The Real Paradigm Shift in Management of
T2DM
Sarosh Ahmed Khan, MBBS; MD; FACP
The year 2018 can be seen as the time from where
our management of type 2 diabetes mellitus has undergone a sea change. Now we
will be addressing this pandemic of T2DM with a different angle.
We know that 90% of
patients with T2DM are overweight or obese. We also know that as weight, body
mass index and waist hip ratio have increased, the world has seen a
corresponding rise in the number of T2DM.
Anecdotal reports on weight
loss leading to excellent control of T2DM have been published from time to
time. But there was no concerted effort to pursue in this direction. Has life
style modification to reduce weight been under stressed? Or have we not
realised its importance? The answer to both, it seems, is in the affirmative
and that should be an eye opener for all of us.
We can also deduce
from studies on the sodium-glucose co-transporter 2 inhibitors (SGLT2i) that
the cardiovascular benefit, as against safety only, is mainly because of the
loss of glucose and sodium these induce leading to weight loss. A few kilograms
of loss translates into a better metabolic profile of the patient. And then we
got the ground breaking studies on glucagon like peptide 1 receptor agonists (GLP1-RA)
liraglutide and dulaglutide. The Leader Trial and REWIND Trial (1,2)
amplified the concept of weight loss and the benefits associated with it. Full details of
the REWIND study will be reported at the American Diabetes Association
Scientific Sessions in San Francisco in 2019.
But the study which
has proved to be the game changer is the DiRECT Trial conducted in Scotland and
the Tyneside region of England(3). On a very low calorie diet, after
stopping all treatment for DM and hypertension, the results were astonishing. At
12 months, they recorded weight loss of 15 kg or more in 36 (24%) participants
in the intervention group and no participants in the control group
(p<0·0001). Diabetes remission was achieved in 68 (46%) participants in the
intervention group and six (4%) participants in the control group (odds ratio
19·7, 95% CI 7·8–49·8; p<0·0001).
That for me is the
real paradigm shift in the management of patients with T2DM. We also expect the
newer guidelines for DM from ADA and AACE would be certainly made with these
important studies taken into consideration.
References:
1.
Liraglutide
and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med 2016;
375:311-322 https://www.nejm.org/doi/full/10.1056/NEJMoa1603827
DOI: 10.1056/NEJMoa1603827
2.
Nainggolan L. REWIND: Once-Weekly GLP-1 Agonist Cuts CVD
in Type 2 Diabetes. November 5, 2018. https://www.medscape.com/viewarticle/904373
3.
Lean MEJ, Leslie WS, Barnes AC et al. Primary care-led
weight management for remission of type 2 diabetes (DiRECT): an open-label,
cluster-randomised trial. The Lancet. Feb 2018. 391 (10120): 541-551
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)33102-1/fulltext
Author
Information: Dr. Sarosh A. Khan is Senior Consultant, Internal Medicine and Director
Naseem Medical Center, Baghe-Mehtab, Srinagar, Kashmir, India. Pin: 190019. He
is the Editor in Chief of Physicians Academy. Affiliations: Governing Council Member of American College of
Physicians (India Chapter) from 2014-2017. Email:
drsarosh@gmail.com To Get This Article in PDF CLICK HERE |