Good medical news: New pill approved to treat Type II diabetes

A new pill called canagliflozin is a “sweet” way to treat Type II diabetes.

The Food and Drug Administration (FDA) has approved the first of a new class of anti-diabetic medications. This medication helps patients with Type II diabetes control their blood sugar levels in a way that hasn’t been used before.

This new class of drugs, SGLT2 inhibitors (short for sodium-glucose co-transporter 2), acts to allow diabetics to release more glucose into their urine and thus decrease blood glucose levels. This medicine, recently approved by the FDA, is canagliflozin (Invokana is the brand name.) A similar SGLT2 drug is already in use in Europe.

The dangers of diabetes

Diabetes is a disease that causes affected patients to have problems with keeping their blood sugar (glucose) levels in the normal range. Elevated levels of blood glucose can cause multiple problems if untreated. They can range from cardiovascular disease leading to heart attacks or strokes, to loss of vision, neuropathic pain, vascular disease that may lead to amputation of limbs, coma and even death. It is estimated that around 25 million Americans are diabetic. And that number is constantly growing. So this class of medications could potentially benefit millions of people.

Diabetes via Shutterstock

Diabetes via Shutterstock

What is diabetes?

There are two major types of diabetes labeled Type I and Type II. Type I diabetes (which used to be called juvenile-onset diabetes or insulin-dependent diabetes) happens when the pancreas is unable to produce insulin (a hormone necessary for most cells to be able to utilize glucose.) Type I diabetes needs to be treated by insulin injections.

Type II diabetes (formerly called adult-onset diabetes or non-insulin dependent diabetes) is a disease that causes the body’s cells to become resistant to the effects of insulin. Often Type II diabetes is treated with oral medications. These oral medications work by different mechanisms to help get blood glucose levels back to normal. These mechanisms include: acting on the intestine to help prevent the absorption of glucose into the blood, reducing insulin resistance by the liver, reducing insulin resistance by muscle and fat tissue and others.

The new SGLT2 inhibitor medications work with the normal kidney physiology to get rid of excess glucose.

How the new drug canagliflozin works

Briefly, urine normally gets made like this. The kidney filters blood that passes through it. Many chemical compounds get filtered out into the fluid that will become urine. Things like salts and other ions, urea, glucose and other relatively small molecules. A little later on in the process, the kidney reabsorbs the things that it deems valuable (some ions, glucose, etc.) and lets the remaining waste continue to move on and become urine.

So people with normally functioning kidneys, who don’t have diabetes, will essentially have no glucose in the urine that they produce. However, as the blood sugar rises above a certain limit, the kidney, as efficient as it is, becomes overwhelmed and can’t reabsorb all of the glucose. So some begins to spill out into the urine. Before the development of the current finger stick blood glucose analyzers, diabetic patients tested their urines for glucose. That gave them an idea of how high their blood glucoses were. The higher the blood glucose, the more glucose in the urine. The SGLT2 inhibitors act to block the reuptake of glucose. As a result, more glucose is allowed to spill out into the urine, and the blood glucose decreases.

Canagliflozin’s side effects

Like all medications, this one has side effects. Women taking it seem to experience a higher incidence of vaginal yeast infections, and both sexes are at increased risk for urinary tract infections. Also, it slightly increases both good and bad forms of cholesterol. There may be a slightly increased risk of stroke and heart attack for some patients. Though the FDA isn’t sure of the significance of the stroke and heart attack data.

But it also has good side effects. One is it promotes mild weight loss (some other anti-diabetes medications promote weight gain.) Another is that it also acts to lower blood pressure. Some other anti-diabetic medications can cause hypoglycemia, a condition where the blood sugar gets too low. This can cause the patient to develop a variety of symptoms while hypoglycemic (confusion, a feeling of shakiness, anxiety, sweating and others.) Canagliflozin doesn’t seem to produce hypoglycemia.

As with almost all new drugs, it will be fairly expensive, probably costing nearly $300/month for the daily dose. However, once the drug gets placed on insurance company formularies, the insured patients will only have the co-pay to worry about.

Why as a doctor I’m excited about Canagliflozin

This medication may be very useful for some Type II diabetics. Some are currently on multiple medications daily. Some fraction of those might be able to be switched over to a SGLT2 and get off of some other medications. Others who are having problems with weight loss, might benefit from being placed on this, either as a single medication or as part of a combination.

With diabetes being a widespread disease, causing much morbidity and contributing to many deaths, new, effective drugs are always welcome.

Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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