More versatile therapies, which in addition to lowering blood sugar have protective effects on the kidneys and heart – the weak point of people with diabetes – and which, above all, cause weight loss. Which, for those who are overweight, is enough by itself to improve all metabolic parameters. Welcome to the new era of Type 2 diabetes treatment. It was going on for a while with more and more new (and underprescribed) drugs and more and better ones on the way.
With so many studies arriving this year from Ada, the American congress dedicated to diabetes, one of the largest in the world, a meeting and presentation point – albeit still virtually this year – of experts from all over the world and of the stages of the most important studies. Summarized this year in a meeting – also virtual – planned by Sid, the Italian Diabetes Society.
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Among the many innovations of Ada, one concerns the therapy and a molecule, the terzipatide, double agonist GLP-1 and GIP, protanist of the phase 3 Surpass study. What are the advantages? Professor tells them Agostino Consoli, President Sid: “It is an injective drug, one injection a week, not yet available even though I think the time will not be long. With effects not only – and I would say obviously – on glycated hemoglobin, given that about 90% of patients manage to drop below 7% starting from 8 in about 40 weeks. But this new molecule has marked effects on weight, very performing: about ten kilos less, again in 40 weeks. Demonstrating greater efficacy than both insulin therapy than to the commonly used GLP-1 analogue, semaglutide, which to date is the most effective both in the control of glycated hemoglobin and for weight loss. With comparable side effects, therefore above all nausea, in 20-25% of cases, vomiting, more rarely diarrhea. In short, an additional weapon for us diabetologists, and also for patients “.
Waiting for new molecules, Sid is still taking stock of the drugs already available, but which are not prescribed to all patients who would need them. Especially in those suffering from heart failure. “Kidney and heart have a common fate in patients with diabetes – recalls the professor Angelo Avogaro, president-elect Sid – an indissoluble marriage. Suffice it to say that the diabetic patient with heart failure three years after diagnosis has a 55% higher mortality. And that heart failure is one of the most frequent complications in patients with type 2 diabetes. And when there is decompensation there is almost always an alteration of renal function: the common denominators that lead to combined kidney and heart damage are excessive sodium retention, activation of the renin-angiotensin system, activation of the adrenergic system, and an inflammatory state ”.
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Among the drugs available for the treatment of diabetes, renal glucose reabsorption inhibitors called gliflozines not only reduce blood sugar but are able to protect the diabetic patient and not from the risk of heart failure. “However, among the gliflozines there are some which, in addition to acting on the renal reabsorption of glucose, also act on the intestinal reabsorption of the same: among these, canagliflozin and sotagliflozin. These two glyflozines are therefore dual inhibitors of glucose reabsorption. Of the two , sotagliflozin is not yet available in Italy, despite the data obtained in diabetic patients with heart failure and chronic kidney disease have already been published in the New England Journal of Medicine. Unfortunately, due to lack of funds from the sponsor, a significantly lower number of patients than expected was enrolled: in the SOLOIST-WHF study, compared to an expected number of patients to be enrolled of about 4,000, 1,222 were enrolled. In contrast, 10,584 patients were enrolled in the SCORED study “.
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To be even clearer, Avogaro gives an example: the kidney retains 120 grams of glucose per day. “To be clear, the amount of 4 cans of a Cola. Drugs that help excrete glucose with urine allow you to lose about 80 grams of glucose per day. Each gram of glucose is worth 5 calories and therefore 400 calories are lost per day. day. With a visible effect on weight loss. These drugs also induce sodium excretion, with beneficial effects on inflammation and oxidative stress and an extraordinary beneficial action on the kidney. Not prescribing them is almost unethical. “
As always, therapy must be personalized and include – in addition to drugs – a radical change in lifestyle. “No smoke – attack Anna Solini, associate of Internal Medicine at the University of Pisa – a diet that avoids salt, sauces, especially soy, and that favors herbs to flavor instead of salt. And control hypertension. The KDIGO (Kidney Disease Improving Global Outcomes) guidelines, awaited for years and just published, are clear: in the person with diabetes and kidney disease, extreme low-protein diets are abandoned, leading to malnutrition; hypertension drugs should be used at the maximum tolerated dose; use of an SGLT “inhibitor, along with metformin, in all patients with diabetes, kidney disease and glomerular filtrate greater than 30 ml / ml. And then educational programs”. Not only to explain well to patients what therapies they are following, and to convince them that it must be done consistently, but to change lifestyle. This is anything but easy.
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