Recent Research in Diagnosis and Treatment of Diabetes
Diagnosis of diabetes has been evolving to decrease discomfort
of procedural restrictions, says, Dr N K Agrawal, Associate Prof and
Head, Department of Endocrinology and Metabolism, Institute of Medical Sciences,
Banaras Hindu University, Varanasi
Dr
N K Agrawal
Asso. Prof. Head, Dept. of Endocrinology Metabolism, Institute
of Medical Sciences, Banaras Hindu University, Varanasi
The ?diabetes capital of world? status is quite
ironical and may have been possibly taken by China as per disagreed publication1,2,3;
however the rising trend in India is quite disturbing.
Diagnosis of diabetes has to be robust and thus we stick
to the blood samples drawn in fasting and glucose-load state (glucose challenge
test). Newer data on applicability of glycosylated hemoglobin (Hb A1c) beyond
6.5 per cent for diagnosis of diabetes mellitus is being increasingly accepted.
To depend heavily on a test, it has to be robust, reproducible and comparable.
The A1c standardisation facilitates its use as diagnostic criteria.4
The progression from normal state to a diabetic state is a gradual process which
may have different pace. The initial phase may be a mild impairment in ability
to handle glucose [pre-diabetes namely, impaired fasting glucose (fasting plasma
glucose 100-125 mg/dl), impaired glucose tolerance (post glucose challenge 140-200
mg/dl) or A1c between 5.7-6.5 per cent]. This is a phase in which approximately
30 per cent can convert to diabetes especially in those with high risk profile
(obesity, family history, Asians, giving birth to large babies). Such people
need to improve their lifestyle to reach ideal body weight and continuously
undertake exercises. The weight reduction of at least seven per cent of initial
body weight through a healthy low-calorie, low-fat diet and to engage in physical
activity of moderate intensity, such as brisk walking, for at least 150 minutes
per week has been shown to reduce new onset diabetes by 58 per cent Vs 31 per
cent with use of medication.5 This is a challenge which produces great results.
Kowall and co-workers conclude in their study that ?In older adults, weight
loss strongly increased the chances of returning from prediabetes to NGT irrespective
of initial BMI. Long-term persistence of NGT depended both on initial BMI and
on BMI change.?6
The treatment for diabetes mellitus has been researched extensively.
The pathogenic mechanisms are being targeted to find out an easy-to-use way
for the suffering humanity. Oral medications have taken profound leap; however,
the cost-effective analysis in Indian scenario may be a limiting factor. Oral
DPP-4 inhibitors are being used and many are to follow as is the development
of oral insulin.7 The trials of oral insulin are underway (Novo Nordisk NN1952,
Oramed ORMD-0801, Biodel, Inc. VIAtab, Biocon India IN-105) in various clinical
trial stages. The clinical uses for such drugs are pending. The use of analogs
to enhance GLP-1 like effect is being extensively researched. Longer acting
formulation of Exenatide (once a week) is undergoing clinical trials.8
Researchers from India?s National Institute of Immunology
developed a new insulin (supramolecular insulin assembly II SIA-II), which has
only been tested on rats, mice and rabbits up until this point, with just a
single injection released the hormone capable of maintaining physiologic glucose
levels for 120 days for bovine and 140 days for recombinant human
insulin without fasting hypoglycemia.
This will be a breakthrough for providing basal insulin levels.
The requirement of post-meal control may be addressed with other drugs.9
The newer formulations in insulin sensitiser drugs glitazones
are on anvil. The Indian pharma researchers are developing novel glitazones
without the so-called side effect profiles as their predecessors.10
Opexa Therapeutics used multi-potent stem cell derived from
peripheral blood monocytes to make islet like cells.11 Similar work by autologous
bone marrow-derived stem cell transplantation has been carried out in PGI, Chandigarh
with reasonable benefits.12,13
The diagnosis of diabetes has been evolving to decrease discomforts
of procedural restrictions. However, the newer modalities are falling short
of being comprehensive and complete. A1c measurement is such a diagnostic tool.
The trend of rising diabetes prevalence in Asia needs prevention with lifestyle
modification in view of the socio-economic scenario.
The prediabetes to normoglycemia is a possibility with these
measures. Newer drugs and formulations have been and will be innovated continuously
for the suffering diabetic with the intent of increasing compliance. To cure
diabetes, we have moved forward with stem cell research, however, there are
many miles to go before we sleep.
References
1.http://www.thestarphoenix.com/health/China+becomes+world+diabetes+capital/2725659/story.html
accessed Aug 30,2011.
2. Yang SH, Dou KF, Song WJ. Prevalence of diabetes among men and women
in China. N Engl J Med. 2010 Jun 24;362(25):2425-6; author reply 2426.
3. Shi Z.Prevalence of diabetes among men and women in China. N Engl
J Med. 2010 Jun 24;362(25):2425; author reply 2426
4. American Association of Clinical Endocrinologists Board of Directors;
American College of Endocrinologists Board of Trustees. American Association
of Clinical Endocrinologists/American College of Endocrinology statement on
the use of hemoglobin A1c for the diagnosis of diabetes. Endocr Pract. 2010
Mar-Apr;16(2):155-6.
5. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker
EA, Nathan DM; Diabetes Prevention Program Research Group.) Reduction in the
incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl
J Med. 2002 Feb 7;346(6):393-403.
6. Kowall B, Rathmann W, Heier M, Holle R, Peters A, Thorand B, Herder
C, Strassburger K, Giani G, Meisinger C.Impact of weight and weight change on
normalization of prediabetes and on persistence of normal glucose tolerance
in an older population: the KORA S4/F4 study. Int J Obes (Lond). 2011 Aug 23.
doi: 10.1038/ijo.2011.161. [Epub ahead of print]
7. Pozzilli P, Raskin P, Parkin CG. Review of clinical trials: update
on oral insulin spray formulation. Diabetes Obes Metab. 2010 Feb;12(2):91-6.
Epub 2009 Nov 2.
8. Buse JB, Drucker DJ, Taylor KL, Kim T, Walsh B, Hu H, Wilhelm K, Trautmann
M, Shen LZ, Porter LE; DURATION-1 Study Group. DURATION-1: exenatide once weekly
produces sustained glycemic control and weight loss over 52 weeks. Diabetes
Care. 2010 Jun;33(6):1255-61. Epub 2010 Mar 9.
9. Gupta S, Chattopadhyay T, Pal Singh M, Surolia A.Supramolecular insulin
assembly II for a sustained treatment of type 1 diabetes mellitus. . Proc Natl
Acad Sci U S A. 2010 Jul 27;107(30):13246-51. Epub 2010 Jul 13.
10.http://www.financialexpress.com/news/zydus-files-new-drug-application-for-metabolic-disorder-treatment-agent/126598/0
accessed Aug 30, 2011.
11.http://www.stemcellresearchnews.com/absolutenm/anmviewer.asp?a=1619z=5
accessed Aug 30, 2011.
12. Bhansali A, Upreti V, Khandelwal N, Marwaha N, Gupta V, Sachdeva
N, Sharma RR, Saluja K, Dutta P, Walia R, Minz R, Bhadada S, Das S, Ramakrishnan
S. Efficacy of autologous bone marrow-derived stem cell transplantation in patients
with type 2 diabetes mellitus. Stem Cells Dev. 2009 Dec;18(10):1407-16.
13.http://www.indianexpress.com/news/treatment-for-type-2-diabetes-available-at-pgi-from-next-week/541317/0
accessed Aug 30, 2011.
