Alabama is at the epicenter of an epidemic doctors are referring to as “diabesity,” with rates of diabetes and obesity among the highest in the nation. According to the American Diabetes Association, diabetics are two to four times more likely to face heart disease and stroke, as well as higher risks for eye and kidney problems, nerve damage, slow healing wounds, amputations and other health issues. The good news is that today healthcare professionals have more treatment options available to find the right combination to help patients bring their blood sugar into balance. The not-so-good news is that some drugs are making headlines for unexpected problems. “Since the New England Journal of Medicine article last summer, a lot of physicians are discontinuing Avandia,” said Edison Goncalves, MD, a Brookwood-based endocrinologist. “Although the data wasn’t definitive, it suggested that patients taking Avandia could be at increased risk of heart problems, particularly heart failure.” By the time the FDA voted to keep Avandia on the market, the study was already being reported in the media. “Patients ask about Avandia,” said Rebecca Byrd, MD, an internist with Medicine/Montclair. “Our doctors at Trinity have been talking about it, and we discussed it at a conference. After the follow-up article in the Journal of the American Medical Association, it isn’t looking that good. Actos, a drug in the same class, is looking a lot better. There is also a black box warning with it, but the numbers don’t show an increased risk for the same problems.” Dr. Goncalves agreed. “Neither of these drugs should be used in patients with Class 3 and 4 congestive heart failure, but Actos actually has a positive effect on lipids. It seems to lower the risk of ischemic events and death while also making tissues more sensitive to insulin.” A wide range of drugs working with different modes of action now gives physicians more flexibility to adjust treatment based on how their patients respond. “Byetta is a mimetic that actually helps with weight loss. It stimulates the pancreas, slows digestion and suppresses the appetite,” Goncalves said. “Januvia is a DPP-4 inhibitor that also helps many patients, and it is weight neutral. My patients are also doing well with the insulin pens. They are small, disposable and easily portable, with an extremely fine needle and they seem to be easy for patients to use.” New sensor-augmented pumps that continually monitor blood sugar levels have also been in the news. “These would probably work best for brittle diabetics who have a difficult time controlling their blood sugar, and patients with hypoglycemia unawareness or autonomic neuropathy,” Goncalves said. “The primary barrier is expense. These aren’t usually covered by insurance. Also, they are about 20 to 30 minutes behind, since they measure interstitial fluid glucose rather than serum. Still, they can be helpful in the right patients, and the technology is promising.” The new basal insulin released a year ago is also gaining fans among physicians and patients. “The response is very predictable. It’s a long-acting insulin that is quite effective in lowering blood sugar. There’s less weight gain and sometimes even weight loss when switching a patient from another form of insulin,” Goncalves said. There are also medications designed to deal with diabetic neuropathy, the pain in extremities that results from nerve damage. Scott Wepfer, RPh of The Compounding Shoppe has had success using transdermal pain gels. “Most patients report a 30 percent to 50 percent reduction in the burning pain in their feet within one to two minutes of applying the gel to the hunter’s canal of the saphenous nerve,” Wepfer said. “We also get a lot of requests for special blends of creams and topical medications for wounds that are slow to heal. We work closely with physicians to customize the combination of drugs and other ingredients we use, and we review the other medications the patient is taking to avoid interactions. The results we are getting, especially the immediate relief with the pain gels, is very gratifying to see.” Patients have also begun asking physicians about the health benefits of cinnamon. Reports have appeared in the media suggesting that cinnamon might help reduce blood sugar levels. The consensus among Birmingham area physicians is that the research looks interesting, but they want to see more data before prescribing it. One did report an anecdotal case of a diabetic having difficulty with sudden drops in blood sugar that seemed to be associated with a high intake of cinnamon. Two physicians said they would tell patients with borderline blood sugar levels it should be okay to try cinnamon, “as long as they don’t sprinkle it on doughnuts.” November 2007