Early detection of diabetes as well as its prevention along with the right line of treatment of both prediabetes and diabetes, is critical to the health of our country as India is emerging as the diabetes capital of the world. Here, Dr. Aju Mathew lists down some crucial updates and new findings on diabetes therapies from renowned peer-reviewed journals. that will help you stay on top of things.

An introduction to diabetes

A study of more than a million Indians found that 7.5% of us have diabetes.[1] I often refer to the disease as a silent killer. Before most of our patients start taking action to control their blood sugars, the disease may have started damaging the end-organs – mainly the cardiovascular system, kidney and eyes.

But there are several advances in the field that has changed the outcomes for our patients. Let me refer to the key changes using the catchphrase – 3G: Gliptins, Glifozins and Glutides. In other words, DPP-4 inhibitors, SGLT2 inhibitors and GLP-1 receptor agonists. To this illustrious list comes the new kid on the block – Tirzepatide.

SURPASSing through the SURPASS trials

Through a series of trials called the SURPASS trials (numbered as 1, 2, 3, 4 and 5), Tirzepatide, a once-weekly injectable DUAL glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonist, has been shown to have superior efficacy on a number of outcomes – compared to placebo by itself (SURPASS-1 trial) [2] and in combination with insulin glargine (SURPASS-5 trial), semaglutide (a GLP-1 receptor agonist) (SURPASS-2 trial) [3] and insulin deludec, an ultra-long acting basal insulin (SURPASS-3 trial).[4,5]

It is not often we see such a comprehensive drug evaluation process addressed at various stages of the disease and against various control arms. SURPASS trials have the potential to surpass new boundaries in anti-diabetes therapy. Oh, I forgot to add – there is a significant weight loss benefit as well.

Give a leg up for weight loss

Tirzepatide is not the only drug that has shown significant weight loss benefits. In a recent trial called the STEP2, Semaglutide, a GLP-1 receptor agonist showed clinically meaningful weight loss when compared to placebo. A higher dose of the drug caused more weight loss when compared to a lower dose (2.4mg Vs 1mg) – at least a 15% body weight loss was seen in 25.8% on the 2.4mg dose Vs 13.7% on the 1 mg dose Vs 3% in placebo. There were more gastrointestinal adverse effects with the higher dose. The improvement in glucose control was insignificant with the increase in dose.

More recently, another GLP-1 receptor agonist, Liraglutide, was shown to have significant weight loss after one year of use when compared to placebo, in non-diabetic patients with obesity. [6] In fact, the combination of exercise and liraglutide caused significant improvement in weight loss, insulin sensitivity, glucose control and cardiac fitness. There were no serious adverse events. Clearly, we are seeing the dawn of new therapies that are effective in producing sustained weight loss.

Will the EMPEROR be preserved?

Empaglifozin, an SGLT2 inhibitor, was noted to have a cardiac protective role in patients with Type 2 diabetes (EMPA-REG-OUTCOME).[7] Later, last year the drug was found to have a remarkable cardioprotective role for heart failure outcomes in patients with reduced ejection fraction; regardless of diabetes status (EMPEROR Reduced). [8]

Now, we hear that the EMPEROR Preserved trial will be presented in August 2021 and will herald a new milestone in heart failure management. It appears that the drug has a cardioprotective role in patients with preserved ejection fraction. I will update the details once the trial happens. [9]

Redefining healthy BMI

A large pooled data study using the WHO STEPS survey in 57 low-middle-income countries have found that the threshold at which one’s risk for diabetes is high is at a lower BMI than previously thought. [10] The prevalence of overweight (BMI 25-29.9) was 27% and obesity was 21% (BMI ≥ 30). The prevalence of diabetes was 9%. When compared to persons with BMI <23, those individuals with a greater BMI had a 40% more risk for developing diabetes.

One thing I learnt from this study is that diabetes is not just a disease of affluent societies. The only way to reduce the burden of diabetes in our nation is by inculcating a healthy lifestyle and diet.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

Dr Aju Mathew is a medical oncologist, haematologist, internist and epidemiologist practising in Kochi.