the back of the arm, and the thigh. It is important to note that amylin cannot be taken in the same syringe as insulin.

The side effects for the GLP-1 class are also manageable in most cases. They’re mostly gastrointestinal, like bloating, nausea, diarrhea or constipation. But in most cases, an attentive physician can help you manage them. For example, when you use certain GLP-1 drugs, your physician can start with a low dose and gradullay increase it to help you tolerate the medicine. Understanding how GLP-1 drugs make you feel when you first start taking them is also important. Many patients report that after taking these drugs they feel uncomfortably full. I counsel patients to proactively cut back on how much they eat and learn to stop eating just before they feel full. The amylin analog’s side effects are also gastrointestinal, with nausea being the primary side effect. Practicing mindfulness and portion control can help you get the most out of these injections without the discomfort.

Who isn’t a good candidate?

The main limiting factor with the GLP-1 class is cost, which could be very expensive. In addition to cost, there are several conditions that might also prevent you from trying a GLP-1 injectable drug, or that might make those early side effects worse.

I don’t prescribe any drugs in the GLP-1 class or the amylin analog for anyone with gastroparesis, a disease in which the stomach doesn’t contract normally and holds food longer than it should. The GLP-1 drugs function in part by keeping food in the stomach, so these drugs might actually make a patient with this condition feel worse.

Lastly, if you have repeated bouts of acute pancreatitis in the past or if you or your relatives have a rare type of thyroid cancer — medullary thyroid cancer or a mutation that predisposes you to this type of cancer, you should not take the GLP-1 agonist drugs.

If you aren’t taking an insulin injection before every meal, the amylin analog is not approved for use in the treatment of your diabetes.

Non-insulin injectables: The big picture

Because they attack the core of the problem, which is often weight gain and other metabolic issues associated with diabetes, these drugs can have a big impact on patients’ health. I work with patients to find a treatment that controls their diabetes symptoms in a way that is effective and also works with their needs. For example, if a patient is having difficulty taking multiple pills, they may benefit from a once-weekly injection — as some of the GLP-1 class drugs offer.

If you have type 2 diabetes, I would encourage you to talk to your doctor about non-insulin injectables. The improvements you might see in your diabetes, weight, blood sugar levels, and even blood pressure may help you establish a healthier lifestyle as you keep your diabetes under control.

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THIS CONTENT DOES NOT PROVIDE MEDICAL ADVICE. This content is provided for informational purposes and reflects the opinions of the author. It is not a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of a qualified healthcare professional regarding your health. If you think you may have a medical emergency, contact your doctor immediately or call 911.