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The Oct. 18 issue of Annals of Internal Medicine describes two new diabetes treatments: exenatide, an injected drug; and inhaled insulin. Both treatments have pluses and minuses and were tested on people with type 2 diabetes who were already taking two oral blood-sugar-lowering drugs but whose levels were not under control.
A 26-week trial comparing benefits and harms of exenatide and insulin glargine injections in 551 patients with type 2 diabetes found that both drugs improved overall sugar control, but patients in the exenatide group lost about five pounds, whereas patients in the insulin glargine group gained about four pounds (Article, p. 559). Patients in the exenatide group had more bad side effects, such as nausea, vomiting and diarrhea, and more patients in this group dropped out of the study than in the insulin glargine group. Neither drug helped patients achieve recommend fasting sugar levels; only 21.6 percent of the exenatide group and 8.6 percent of the insulin group achieved target blood sugar levels. Also the study participants included only a few African-Americans, a group with a high rate of type 2 diabetes.
A 12-week trial comparing effects of inhaled insulin (a fast-acting insulin) with oral drug therapy in 309 patients, assigned patients to one of three treatments: inhaled insulin alone, inhaled insulin added to two blood-sugar-lowing oral drugs, or oral drug therapy alone (Article, p. 549). Researchers found that both groups receiving insulin therapy improved blood sugar levels. Patients receiving inhaled insulin gained more weight and had more episodes of hypoglycemia (abnormally low level of blood sugar or glucose) and cough than the oral therapy alone group. The study didn't compare inhaled insulin with injected insulin and only lasted 12 weeks, so the drug's long-term effects on the lungs or on diabetes control are not clear. The current inhaler device, used before each meal, is large and only allows dosing of 2.5 to 3.0 units of insulin, while injected insulin currently allows for finer adjustments in dose. An editorial writer says that the two new treatments provide much-needed options for treating the later stages of diabetes (Editorial, p. 609). However, until development of "precise molecular targets" for type 2 diabetes, lifestyle choices (increasing exercise and reducing weight) will be the cornerstone of managing this debilitating and increasingly common disease.
An internal medicine practice calculated drug expenses for 137 low-income Medicare patients without drug prescription coverage who had, at some point, received aid from pharmaceutical company assistance programs (Article, p. 600). Authors put the patients into one of four hypothetical groups: no financial assistance, aid from pharmaceutical programs, Medicare drug discount cards (providing transitional assistance) and the new Medicare prescription benefit, which will take effect in 2006. They then figured out-of-pocket expenses for the patients' prescribed drugs. For these low-income people, the pharmaceutical programs offered the most savings. All plans provided cheaper drugs than having no coverage. Month-to-month expenses for the two Medicare programs varied, depending on deductibles. The authors say that before enrolling in a new drug benefit program, individuals should "consider their eligibility for low-income subsidies and their prescription needs and projected costs; for some seniors, such alternatives as pharmaceutical company assistance programs may provide more cost savings."