5 min readMar 23, 2024 06:00 PM IST
First published on: Mar 23, 2024 at 06:00 PM IST
In recent months, there has been a lot of noise regarding diabetes reversal programmes — especially through paid advertisements during popular interviews on various social media platforms. These ads vehemently criticise the drugs used for diabetes and call them “toxic” chemicals that can potentially damage vital organs like kidneys, liver and heart. The programmes invite listeners to subscribe and join paid training courses with a guarantee of taking the patients off medicines.
However, these measures, also known as lifestyle modifications for managing established diabetes, have been well-established for several decades. They consist of maintenance of an ideal weight, regular exercise, consumption of low carbohydrates in the diet, plenty of fresh vegetables and fruits and behavioural modification. If not put into proper perspective, these advertisements can be misleading for the around 101 million known diabetics in our country. I have personally seen many persons fall into this trap, stop all their drugs and then end up in hospital with complications that are sometimes life-threatening.
Despite following lifestyle measures, around 60 per cent of established diabetics still need drugs in addition to controlling sugar and glycosylated haemoglobin (HbA1c). These drugs, however, must be safe and preferably protective for the heart, vascular system and kidneys. Heart attacks, heart failure, strokes and kidney failure are common issues in diabetics — especially long-standing cases, despite good sugar control. Besides this, impairment or loss of vision, ulcerations and gangrene of the toes are also known problems.
The choice of drugs is thus very important for improving the condition of diabetic patients both with and without established vascular and renal complications. The first breakthrough in the treatment came with the discovery of insulin in 1921, which lowered blood sugar and improved the prognosis of diabetics. Since it is a protein, it has to be administered as an injection. There are several types of insulin available nowadays. All patients suffering from Type 1 diabetes, which means that those whose pancreas makes little to no insulin, need insulin injections. These diabetics are insulin-dependent throughout their lives.
Type 2 diabetes, on the other hand, is diagnosed in adulthood and is because of a deficiency of insulin. These individuals are often obese with a family history of diabetes. Many of them need agents other than insulin to both control blood sugar levels and reduce vascular complications. There are several agents available for this purpose. These can be used individually or in combination in around 60 to 70 percent of cases, without the need for insulin. These drugs work in multiple ways: 1) They cause the pancreas to make and release more insulin; 2) They limit the liver’s ability to make and release sugar; 3) They block the action of enzymes in the intestines that break down carbohydrates, slowing the uptake of carbohydrates; 4) They improve cells’ sensitivity to insulin; 5) They excrete sugar from blood into urine through the filtration process of the kidneys; 6) They slow the movement of food through the stomach and reduce appetite.
Even so, of note are the drugs that not only control sugar by reducing HbA1c by around one per cent but also improve the outcome for diabetics — which was less likely through other agents. These belong to the following two groups.
SGLT2 (sodium glucose cotransporter-2) inhibitors: Canagliflozin, dapagliflozin, empagliflozin and ertugliflozin. These agents reduce the chances of heart failure for both sub-clinical and clinically overt patients, protect kidneys and help in stabilising diabetic kidney disease. In addition, they reduce weight and blood pressure modestly. It is recommended that all type 2 diabetics take these agents unless there is a urinary or genital infection that can be aggravated because of the excretion of sugar through urine.
GLP1 (glucagon-like peptides 1): These agents are important drugs for reducing vascular events (heart attacks, strokes, etc) in diabetics with existing heart disease or multiple risk factors (high BP, high cholesterol, family history, overweight, smoking, etc). However, as proteins, they are to be administered as injections once a day (liraglutide). Recently, once-a-week options have become available as well (Semaglutide, Tirzepatide, Dulaglutide etc). Besides reducing vascular issues and sugar levels, these drugs also reduce body weight significantly. Semaglutide and Tirzepatide have become very sought-after agents in the US and Europe for weight reduction even in the absence of diabetes. An oral Semaglutide preparation has been developed after path-breaking research to make a protein in a pill possible. This is available in oral form as Rybelsus.
The last few decades have ensured much better drug treatment of diabetes for individuals whose lifestyle management is not adequate to control the condition. These agents are useful even when blood sugar levels are under control because vascular complications can occur despite good sugar control. A large number of diabetics also need medicines for high blood pressure, high cholesterol levels and chronic kidney disease. Lifestyle modifications in isolation and making statements on reversing diabetes without drugs may, therefore, be misleading.
The writer is a cardiologist and founder of Gauri Kaul Foundation
The programmes invite listeners to subscribe and join paid training courses with a guarantee of taking the patients off medicines. (Photo: Pexels/ Representational) 
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