Ask the Expert

This month’s Ask the Doc is brought to you by Dr. John J. Merendino Jr. A native of Washington, D.C., Dr. Merendino received his M.D. degree from the Yale University School of Medicine in 1985. After completing an internship and residency in internal medicine at the Brigham and Women’s Hospital, Harvard Medical School from 1985 until 1988, he did specialty training and research in endocrinology at the National Institutes of Health. He has authored numerous scientific papers and is certified by the American Board of Internal Medicine in Endocrinology, Diabetes, and Metabolism. Since 1994, he has been in private practice in Bethesda, and remains active in teaching and clinical research. Dr. Merendino also is an instructor with the Diabetes Education Program at Suburban Hospital (www.suburbanhospital.org/diabetes).

1. What is diabetes?

Diabetes is a serious medical problem affecting more than 16 million Americans. While there is no cure, the disease can be controlled through lifestyle changes and medication.

For people with diabetes, the pancreas either does not produce insulin or produces only a limited amount of insulin to control blood sugar. Insulin is a hormone that allows glucose (sugar) to enter cells and be converted to energy. When diabetes is not controlled, glucose and fats remain in the blood and, over time, damage vital organs. Diabetes can cause heart disease, stroke, blindness, kidney failure, and lower-extremity amputation. Diabetes is a major cause of complications in pregnancy. People with diabetes have an increased risk of death related to flu or pneumonia.

There are two main types of diabetes: Type 1 is an auto-immune disease that most often appears during childhood or adolescence; Type 2 diabetes is a metabolic disorder linked to obesity, heredity and physical inactivity. Type 2 diabetes accounts for up to 95% of diabetes cases and most often appears in people older than 40. However, with the increase in childhood and adolescent obesity, it is now being diagnosed more frequently among children and teens.

Fortunately, it is possible to delay or even prevent Type 2 diabetes. All Americans should learn their risk for developing diabetes and take action to prevent it. Controlling diabetes once it develops can reduce the risk of the various complications that diabetes can cause.

2. What impact does weight have on diabetes patients?

Both genetics and environmental factors such as obesity and a lack of exercise play important roles in the development of diabetes. Nearly 90% of people with newly diagnosed Type 2 diabetes are overweight. Being overweight makes it more difficult to control blood glucose and increases the chances of cardiovascular complications in diabetic patients. Even a modest weight reduction of 10 to 15 pounds will often help lower blood glucose levels, control blood pressure, and improve the levels of cholesterol and triglycerides in the blood. This weight loss may also help reduce the amount of medication needed.

Weight loss may be especially challenging for patients with diabetes because some medications used to lower blood glucose levels may promote weight gain.

A patient with diabetes who wants to begin a weight loss program should do so with the help of their physician. They may be referred to an endocrinologist, a physician who specializes in the treatment of diabetes, thyroid disease, and other hormone-related disorder. The physician can help determine which medications may control the diabetes while helping the patient in their efforts to lose weight.

3. What can I do to control my weight?

One of the most important steps is to educate oneself about diabetes management and weight-loss strategies. The Eugene B. Casey Diabetes Education Center at Suburban Hospital offers a two-day comprehensive diabetes education program that is recognized by the American Diabetes Association. The program is currently offered to adults, and a similar program for teens will begin soon. To learn more about the program, go to file:///C:/Documents%20and%20Settings/AWaye/Local%20Settings/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/0DQZWHE3/www.suburbanhospital.org/diabetes or call (301) 896-2106.

4. Aside from educating myself, what other weight loss suggestions do you advise for diabetic patients?

For diabetes patients who have been unsuccessful in losing weight through diet and exercise, two medications may help: Byetta and Symlin. Both medications were approved by the U.S. Food and Drug Administration (FDA) in 2005 to control blood sugar levels. Since these medications mimic hormones that slow the emptying of the stomach, diabetes patients feel full longer and eat less. These medications often help a patient to lose weight.

5. What else can you tell me about Byetta?
Byetta is an exciting example of a new approach to diabetes treatment. The drug works by mimicking the effects of a human hormone that is normally released after meals, stimulating digestion and insulin production. It also prevents the overproduction of glucose by the liver during periods of fasting. Byetta was developed after scientists discovered a protein called exendin-4 in the saliva of the Gila monster, a poisonous reptile native to the Arizona and New Mexico deserts. Hormones similar to this were found in humans, where they help control insulin release, reduce glucose production by the liver, and regulate stomach emptying. Byetta's active ingredient, exenatide, is a synthetic version of the reptile protein.
Byetta is only approved by the FDA for patients with Type 2 diabetes. It is most commonly used in combination with other diabetes medications, though some physicians have begun to use the medication alone in the treatment of diabetes. Byetta may help lower blood glucose levels, may allow the doses of other diabetes medications to be reduced, and may help with weight loss. While the weight-loss properties of the medication are desirable, the most important consideration is whether the person’s blood glucose levels are well controlled. Byetta can only be administered by injection, and is usually given twice daily, about one hour before meals.

6. How does Symlin work?
As with Byetta, Symlin is a synthetic version of a naturally occurring hormone, amylin. Symlin also often aids in weight management by causing a feeling of fullness leading to reduced calorie intake. Symlin is also an injectable medication. It is approved by the FDA for adults with either Type 1 or Type 2 diabetes. Symlin may improve blood glucose control in patients taking insulin, may reduce fluctuations in blood glucose levels, and may help with efforts to lose weight. Studies with this medication are presently ongoing to determine whether it may be of value as a weight-loss medication in patients who are obese but do not have diabetes, but it is not presently approved for this purpose.
Byetta and Symlin both frequently cause nausea. In many cases, this side effect becomes less severe or resolves completely with continued use. Some patients do not tolerate the medications, however, and must stop using them.

7. There are a lot of diabetes medications on the market. Won’t any one of these help me lose weight?

There are other medications to help diabetes patients control their blood sugar levels. For example, metformin is a medication that has been in use worldwide for many years. It was approved by the FDA in 1994 as a diabetes medication. Metformin may promote weight loss in some patients. Partly for this reason, metformin is the most widely prescribed initial medication for diabetes management.

As with all drugs, patients vary in their response to Byetta, Symlin, metformin or any other diabetes or weight-loss medication. The important thing to remember is that medication alone is not an effective solution for weight loss in patients with diabetes. Choosing the proper medication may help a patient in the effort to lose weight, but proper diet and exercise is required for patients will to lose significant weight and maintain the weight loss long-term.

8. I’m afraid to take an injection. What can I do?

I think it is perfectly natural for someone to be afraid of taking an injection, but this is a fear that almost everyone can easily overcome. This fear extends not only to Byetta and Symlin, but even more importantly to insulin, which remains the most important tool overall for diabetes treatment.

People fear insulin not only because of the injections, but also because they think that being placed on insulin means that their diabetes is more serious than if they are treated with oral medication. Nothing could be further from the truth. What makes diabetes severe is whether the blood sugar levels are well controlled. Someone with good blood glucose levels on insulin has a much lower chance of developing problems than someone else who is taking oral medication only but has poor blood sugar control. Recently, an inhaled form of insulin—Exubera—was approved by the FDA. This form of insulin may be right for some people, but it will not replace injectable insulin in most people.

As with insulin injections, injections with Byetta and Symlin usually do not hurt. The needles are very small, and most people do not have any discomfort when injecting. The injections are done in the abdomen where the skin is not very sensitive. Almost all patients report that testing their blood glucose by finger stick causes more discomfort than injection with Byetta, Symlin or insulin.

To make things even easier, Byetta is administered using a pre-filled device referred to as a pen. One pen contains a full month of medication. A new needle is placed on the pen prior to each injection, but there is no need to draw the medication up into a syringe. This makes it very easy for almost all patients, and the pen will only deliver the correct dose. Symlin is presently administered using a syringe, but the manufacturer is planning to make a pen form of the medication available. Many forms of insulin are also available in pen form, often the easiest and most convenient way to administer these medications.

9. I’ve read about a new medication, Acomplia. How can it help diabetes patients?

Acomplia is the intended brand name for a medication—generic name rimonabant—that is likely to become available in the United States for the treatment of obesity within the next several months. This medication blocks naturally occurring substances in the brain that increase appetite. The medication is already in use in Europe. Some studies have also shown that it is effective to help with smoking cessation. While it will not be approved for the treatment of diabetes, anything that causes gradual, sustained weight loss will help diabetes control in many patients. When available, this medication may be helpful for some patients with diabetes in their effort to lose weight.

For more information about diabetes education and research, visit the American Diabetes Association Web site at www.diabetes.org. If you need assistance finding an appropriate physician, call Suburban On Call at (301) 896-3939. To learn more about the services offered by Dr. Merendino, call (301) 230-0300. His office is located in the Camalier Building, 10215 Fernwood Road, Suite 405, Bethesda, MD, 20817.