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Patient Webinar – Dr Harvinder Chahal – Latest treatment options for type 2 diabetes

Dr Harvinder Chahal:
Great.; So thank you for everyone joining me today. So I’m Harvey Chahal, I’m an endocrinologist, and I’ve got a very specialist interest in patients with type two diabetes and obesity. And what I hope to do today is to talk to you about some latest treatments options for type two diabetes, and particularly from a medical point of view, medications, some of these medications you may have heard about, but others you may not have heard about. And this is a very good opportunity to think about whether you should be on these type of medications for your type two diabetes. So I’m just going to touch upon lifestyle interventions for type two diabetes, but the talk primarily is on two different classes of diabetes medications that you should make sure you’ve been offered or are commonly on.

Dr Harvinder Chahal:
But as everyone probably is aware, we have a high prevalence of type two diabetes in the UK. It is estimated approximately 3 million of us have type two diabetes and if I give this talk in the next 10 years, we’re probably looking at about five to 6 million of the population having this condition. And many of you may solely be treated in the NHS sector, and a lot of money is being spent on trying to reduce the complications of type two diabetes. But the one thing we can offer you in the private sector is very tailored treatment options for your type two diabetes to try to minimize the complications that you may be more at risk of that’s particularly the heart complications, the problems with the eyes, the kidneys and the feet.

Speaker 3:
[inaudible 00:02:03].

Dr Harvinder Chahal:
I think someone’s microphone is on. Very good. So the other thing to just bear in mind also is there is a lot of individuals in the community who may not even know they have type two diabetes, and these are the patients that it’s very important to do screening tests on, to work out, do they have type two diabetes or not? Because patients can come into a hospital setting very unwell, newly presenting with type two diabetes.

Dr Harvinder Chahal:
The other thing that’s everyone is well aware of is we’re in the COVID environment at the moment. And you may have heard about the risk of COVID if you have type two diabetes or obesity. And not to alarm the audience, but if you do have uncontrollable type two diabetes, then it has been shown that if you do get COVID, then naturally, you may get a more severe form of COVID compared to if you had very good glucose control or weight control. And hopefully talking about the newer type of medications for type two diabetes will put everyone who may have type two diabetes in the audience in a better metabolic state. But we have found patients during the COVID environment coming into the hospital setting with type two diabetes. And at the beginning of COVID, general practitioners were alerted to the factor that they should prioritize patients with type two diabetes who had poorly controlled diabetes so an HBA1C greater than 75 millimoles per mole.

Dr Harvinder Chahal:
Now, one thing you may not appreciate is having type two diabetes can actually cause in the future problems with the pancreas. So we do know patients with type two diabetes are insulin resistant, and because they still produce insulin because many of our patients with type two diabetes may be overweight or obese, that level of insulin that’s being produced, or may not be fully functioning to try to lower your glucose levels. And this is a nice diagram looking at the cells in the pancreas, which are your beta cells, these are the cells that make insulin. And actually at the time of diagnosis, you may not be fully aware that probably half of the pancreas may not be functioning as well as it should be. And the whole aim of our treatments for type two diabetes is to prevent the pancreas from reducing the insulin production and also by trying to reduce insulin resistance over time.

Dr Harvinder Chahal:
And there are different ways we can do this. Lifestyle is very important, but I do see a lot of patients who try their hardest with lifestyle and unfortunately are unable to maintain any good degree of weight loss that will really help with their type two diabetes course. But there are other medications that we’re going to talk about which can try to reduce the failure of beta cell function over time, thus preserving the amount of insulin in your bloodstream. So one study I want to show you, and there are a few studies I’m going to show you today, but I will take you through them one by one, is this study that was done in 2017, which from a dietary perspective looked at patients with type two diabetes.

Dr Harvinder Chahal:
And they chose half of patients who had diabetes with a duration of about six to eight years and they actually ask patients to come off their diabetes medications, but also ask patients to go onto a very low calorie diet. In the study, patients were asked to go on to an 800 kilocalories diet, which occurred for about two to three months. And then food was reintroduced at a much lower calorie content, about 1,200 calories to about 1,400 calories. And the most striking thing in the trial, which was done over a year period, was that patients could actually get 15% weight loss. So about one in five patients were getting a 15% weight loss. And those patients that tended to get more weight loss were more likely to go into type two diabetes remission, and type two diabetes remission means that patients are completely off their diabetes medications and have an HBA 1C that’s below 42 millimoles per mole.

Dr Harvinder Chahal:
So the real aim of showing this to you is if anyone in the audience has recent onset type two diabetes, we normally say less than 10 years, and if you are able to lose about 15% of your weight through dietary maneuvers, then actually you have a very good chance to go into type two diabetes remission, meaning not needing any medications whatsoever. If your type two diabetes is of slightly longer duration, maybe 20 or 30 years, then actually having this degree of weight loss may mean you still have type two diabetes, but some of your treatments you’re on may actually be reduced if you do get this meaningful weight loss.

Dr Harvinder Chahal:
So just for you to think about, if you are aiming for good weight loss, you should be thinking about 15% weight loss to make a good metabolic change in your type two diabetes. But again, as I’ve mentioned, a lot of patients will not be able to do that and that’s where medications really come in to helping your type two diabetes. And the medication that you should look to see whether you’re on is two different classes, the first class is SGLT2 inhibitors. So have a look at your treatments that you’re on and see whether you’ve ever been offered these type of treatments for your type two diabetes.

Dr Harvinder Chahal:
And we have three different SGLT2 inhibitors, that’s the class of medication. We have dapagliflozin, which is called Forxiga, we have canagliflozin which is called Invokana and we also have empagliflozin whose trade name is Jardiance. And these medications have been out since 2012, that’s when the first SGLT2 inhibitor was in routine clinical practice. And the beauty of these medications is that they work on your kidneys at a point in your kidney which is called a receptor that causes glucose to go back in to your bloodstream. So we do have receptors of SGLT2 receptors in the kidneys, which are located here, this is a diagram of the kidney, and the majority of the glucose that goes out of your kidneys is reabsorbed or taken back into the body through these SGLT2 receptors.

Dr Harvinder Chahal:
So these medications actually inhibits or prevents the absorption of glucose back into the bloodstream at this point. So that means that once glucose goes out of your kidneys from the circulation, it goes right through the kidneys into your urine. So it’s a bit like turning on the tap to cause glucose to filter out of your kidneys and patients lose approximately 200 to 300 kilocalories a day, which is really meaningful calorie loss that can promote weight loss. So this is one such SGLT2 inhibitor, it’s called dapagliflozin, and essentially by inhibiting these receptors, glucose goes right out through the urine.

Dr Harvinder Chahal:
Now, the beauty of these class of medication is that we now have very good cardiovascular data on these agents. So if you’re on this type of medication, as well as your glucose coming down, there is also good evidence that these medications can protect your heart from heart disease. There’s also good evidence that some of these medications can also protect your kidneys from diabetes and preventing further kidney disease from occurring. So diabetes medicine has changed so much over the last 10 to 15 years, we don’t just focus on the glucose control, we focus on medications that really help with the heart as well as the kidneys and preventing any further complications in those organs.

Dr Harvinder Chahal:
The other benefits of this class of medications is as well as helping with kidneys and heart, patients can lose a bit of weight on these medications as well. A lot of my patients on these medications can lose three or four kilograms of weight, which is really meaningful weight loss. Patients also have good blood pressure reduction as well. So some of my patients on these medications have been able to reduce some of their other blood pressure agents because these type of medications can lower your blood pressure as well. So very meaningful effects, not just glucose effects.

Dr Harvinder Chahal:
Now, the other class of medication, I really want you to see whether you are on are GLP-1 agonists. So these type of medications work on receptors in the body called GLP-1 receptors, and we’re around about six o’clock today this evening so hopefully some of you may be tucking into your evening meal and after you have your evening meal in about 30 minutes, time to an hour, your levels of GLP-1 produced by the intestine should go up. And this hormone has been found to make patients feel more full, more satisfied with food, and it can also change their insulin to glucose balance in a more favorable fashion.

Dr Harvinder Chahal:
Now in 2006, if I take you back to 2006, our patients with type two diabetes were found to lack this hormone GLP-1, meaning that after eating, patients with type two diabetes may not feel as full and also the insulin production through the pancreas may not be as much as patients without type two diabetes. And these class of medications have been out now since 2006 to help our patients with type two diabetes because once you’re on a GLP-1 agonist, you should feel more full and also your metabolic side should improve as well so the production of incident increases, and there’s also another hormone called glucagon, which is a hormone that causes glucose to go out of the liver into the circulation, and by promoting GLP-1 effects, your levels of glucagon will go down as well.

Dr Harvinder Chahal:
The other beauty of this type of medications is the absorption of food in the stomach is delayed, so actually some of the metabolic effects can be promoted because of the delayed gastric emptying. There are different GLP-1 agonists now on the market. Some of you may have been treated a long time ago with exenatide, which initially was a twice daily medication. It can be given as a weekly formulation, which is called exenatide. We also have a daily preparation called lixisenatide. But the better GLP-1 agonist is actually semaglutide. So this is a medication that has come onto the market since January, 2020, and it’s the most powerful GLP-1 agonist we know about.

Dr Harvinder Chahal:
These medications I’m showing you, all these names of medications are injectable medications. So we have them in a pen device and we teach patients how to inject into the fatty tissues around the stomach or on the thigh area. The injection is very easy to do. And actually, honestly speaking, when I say to patients is an injection, you can see it in their eyes, they’re thinking, “Could it not be a tablet?” But once patients are taught how to inject and inject on a weekly basis, the injection is never an issue at all. The needle is very fine, it’s two of your hair strands together so four millimeters. But if any of the audience out there does not want to think about an injection, we do now have oral version of GLP-1 agonists, which we’ll go into in a bit. And this is an oral medication which has similar effects to the other GLP-1 agonists and it’s a medication you can take on a daily basis and it’s a tablet.

Dr Harvinder Chahal:
But going on to the medication which I think the majority of you should be on, if you’ve never tried it before, it’s this medication called semaglutide, which is a weekly medication. And I’m going to show you some slides now, which are trial data slides which are now in clinical practice. And I’ll take you through one by one so don’t get too concerned. I’m showing you a lot of data here. But the reason to show you this data is that a lot of good evidence is now out and in the medical literature on the effect of this type of medication called semaglutide to help patients have good glucose control.

Dr Harvinder Chahal:
And the way we look at glucose control issue is your HBA1C, this here shows changes in HBA1C so the graphs going down or the areas going down are the reduction in HBA1C. And there are different trials that have been studied, so this is patients on no other therapy apart from this medications, semaglutide. These are patients who have been compared to patients who are also on a tablet called sitagliptin, which some of you may be on or have been on. This is a trial comparing individuals to another GLP-1 agonist called exenatide. This is a trial comparing patients on insulin and this medication, and this is a trial comparing individuals to another GLP-1 agonists called dulaglutide.

Dr Harvinder Chahal:
And what I want to really illustrate on this diagram or these diagrams are the blue bars here, so this is the lower dose of semaglutide. The trade name is Ozempic, and this is the higher dose of semaglutide. Again, trade name Ozempic. And we can see all the way throughout, no matter what it was compared to, patients on semaglutide were getting much better reductions in HBA1C. Some patients were getting at least 1.8% reduction, which is really meaningful. So if your HBA1C is around about 10%, patients were getting it as close to below 8% as possible with this type of medication, which is really meaningful.

Dr Harvinder Chahal:
Why I’m interested in this medication is I have a real specialist interest in helping patients lose weight. And the beauty if you were to go on to this medication is that you’re going to lose about four to six kilograms in weight on this preparation, which is really meaningful both from an overall health perspective, because weight increases your risk of other medical conditions, but also from a type two diabetes perspective. And the holy grail in the field of diabetes as well as obesity medicine is to try to get patients to have at least 10% weight loss. And all throughout these trials on the medication, patients were achieving greater than 10% weight loss at one milligram of semaglutide. So I think if you haven’t been offered this medication, then you should think about either coming to us at the London Medical, and we can see whether you can be offered it, or if you’re under your GP care to get your GP to refer you to us so we can consider this medication.

Dr Harvinder Chahal:
But the other slide or types of slides I want to show you is there is some new exciting data recently on a higher dose of some semaglutide really helping patients with type two diabetes lose weight. And I said the holy grail is, in the field of diabetes, getting our patients to lose 10% of weight, but actually having patients losing near enough 20% weight loss is never heard of in the field of diabetes from medical therapy, but with patients on a higher dose of semaglutide, this is data recently being published. There were patients, about 13% of patients losing, over 20% weight loss at a much higher dose of semaglutide. So the real reason to share this data with you is that we are now getting into a field of type two diabetes medicine where we’re able to offer some patients really meaningful weight loss on this medication.

Dr Harvinder Chahal:
And some of you may have heard about another form of treatment for diabetes called bariatric surgery. Well, patients who undergo bariatric surgery for diabetes tend to lose 20 to 30% of their weight. Well, if you go onto this type of medication and you’re a very good responder, you’re really getting into bariatric surgery territory with the medication. So not with surgery, but with a medication that we can tailor make for your treatments to actually really help with your metabolic and weight control. Now, I said to you that this semaglutide was a weekly injection. If any of you have concerns about an injection, which you shouldn’t really have because the needle is very small, we do have an oral version of the same product.

Dr Harvinder Chahal:
And this is called rybelsus, it’s recently come onto the market and we’ve been giving it to a lot of patients here at the London Medical. But the beauty of this medication is that you can still have the beneficial effects of the weekly injection in the tablet version. And that’s been shown again in similar type of studies comparing with other diabetes products, so empagliflozin is an SGLT2 inhibitor, which I mentioned before, you’ve got sitagliptin, liraglutide, another GLP-1 agonist and patients in these types of studies, some of them had kidney problems or were on insulin. And the rybelsus that all were tablets at the maximum dose we can give is 14 milligrams. And again, all throughout the trials, 14 milligrams of oral semaglutide rybelsus was giving much more meaningful glucose reduction. There’s also good weight loss reduction on this medication as well. So really, really a beneficial effect on your type two diabetes.

Dr Harvinder Chahal:
So just to end off with, I thought I’d just illustrate the different diabetes medications we do have available to our patients with type two diabetes. And some of you may have tried some of these medications before, but we’re now learning that some classes of type two diabetes medications are more beneficial for patients. So if you’re really looking for cardiovascular protection, kidney protection and weight loss, as well as glucose reduction, then really we should be focusing on these last two columns here, so SGLT2 inhibitors, which I talked to you about first, as well as GLP-1 agonists, because if you go onto these two types of medications, you’re going to get weight loss, you’re also again to get blood pressure reduction, cardiovascular protection, renal protection in some of the SGLT2s, but also the beauty is you will not be at higher risk of hypoglycemia unless you on any other medication that cause hypoglycemia like insulin or glipizide.

Dr Harvinder Chahal:
Now, some of you may still be on glipizide, glipizide is a sulfonylurea. I don’t tend to use glipizide as much in my practice because patients can be at risk of hypoglycemia, as well as weight gain if they’re having regular low glucose levels, because patients are constantly trying to eat to try to keep up with the low sugar levels. So I’m very active in trying to change my patients who may be on glipizide or sulfonylurea onto SGLT2 or GLP-1s.

Dr Harvinder Chahal:
Now, some of you may still be on DPP-4 inhibitors so the most common ones are sitagliptin, saxagliptin, alogliptin or linagliptin. Now these medications are weight neutral, so you’re not going to get weight gain, but certainly you’re not going to get weight loss as compared to the SGLT2s or GLP-1s. So again, if you’re still on the DPP-4 inhibitors, and you want to think about changing over to SGLT2 or GLP-1s, then certainly book in to see me at the London Medical and happy to go through that.

Dr Harvinder Chahal:
Metformin is probably what most of you are still on, or have tried. If you’re able to tolerate it, it’s still a very good medication because patients will lose weight on it and it does tend to reduce insulin resistance. So I do try to see if my patients can still stay on Metformin, but some of you may have had side effects to Metformin such as gastric side effects, which may mean it’s not a medication we can continue. So I think that’s a lot of me talking, so hopefully I’ve given you a quick overview of some of the newer type of medications in type two diabetes, particularly the SGLT2s and the GLP-1s, but delighted to take any questions you may have for me today.

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