Diabetes Medication

Day 3 ADA Chicago: Incretins


The third day of the American Diabetes Association’s convention in the so-called Windy City blew me away in more ways than one.

While Chicago is in fact hardly as windy as my hometown of Boulder, Colorado, I was blown away not only by the shear size and efficiency of the Second City, its other and more appropriate moniker for this still first-rate city. Beyond that, a powerful presentation at the end of the third day concluded my active participation in the convention and was a real blow-out for me.

Novo Nordisk hosted the presentation, which it billed as an interactive discussion about the two newest classes of diabetes drugs. Only one drug in each class is available yet: Byetta is the first GLP-1, and Januvia is the first DPP-4.

But Novo Nordisk now has a second and most promising GLP-1 mimetic in Phase 3 trials and hopes to have it available for us to use in a year or two. It’s called liraglutide, pronounced with the stress on the second syllable, like li-RA-glu-tide. Like Byetta, it mimics the action of human glucagon-like peptide, except that it lasts a lot longer in our systems and is therefore a lot more powerful.

By coincidence the presentation that I attended last night at the end of the third day of this year’s convention mimics two presentations that I went to at last year’s ADA convention. Last year the high point was these exciting and huge presentations that drew crowds of 1,000 of us to hear about new research on Byetta. Last night’s presentation was likewise exciting and huge.

Again about 1,000 of us crowded into a huge room to get ourselves up-to-date about Byetta and similar drugs. Over an excellent dinner of Chilean sea bass and chicken, about 900 of us got seats at 90 tables in the Fairmont’s “Imperial Ballroom.” Another hundred or two unlucky souls came too late for the dinner and had to sit at the back of the huge hall without food.

The Chicago convention center itself just doesn’t have room for that big a dinner. It is packed full of meetings from 8 a.m. until late in the evening. So the overflow has to go to the big hotels like the Fairmont in Chicago’s New East Side.

Dr. Daniel Drucker, a professor at the University of Toronto, moderated the presentation. He is North America’s leading expert on GLP-1 mimics (which he prefers to call GLP-1 agonists). I had consulted with him early this year on some technical points for my forthcoming book about losing weight with Byetta.

The other two speakers were Dr. Jens Holst, a professor at the University of Copenhagen, who probably has written more professional journal articles about GLP-1 than anyone else, and Dr. Robert Ratner, vice president for scientific affairs at MedStar Research Institute in Hyattsville, Maryland, and a professor of medicine at the Georgetown University Medical School.

The unscripted part of the presentation was the best part. With one exception, the scripted parts – the talks that the speakers prepared and rehearsed ahead of time – were old news to me. The one exception was Dr. Holst’s summary of the positive cardiovascular benefits that GLP-1 offers. I plan a future article about that here after I get a chance to study the half-dozen journal articles that he referenced.

Dr. Holst’s English wasn’t easy for me to understand from my vantage point near the back of the hall. But I was able to follow along with his PowerPoint slides.

Dr. Ratner was the big and pleasant surprise, and he made several points well worth repeating here. Unlike the two other professors, he seems to have hands-on experience in prescribing Byetta to patients.

In a question passed up to Dr. Drucker as the moderator, someone asked what Dr. Drucker says is the most common question he gets asked at presentations like these, “What diet should I be on when I use a GLP-1?”

“A low-calorie diet,” responded Dr. Ratner when Dr. Drucker passed on the question to him. “And when you feel full, stop eating.”

Dr. Ratner appropriately related this question to nausea, which almost half of the people in Byetta’s clinical trials seemed to have experienced. “But sometimes what gets coded as nausea is satiety,” he pointed out. “When you get full and don’t stop eating, you get nausea.” The problem is that so many people with type 2 diabetes have a hard time figuring out what the feeling of fullness is.

Nausea also related to gastroparesis, which is delayed stomach emptying. Dr. Ratner says that it comes in two distinct types. For some it is so serious it is an end-stage disease, but for most, who have what he calls “functional gastroparesis,” when they get their glucose levels down, the gastroparesis goes away.

Some statistics show that a quarter of people with diabetes have gastroparesis, as I wrote here earlier. But Dr. Holst noted that it’s not something that he has seen at all in his country.

Dr. Ratner thinks that GLP-1 mimetics, like Byetta and the forthcoming liraglutide, are not appropriate for these groups of people with type 2 diabetes:

  1. For those who don’t care about losing weight. They should stay on an oral diabetes medication, he says.
  2. If they are truly needle-phobic. But this is rare, he says. “I have seen only one in my life.”
  3. If they physically can’t handle the pen and needle.
  4. And if they have severe gastric problems.

But for the rest of us, Dr. Ratner concluded by saying that GLP-1 mimetics are “the perfect agents for weight loss.” Doctors should be prescribing them earlier in the course of their treating type 2 diabetes.

I would have wanted to use Byetta much earlier in the course of my diabetes. But when I got my diagnosis in 1994, the only medication available was insulin and the sulfonylureas. Byetta only became available two years ago, and I can truly say that it changed my life.

This article is based on an earlier version of my article published by HealthCentral.

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