Transcript Weight loss drugs

Nailsea 2009
[email protected]
Plan
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Hypos
Weight
Holidays
Hypos
Hypos
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Low blood glucose
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How low?
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Probably under 4.0 mM
Hypo symptoms
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Sweating
Tremor
Almost anything:
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Headache / muzzy head
Weakness / fit / off legs
Wobbly legs
Confusion
Blurred vision
Palpitations
Anxiety
Hunger
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Family may note:
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Aggressive
Glazed look
Slurred speech
Pale
Poor concentration
People are not
consistent in their
symptoms
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We used to think that they
were
Night time hypos
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Commoner than thought
Awake with:Muzzy head / headache
 Sweat
 Sometimes high blood glucose
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body over-corrects
“I get hypo at normal blood glucose”
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If used to a highish blood glucose:Get symptoms at Normal glucose
 But never come to harm
 Resolves once used to lower blood glucose levels
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Causes of Hypo
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Insulin or Sulphonylurea
Some more than others
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Very rarely repaglinide, nateglinide
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Should not go hypo if not on above
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The usual causes:Too much treatment
 Too much exercise
 Too little food
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Tight glucose control:
Lower HbA1c = Lower risk of complications
Lower HbA1c =Higher risk of hypo
HbA1c
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Average of blood glucose levels
Might be stable blood glucose levels
Or might be very fluctuant levels
If 2.0 mM to 12 mM, HbA1c approx 7.0%
 Remove the “Lows” & the “Highs” generally do
not worsen
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Other causes
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Alcohol
Drink may raise glucose level initially
 But then drops glucose level for up to 8 hours
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Exercise
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May drop at time, or later, up to 8 hours
The effect of hypo
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After hypo:Blood glucose level will rise as body & patient
overcompensate
 More likely to go hypo in next few days
 Less likely to spot next hypo
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So hypos often come in clusters
Particularly if nocturnal hypos not spotted
Treatment
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Immediate glucose to get blood glucose up
Eg 3 dextrosols
 3 teaspoons sugar
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Long acting unrefined carbohydrate to keep
glucose up
Eg 2 biscuits
 1-2 slices of bread
 Next meal if due
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Address cause
If hypo at start of meal, meal then insulin
Driving Cars on Insulin or Sulphonylurea
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Should test before getting in car
Probably want glucose above 6.0 mM
Should test every 60 – 90 minutes
If had hypo, should wait 45-60 mins before
driving again
If hypo in car, should not sit in driver’s seat
“Chasing sugars”
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Blood glucose high, so extra insulin taken
Blood glucose then low so go hypo
So insulin reduced & then glucose high
ie need to pick a sensible insulin dose
with low chance of hypo, try for a while eg
1 week, and see effect
Weight
Weight
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Weight goes up in the UK population
Weight goes up on many diabetes drugs:Insulin
 Sulphonylureas eg gliclazide
 TZDs eg Pioglitazone, Rosiglitazone
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A Problem
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Higher weight increases:Blood glucose
 Blood pressure
 Cholesterol
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And other health problems
Sums
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1Kg fat = 7,000 Kcal
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So it takes a lot of exercise or diet to lose
weight
Diet
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The cornerstone
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Will see other options not great
Diet + zero exercise = lose water & muscle
Diet + exercise = lose fat
Exercise also improves insulin sensitivity,
ie diabetes treatment works better
Drugs for Type 2 Diabetes
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Some gain weight
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Some weight neutral eg
Metformin
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Such a good drug, hence Doctors push it
 Diarrhoea – might be OK on MR Metformin
 Renal impairment precludes metformin
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Metformin does not worsen kidneys
“Gliptins” – sitagliptin, vildagliptin, saxagliptin
Nateglinide / starlix
Acarbose
Insulins
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Most put weight on
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Stop losing calories from sugar in urine
May stimulate appetite
Less problems if;
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Insulin just at bedtime
Levemir as long acting insulin
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But often not as “strong” as others
Giving with metformin, possibly acarbose, ??? gliptin
Avoid hypos
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Avoid extra CHO to treat them
Avoid extra insulin to cause them
GLP-1 analogues etc
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Byetta / exenetide; liraglutide injections
Modest drop in HbA1c
5% cannot take due to vomiting
Limited at present by cost
Cannot use Byetta in modest renal
impairment
Weight loss drugs
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Orlistat
Acts just on gut lining ie not absorbed
 Stops absorption of fat
 Causes dramatic diarrhoea
 On average, 3-5% weight loss per year
 Some do better, but if not losing weight, stop drug
 Now available over counter; half strength, double
cost
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Weight loss drugs
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Sibutramine
Acts on brain to decrease appetite
 Raises pulse & blood pressure
 Cannot use if heart disease or antidepressant
 Works in most people to lose >5% weight per
year
 Need to monitor pulse & BP
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Weight loss drugs
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Rimonobant
Lose 6 Kg in first year
 Gain 5 Kg in second year
 £60 per month
 5% get significant depression
 Withdrawn
 But has glucose / lipid benefits greater than
weight reduction would predict
 Others in pipeline
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Weight loss drugs
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Gastric surgery
Drastic
But can work very well
Classic study
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Dropped from 300 lbs to 200 lbs in 10 yrs
Ops getting less invasive eg gastric banding &
getting more practised
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But definitely not without risk
Holidays
Holidays
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Prepare well in advance:Supplies
Insulin & testing equipment in hand luggage,
 Take twice what need,
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split between two people’s hand luggage if possible
Most things available worldwide
Different names
 Same colours / marks
 You would have to pay for it – maybe not cheap
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Adequate supply dextrosol tablets on self
Holidays
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Holiday insurance – really difficult
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European Health Insurance Card
www.ehic.uk.com
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Not a substitute for health insurance
Evidence have diabetes
Eg letter from doctor
 DUK insulin card – also has “I have diabetes” in
many languages
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Language
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“Balance” had useful articles on key phrases
Journey details
Crossing Time Zones
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If flying east, days shorter, so maybe less
insulin that day
If flying west, days longer, so maybe an extra
shot of insulin that day
If on once daily basal insulin, often just keep
on same
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eg bedtime glargine not breakfast time if gone to
Australia
ie need to know meal plans for travel and
time difference at destination
Hot weather
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Keep insulin cool
Meter probably OK – but check with
manufacturer / manual
ie need to know anticipated temperature
Glucose control
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Diet may be different
Meals at different times in other countries
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Eg Spain – lunch & evening meals seem later
Alcohol intake may be different
Very hot weather seems to decrease blood
glucose if on insulin
The Europeans often regard the British as
drunks, so avoid hypos
So frequent monitoring – sorry.
Tummy bug
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Hopefully just food poisoning
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But could be proper tummy bug
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Vomit for just very short time & OK for next meal
Drink plenty
Test four times per day
Usual insulin
Food, or sip sugary drink - not both
If tests 15 or more, add 4 to insulin doses
If cannot keep anything down
Or Drowsy
Or Confused
GO TO HOSPITAL
Feet
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Ensure shoes etc OK before leave
There are hybrid trainers / sandals around
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Which I wear with socks
Watch out for sunburn of feet if neuropathy
Do not walk barefoot
“Holiday foot” is a recognised medical problem
The End
Questions on anything?
Big Lantus / Glargine dose?
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40 units max
on Optiset
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vs
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80 units max on
SoloStar
The Aspirin Question
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1980’s – Type 2 Diabetes was as bad as heart
attack for future heart attack
But now outlook improved greatly:
Aggressive BP control
 Aggressive Cholesterol control
 Better glucose control
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People at most benefit from aspirin also at
most risk from aspirin
The Aspirin Question
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If had heart attack, stroke etc
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If on aspirin and OK, likely little risk from Aspirin
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Take aspirin
Could continue, or could do what one likes
If not sure:Could put details in QRISK2 risk engine for
heart attack & give aspirin if high risk eg 20% ( I
have just made this up)
OR
Enter ASCEND Trials, Jane Armitage, Oxford
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This is best option