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Sweating out the sweet
With the largest number of diabetics in the world, India
has emerged as a huge ground for exploring newer therapies and research on diabetes.
Sachin Jagdale finds out what treatments are underway
 Diabetes
is a silent killer and ironically this bitter fact has sweet roots. The fact
that India is tipped to be the diabetic capital of the world is an unsavoury
fallout of our tradition to celebrate happy occasions by distributing sweets.
If diabetologists are to be believed, by 2025 there will be more than 55 million
diabetic patients in India. In other countries as well, incidence of diabetes
will increase as their population ages.
Since the forecast is not promising and things are set to
go from bad to worse, scientists across the world are searching for different
remedies/treatments to fight the disease whose sly attitude is perhaps more
threatening than AIDS and cancer. Perhaps the best description of the disease
comes from the blog of Scott Johnson, Minneapolis, US who was diagnosed with
type 1 diabetes in April 1980. In his blog, he quotes Marlene Less: "Diabetes
is like being expected to play the piano with one hand while juggling items
with another hand, all while balancing with deftness and dexterity on a tightrope."
Basket of hope
For many decades tablets and insulin injections have remained the treatments
of choice for doctors and diabetic patients. However, over the years the incidence
of diabetes assumed pandemic proportions and researchers started trying different
sorts of drug delivery methods. The main aim of these projects is to reduce
pain and improve patient compliance, because if the patient dreads injections,
he will unwittingly postpone the injection which will result in improper blood
sugar levels. Although not all treatments received accolades, they definitely
set the tempo to try something new. Efforts to make insulin available in tablet
form and insulin pumps are some attempts in this direction, though the pumps
did not live up to expectations.
"Current methods of treatment of diabetes include the
use of tablets (oral hypoglycemic agents, OHAs) and insulin. Different classes
of OHAs and insulin are in use. Metformin (insulin sensitiser) and sulphonylureas
(agents which potentates insulin secretion) are the two groups of tablets that
have been in use for long. Recently, newer groups like thiazolidinediones (rosiglitazone
and pioglitazone) and glitinides (repaglinides) have also gained popularity
among physicians. Recent developments in insulin therapy include the use of
insulin analogues like glargine (Lantus) which is given once a day and the insulin
pump," informs Dr V Mohan, President and Chief of Diabetes Research, Madras
Diabetes Research Foundation.
 "Recently,
newer groups like thiazolidinediones (rosiglitazone and pioglitazone) and
glitinides (repaglinides) have also gained popularity among physicians"
- Dr V Mohan
President and Chief of
Diabetes Research
Madras Diabetes Research Foundation
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 "Polypharmacy
(two-drug and three-drug combinations) in diabetes is becoming more and
more popular in India, than anywhere in the world"
- Professor P V Rao
Head-Department of Endocrinology and Metabolism
Nizam's Institute of Medical Sciences, Hyderabad
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 "Current
trend is of aggressive therapy management so as to bring down the A1c levels
to 6.5 percent or even below the six percent mark"
- Dhiren Wagle
Country Manager
Bio-Rad Laboratories
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 "Insulin
analogues have started slowly replacing conventional insulins but one cannot
say that era of conventional insulin has come to an end as it has saved
millions of lives in past 75 years of its invention"
- Dr Anuj Maheshwari
Secretary
Uttar Pradesh Diabetes Association
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According to Dr Anuj Maheshwari, Secretary, Uttar Pradesh Diabetes Association,
insulin analogues have started slowly replacing conventional insulins, but one
cannot say that era of conventional insulin has come to an end as it has saved
millions of lives in past 75 years of its invention. After the improvement of
formulations in insulin purification, recombinant insulins and insulin analogues
have become available.
"Polypharmacy (fixed dose combinations—FDCs—in
two-drug and three-drug combinations) in diabetes is becoming more and more
popular in India, than anywhere in the world. Some of the developed countries
are stricter with FDCs for diabetes, and the medical fraternity in other countries
considers India as a pioneer in introducing FDCs for diabetes and hypertension.
Doctors and patients alike are more in favour of using FDCs in all permutations
and combinations," opines Professor P V Rao, Head, Department of Endocrinology
and Metabolism, Nizam's Institute of Medical Sciences, Hyderabad.
On this count, there are varied opinions from different sectors of industry.
Dhiren Wagle, Country Manager, Bio-Rad Laboratories, feels that current trend
is of aggressive therapy management so as to bring down the A1c levels to 6.5
percent or even below the six percent mark. He says, "This stringent control
is made possible by the latest and more effective insulins and drugs."
| Insulin pump
Insulin pumps are about the size of a pager attached
to the body through a narrow flexible tube with a needle just under the
skin. The insulin pump delivers insulin from a reservoir inside the pump,
through a thin plastic tube (called an infusion set), to the body. Most
infusion sets are worn in the abdominal area and use a tiny, flexible
tube, called a cannula, which is inserted easily into the skin using an
insertion device. Patients generally have to refill insulin and change
the infusion sets every two to three days and frequent glucose monitoring
is necessary. Pump users can easily adjust the pump for changes in lifestyle
needs, and can program insulin delivery at mealtimes. A pump is easy to
program and automatically delivers a constant rate of insulin called a
"basal rate" to keep blood glucose in the desired range between
meals and over night. Pump therapy can replace insulin shots for many
patients, allowing diabetes patients to live a more flexible lifestyle.
However, they are presently very expensive.
Self monitoring of blood glucose
Self monitoring of blood glucose (SMBG) allows patients
with diabetes to measure their blood glucose levels at home, to detect
patterns of glycemia and aid in adjustment of treatment regimens (diet,
exercise, oral anti-diabetic agents, insulin doses) as needed, and achieve
near-normal blood glucose levels. A number of blood glucose meters, (or
monitors as they are called), have been developed to help people test
their blood glucose in the comfort of their homes at any time of the day
or night just using a drop of blood. A range of blood glucose meters to
suit individual's needs are available in the market.
Continuous glucose monitoring system
Important strides are being made in blood glucose monitoring
that allows collection of better data to guide diabetes management. Recently
to overcome problems related to availability of data, devices are being
developed that make it feasible for both physicians and patients to obtain
continuous glucose readings (Continuous Glucose Monitoring System,CGMS).
The CGMS monitors interstitial fluid, which directly
reflects the glucose concentration in the blood. CGMS is a pager sized
electronic system designed to continuously monitor glucose levels by collecting
electric signals from the glucose sensor every ten seconds, converting
those signals into glucose values, and storing an average blood glucose
value every five minutes for up to 72 hours. The system allows for these
values to be downloaded to a personal computer so that the patient and
physician can review the data and make intelligent treatment decisions.
The CGMS can record a glucose measurement every five minutes, for up to
three days, that's 288 readings a day - up to 864 readings in 72 hours.
CGMS can detect hyperglycemic and hypoglycemic excursions in patients
with diabetes. Knowing continuous glucose levels facilitates physicians
to treat diabetic patients better and allows the patients to follow a
treatment program that is more personally tailored. It is an excellent
tool to monitor glucose levels.
Non-invasive blood glucose monitoring: "Glucowatches"
Frequent automatic glucose readings can be obtained non-invasively
through the process of reverse iontophoresis, in which a low electric
current pulls glucose molecules through the skin for collection in a gel
disc. A device that is worn like a wristwatch is approved for patients
aged over 7 years in the United States, but its cost (about $1000 for
the device and more than $100 per disposable 12-hour sensor) limits more
widespread use. It is not yet available in India.
Current treatment strategies not only include treatment
of diabetes, but also "metabolic syndrome", which is characterised
by insulin resistance, obesity and a range of cardiovascular risk factors.
Hence the need for early and aggressive management of insulin resistance
and associated abnormalities, such as dyslipidaemia, hypertension and
albuminuria is also given utmost importance.
Source: Dr V Mohan
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Re-searching health
Despite advances in treatments, a complete cure for diabetes remains elusive.
Recently, researchers at Diabetes Research Institute (DRI) at University of
Miami Miller School of Medicine and Krolinska Institute in Stockholm managed
to see transplanted insulin secreting cells, islets, function when they are
inside living organisms. However, survival of transplanted insulin producing
cells is a big concern in such research projects. Efforts are on to turn stem
cells into insulin producing cells.
"Stem cell therapy, although premature now, will have a potential in near
future. We at NIMS Hospital, for the first time in India, have tried this for
two diabetics in January 2006 with not so encouraging results," says Rao.
After the transplantation of insulin producing cells, it is necessary to protect
them from an immune system attack. Scientists are optimistic about tissue engineering
techniques and nanotechnology to protect insulin producing cells.
Maheshwari provides detailed insights into the benefits of these modern techniques.
He says, "Nanotechnology has come up as saviour in fight against diabetes.
It offers new solutions in treating diabetes mellitus. Boxes with nanopores
that protect transplanted beta cells from the immune system attack, artificial
beta cells and artificial pancreas instead of pancreas transplantation, nanospheres
for biodegradable polymeric carrier for oral delivery of insulin are among those
solutions for which pharma companies are trying to develop targeted drug delivery
system using nanomedicine." He finds the concept of artificial beta pancreas,
whose functioning is also quite simple and more attractive. Explaining the procedure,
he adds, "A sensor electrode repeatedly measures blood glucose level, feeds
these readings into a small computer that energises the insulin pump to provide
needed units of insulin into the blood stream from the cartridge of insulin
or analogue already placed in insulin pump as reservoir. A mini infusion pump,
the size of a mobile phone, can be easily kept in the pocket of patient."
Besides biological work, there is a focus on bringing out new molecules. Many
Indian and foreign companies are working in this direction. "A lot of work
on diabetes research is underway to find better and improved molecules in diabetes
treatment. Liraglutide is a promising once-daily GLP-1 analogue under investigation
for the treatment of people with type 2 diabetes. Its glucose-dependent stimulation
of insulin secretion and inhibition of glucagon improves glycaemic control with
a low risk of hypoglycaemia," informs Melvin D'Souza, MD, Novo Nordisk
India.
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INDIAN DIABETES RISK SCORE [IDRS]
developed by Dr. V. Mohan & colleagues, Dr. Mohan's Diabetes Specialities
Centre & Madras Diabetes Research Foundation, Gopalapuram, Chennai
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| PARTICULARS |
SCORE |
| Age: |
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| <35 years |
0 |
| 35 - 49 years |
20 |
| 50 years |
30 |
| Waist circumference: |
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| Waist < 80 cm [female],
<90 cm [male] |
0 |
| Waist 80 - 89 cm [female], 90 - 99 cm
[male] |
10 |
| Waist 90 cm [female], 100 cm [male] |
20 |
| Physical activity: |
|
| Vigorous exercise [regular] or strenuous
[manual] work at home / work |
0 |
| Moderate exercise [regular] or moderate
physical activity at home / work |
10 |
| Mild exercise [regular] or mild physical
activity at home / work |
20 |
| No exercise and sedentary activities
at home / work |
30 |
| Family history of diabetes: |
|
| No diabetes in parents |
0 |
| One parent is diabetic |
10 |
| Both parents are diabetic |
20 |
Unpleasant tag
According to the World Health Organization (WHO), India is currently home to
over 36 million diabetic patients, constituting 20 percent of the world diabetic
population. So is it possible to change this dubious distinction of India being
home to the world's largest diabetic population? The response to this query
is not encouraging, as for better or worse, it is in our genes. Rao says, "With
the current treatments we will not succeed in wiping out the tag of being diabetic
capital of the world. More and more people who were not diagnosed earlier (almost
twice the number of diagnosed patients) will become known diabetics. India will
have more diabetics in near future. Current and forthcoming therapies will not
reduce the burden of diabetes in India. Non therapeutic modes of diabetes management
(life style changes, relaxation techniques, food preferences etc.) can help
to a certain extent."
Even Wagle echoes Rao's opinion. He says, "Right now hope is not round
the corner." Industry stalwarts like D'Souza feel that India's status as
the diabetes capital of the world is a grave concern for healthcare providers,
governments, as well as for patients themselves and their families. Education
in terms of awareness and therapy options is crucial in delivering a thorough
understanding in the management of the disease. So it seems that in the absence
of a cure, diabetes patients will have to learn to manage the disease and ignore
their cravings for a 'sweet something'.
sachin.jagdale@expressindia.com
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