From Diabetes Forecast Magazine
Feature Article
On Exenatide, A Super Loser
By Carol H. Wysham, MD
More and more, we are learning that type 2 diabetes is not just about
insulin. People with type 2 diabetes may have too little of another
hormone. Normally this other hormone tells you when you have eaten
enough. If you have too little of this hormone, you may overeat. This
hormone also tells your pancreas to release insulin to cover the meal
you just ate.
Exenatide (brand name Byetta) mimics this hormone. It is injected
before breakfast and dinner. When it works well, you get the "I’m
full" signal, so you don’t overeat, and you may lose weight. Exenatide
also helps your pancreas release insulin at the best time, so your
blood glucose levels improve.
Exenatide is approved for patients who are on metformin with or
without a sulfonylurea and are still not hitting their blood glucose
goals. Many of the patients at our clinic have gotten good results
with exenatide.
Case Study
A year ago, Mr. Kirkwood (not his real name), a 57-year-old plumber,
weighed 293 lbs. He was taking four medications for high blood
pressure, and it still wasn’t well controlled. He also took a statin
for high cholesterol.
For his diabetes, he was taking metformin twice a day, a TZD once a
day, and a sulfonylurea once a day. His A1C was 7.1%, and his average
fasting blood glucose was 142 mg/dl. We wanted to get those closer to
normal. At different times we tried insulin, a higher dose of the
sulfonylurea, and repaglinide, but these led to hypoglycemia.
Then we tried exenatide. In the first month on exenatide, Mr. Kirkwood
called to report he was having some lows. We told him to stop taking
the sulfonylurea.
Three months later, Mr. Kirkwood had lost 16 lbs. He said he was
eating much less than he used to. He was beginning to feel more
energetic. His A1C was 6.5%, and his fasting blood glucose level was
133 mg/dl. His blood pressure was lower, so we told him he could stop
taking his fourth blood pressure medication.
At his clinic visit 6 months after starting exenatide, we didn’t
recognize him. He weighed 255 lbs. His A1C was 6.5%; his fasting blood
glucose was 126 mg/dl. He said the exenatide was still working to
decrease his appetite. He was being more active, and he was happy and
hopeful.
At Our Clinic
Mr. Kirkwood is one of what we call our Super Losers: people for whom
exenatide works very well. About 30% of the patients at our clinic are
Super Losers. But not everyone responds to exenatide. In our clinic,
about 12% have seen no difference in their blood glucose levels, and
22% have not lost weight. All who do lose weight do so in the first
month on exenatide. After 2 years, there is a gradual increase in
weight and blood glucose.
In our experience, women tend to do better with exenatide than men.
Perhaps this is because women have typically been on many, many diets
in their lifetimes and are used to cutting back.
What You Can Do
Maximize your chances of success.
People who do a formal weight loss program along with exenatide tend
to lose more weight. When you go on exenatide:
- See a dietitian, or
- Join Weight Watchers
Set yourself up to eat less.
About half our patients say they feel "nausea" in the first few days
or so of using exenatide. Many people with type 2 diabetes are used to
eating large amounts of food without getting the "full" signal. We
think some of the nausea reported may simply be the feeling of being
too full. When you start exenatide:
- Use smaller plates.
- Eat slowly.
- Keep asking yourself, "Have I eaten enough?" As soon as the answer
is "yes," stop.
Take your other meds at the right time.
Exenatide affects how long food stays in your stomach. Some
medications should be taken on an empty stomach (check with your
pharmacist), so take these 1 hour before you eat. These include:
- certain antibiotics
- thyroid hormone
- transplant meds
- bisphosphonates (for osteoporosis)
Carol H. Wysham, MD, is clinical endocrinologist at Rockwood Clinic in
Spokane, Washington, and clinical assistant professor of medicine at
the University of Washington.
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"Tread with gentleness and respect on the Sacred Land: within it are