Prolonging life in type 2 diabetics
Channel: York Cardiology
Date: 01/02/2021

People with type 2 diabetes are more vulnerable to virtually all forms of short-term and long-term health complications and even premature death. Moreover the incidence of type 2 Diabetes is reaching almost epidemic proportions. It is estimated that almost 440 million patients world-wide will have type 2 diabetes by the year 2030 and the majority of patients will be in in the 40-65 year age group.
Type 2 diabetes is thought to be due to poly-genetic and lifestyle factors - in terms of lifestyle, obesity contributes to more than half the number of cases. In addition, a sedentary lifestyle, poor dietary choices, cigarette smoking and excessive alcohol intake can all contribute. Currently the method used to look for diabetes is to use a blood test called HbA1c, which measures blood sugar control over time and if the blood sugar is over 6.5% then a diagnosis of diabetes is made and all efforts are made to reduce this number as a means of controlling the diabetes and minimising complications. It is important to understand however that Diabetes is a process and the number is simply a guide to the process. Unfortunately what has happened is that our emphasis on the number and managing the number has become more important than understanding and managing the process. This approach is wrong because it makes certain assumptions which are wrong.

We make the assumption that the process starts when the number goes up i.e if your number is ok then you don't have diabetes and if the number is up then you do. This is wrong. The process may have started before the number starts going up. In fact a lot of research suggests that up to 25% of patients with type 2 diabetes have micro vascular complications at the time of diagnosis suggesting that the process had been going on for several years before the number reached the point where we make the diagnosis

It makes the assumption that if you control the number, you have controlled the process and that by doing so you prevent bad outcomes for the patient. When we look at the studies, they suggest that yes if you focus on just control blood sugar intensively, we do reduce the chances of microvascular complications such as kidney disease and eye disease but there is no overwhelming reduction in the risk of macro vascular complications such as heart attacks and strokes and this observation may again give credence to the idea that Diabetes is more than just a number and perhaps we should be understanding the underlying process better and treating the process rather than a surrogate i.e the HbA1c. In fact when we combine lifestyle changes with medications, we see better results and perhaps that is because lifestyle measures probably address the underlying process whereas some of the commonly used medications tackle just the number. 

This is where this new set of medications that i am going to talk about come in. These medications are called the SGLT-2 inhibitors and they are being seen as a game changer in Diabetes management because they don't seem to have a dramatic effect on blood sugars but do seem to have a significant benefit on cardiovascular and renal events.