These new medications prolong life and provide quality of life. How? In many ways. At the same time, they effectively reduce blood sugar level, but they also reduce weight and blood pressure. They protect the heart and kidneys. They postpone death.

But the first question is how many types of new medications are there?

There are two groups. They have complicated names, but we can simplify them. One group can be called intestinal hormones, medically speaking – incretin therapy (GLP-1 receptor analogues). The other group may be called renal helpers, medically speaking- renal sodium glucose transporter inhibitors (SGLT2 inhibitors).

Which is better?

There is no direct comparison. They work by different mechanisms. They reduce blood sugar levels very effectively, but they also have other effects on health. They can be combined, and they can be taken independently as well. Also, they can be combined with insulin and tablets for diabetes.

What are the benefits of “intestinal hormones” or “incretin therapy”?

They are referred to as GLP-1 (abbreviation for “glucagon like peptide”) receptor analogs.

Their biggest advantage is weight loss. That is what is first noticed. Appetite is lost due to the effect on the brain. Satiety increases, because food stays in the stomach longer.

The effect on lowering blood sugar levels is not due to reduced appetite and food intake. Blood sugar is lowered in a “natural way” – the disorder that led to diabetes is corrected. These medications stimulate insulin secretion in a rational way and do not cause hypoglycemia. Also, and perhaps more importantly, they inhibit the secretion of another pancreatic hormone, glucagon.

In some people with diabetes, the problem is precisely the inability to block glucagon. Glucagon constantly pushes sugar from the liver into the blood. This is hampered by these new medications.

They have a protective effect on the heart, through numerous mechanisms. They reduce atherogenesis. They improve the ejection fraction after myocardial infarction and in a state of chronic heart failure. GLP-1 RA have a vasodilatory effect and improve endothelial function. They reduce systolic pressure in people with T2 diabetes. Also, they reduce fatty liver.

What are the benefits of medications that act through the kidneys?

These medications have a complicated name – SGLT2 inhibitors (abbreviation for “sodium glucose transporter-2”).

Simply explained, they encourage the excretion of salt, sugar and water through the kidneys. The kidney is a great “saver” – it retains all the useful substances, including sugar and salt. The problem arises when the kidney exaggerates in blood sugar retention. This is a major disorder in many who have type 2 diabetes.

These new medications “open” the kidney. Sugar, salt and water are excreted via urine. This lowers blood sugar levels and blood pressure. The effect of fluid loss is described by patients as “deflating”. When sugar is excreted through the kidneys, it means that calories will be lost by urine. 70 grams of sugar are lost daily, which is 280 kilocalories. Not bad!

These medications do not work as powerfully as diuretics. Urination increases by slightly less than half a liter per day. However, that is enough to relieve the heart and reduce blood pressure. These medications especially help people who have had heart or kidney failure. They prolong their lives!

Are new medications registered in Serbia?

Yes. From the GLP-1RA group, the following were registered: Byetta, Bydureon and Victoza. They are all given via pen, like insulin. Byetta is applied 2 times a day. Victoza is taken once a day, and Bydureon once a week. Victoza is the most popular, because it is best tolerated. Pen has 3 doses of 0.6, 1.2 and 1.8 mg. It always starts with the lowest dose, which is increased by 7 days, up to a maximum of 1.8mg per day.

A combination of Victoza and insulin degludec is also registered. It is called Xultophy. It is the best medication for treating type 2 diabetes, but also the most expensive. Victoza in it reduces appetite, weight and protects the heart, while insulin degludec additionally keeps sugar under control.

Other GLP-1RA are registerd by FDA and EMEA – weekly semaglutide (Ozempic) and oral semaglutide (Rebelsus).

As for SGLT2 inhibitors, Jardiance and Forxiga have been registered in Serbia. Jardiance is available in doses of 10 and 25mg. Forxiga is usually used in a dose of 10mg. It is also approved in a dose of 5mg for type 1 diabetes. These medications are pills – that is why they are so popular!

What is the “revolution” in the treatment of type 2 diabetes?

This can be understood if this is known:

• Every tenth inhabitant of Serbia has type 2 diabetes
• 9 out of 10 patients with type 2 diabetes are obese,
• 6 out of 10 patients have high blood pressure and
• almost all of them have high blood fats.

These are all risk factors for cardiovascular diseases. Diseases of the heart and blood vessels occur 10-15 years earlier in people who have diabetes, as opposed to those who are free of diabetes.

The most common cardiovascular disease is heart failure. Heart failure is hard to recognize, especially in the early stage. People have reduced work tolerance, they feel shortness of breathe and their legs swell. Heart failure is more common than myocardial infarction. Even 7 out of 10 patients in the first 5 years, after the diagnosis of diabetes, have signs of heart failure. Unfortunately, even 7 out of 8 patients will die in the first 5 years if heart failure accompanies diabetes.

The revolution in the treatment of type 2 diabetes are the medications which prevent heart attack, stroke, death from heart disease, from heart failure and from kidney disease.

This modern therapy for diabetes works completely independently of the pancreas and insulin. It can be included in the earliest stages of diabetes (which is the recommendation of all associations), but it can also be added to the existing therapy in people with long-term diabetes. It does not cause hypoglycemia.

Who should use these modern medications for diabetes?

For everyone, and right away! When diabetes is detected, the first medication is metformin. We have it registered as Gluformin, Glucophage, Tefor, Siofor and Metfodiab. These are great medications! But, if HbA1c cannot be kept below 7% with this therapy – it is time for another medication. That other remedy has to be modern – and it is usually thought of Forxiga or Jardiance. Why? Because people with diabetes also have obesity, hypertension and dyslipidemia and all of these can be solved with modern therapy.

It is not necessary to wait for heart failure or heart attack to start treatment with new medications! It is necessary to prevent them from happening.

If you are a man over 55, or a woman over 60 and have type 2 diabetes and an additional risk factor: LDL over 3.36 mmol/l, blood pressure over 140/90 mmHg or you smoke over 5 cigarettes daily for over a year – you can regulate sugar well and prevent heart failure, kidney failure, heart attack and other cardiovascular events by using modern oral medications for type 2 diabetes.