Recent breakthroughs in type 2 diabetes treatments promise new treatment options for type 1 diabetics. Navigating this world of new, and apparently improved drugs, however, is anything but simple or straightforward.
Less than 20 years ago, the only thing type 1 and type 2 diabetes seemed to have in common was a shared name; they were related conditions but only as distant cousins, and once removed, at that. The paradigm at the time was that type 1 and type 2 diabetes required different treatments because they were, in fact, very different conditions. In type 1 diabetes the pancreas stops making insulin so type 1 diabetics injected insulin to replace what the body was no longer producing. Type 2 diabetes, however, was a condition in which a person’s pancreas was producing insulin, but their body was not metabolizing and using the hormone efficiently. Type 2 diabetics took oral medications to help improve their ability to metabolize the insulin their bodies were producing.
It turns out things aren’t so straightforward. The recently realized realities regarding the ways each condition evolves and behaves has led to new ways of treating each type of diabetes and a sharing of therapies between the two.
Doctors and researchers discovered the last decade that, for a variety of reasons, many type 2 diabetics could benefit from taking insulin.
“Unfortunately, many people with type 2 diabetes experience progressive loss of beta cell function,” according to Robert Tanenberg, MD, FACP, who wrote about why type 2 diabetics were increasingly turning to insulin as a treatment option. “Their overworked beta cells seem to burn out, and drugs that were once effective can no longer hold their A1c’s below 7%.”
There are numerous causes for this, according to Andrea Penney, RN, CDE, with the Joslin Diabetes Center. “Sometimes the pancreas becomes unable to produce enough insulin,” Penney says. “This happens frequently with aging. People can also become insulin resistant due to weight gain or chronic emotional or physical stress. Simply put, pills can no longer control diabetes.”
That change in thinking about the ways type 2 diabetes evolves indirectly opened the door to considering new ways of thinking about how type 1 diabetes behaves. That shift led to considering whether that door swung both ways and if type 1 diabetics might benefit from treatments designed to treat type 2 diabetes.
There is only one treatment besides 54 varieties of insulin approved by the Federal Drug Administration for use by type 1 diabetics, according to the University of Maryland Medical Center, and that drug is pramlintide acetate, which is marketed under the name Symlin.
Pramlintide is a small peptide hormone produced in the pancreas and, in people without diabetes, is released alongside insulin after meals or food ingestion, to help reduce high blood sugar. People with type 1 diabetes do not produce any pramlintide.
According to the FDA, which approved Symlin for use in treating type 1 diabetes in 2005, “Symlim is an injectable medicine for adults with type 2 and type 1 diabetes to control blood sugar. Symlin slows down the movement of food through your stomach. This affects how fast sugar enters your blood after eating. Symlin is always used with insulin to help lower blood sugar during the 3 hours after meals.”
Symlin’s manufacturer, Amylin Pharmaceuticals, Inc., says that Symlin works to reduce blood sugar by generating a feeling of fullness after meals, slowing the rate that the stomach empties after meals, and reduces the release of glucagon from the liver after meals. Symlin is recommended for type 1 diabetics who have not achieved good blood sugar control, which is decided on a case-by-cases basis by a person’s physician.
Some doctors are also prescribing metformin, which is the most prescribed oral type 2 diabetes treatment in the United States, off label as an adjunct to insulin for type 1 diabetics. “Some of the more creative and aggressive endos are prescribing metformin for type 1’s, particularly if they are overweight or requiring very large basal insulin doses,” according to Gary Scheiner, a Certified Diabetes Educator. “In addition to having some mild appetite-suppression effects, it will enhance insulin sensitivity by hepatic cells (in the liver) and limit the amount of glucose secreted by the liver. Personally, I think it can be helpful during adolescence as well. As long as the patient has good liver and kidney function, the side effects and risks are negligible.”
Other drugs used to treat type 2 diabetics are being studied to see if they should be submitted to the FDA for approval to treat type 1 diabetics. These drugs, once-daily injectable Victoza, Byetta, and once-weekly injectable Bydureon, are all GLP-1 agonists.
GLP-1 is a naturally occurring hormone released in the intestine that stimulates the release of insulin from pancreatic beta cells when carbohydrates are absorbed in the intestine. Additionally, GLP-1 (which stands for “glucagon like peptide”) is also present in the brain, where it acts as an appetite suppressant and produces one of the same effects of taking Symlin.
Some limited research suggests that GLP-1 treatments might be effective in helping type 1 diabetics better control their blood sugar.
“Several small studies done on GLP-1 agonists for type 1 diabetes show encouraging potential for improving A1c and glycemic control, reducing insulin dose, reducing the risk of hypoglycemia, and helping with weight loss,” the research website diaTribe reported in November 2013 as part of its of the coverage of the European Association for the Study of Diabetes conference.
A full-scale clinical trial of Victoza on type 1 diabetics is potentially in the works from the maker of Victoza. Word of this comes after diaTribe’s Editor-in-Chief, and type 1 diabetic, Kelly Close wrote about her positive experience taking Victoza for a “test drive.”
“I realize, in my case with Victoza, that I am a sample of only one, but in that one, Victoza not only improved my glucose control but also bolstered my faith in the continued progress of diabetic therapies,” Close wrote 2010. “All type 1 patients should have that opportunity. I urge Novo Nordisk to make the commitment, make the investment, and make it happen.”
After that article, Novo Nordisk responded to Close by indicating it was considering sponsoring a wide-scale study: “Your personal experience provides one of many reasons why Novo Nordisk is currently considering exploring the use of Victoza for type 1 diabetes in well-designed, controlled, randomized clinical trials. While we can not guarantee the time course or the outcome, we are carefully evaluating the possibilities for launching such a program.”
Then, this January Novo Nordisk started recruiting more than 1,400 subjects for a 52-week trial on the effects of Victoza on type 1 diabetics.
Until that trial is completed and the FDA acts, however, Byetta, Victoza, and Bydureon are explicitly not approved for use by type 1 diabetics, according to the product warnings on each drug.
If any type 1 diabetic wishes to try the drugs off label (which is the medical jargon for when patients receive a prescription to use a drug for a purpose for which it has not been FDA approved) researchers and doctors suggest consulting with a qualified endocrinologist experienced both in prescribing GLP-1 drugs and treating type 1 diabetics.