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Pharmacological treatment for the diabetic obese patient
Professor John Wilding, University of Liverpool, UK outlined the current status of obesity and diabetes treatment. “In the diabetic patient the important consideration is the prevention or delay in the development of diabetes related diseases and/or conditions,” said Wilding. “However, one of the most important concerns of a diabetic patient is weight gain as most of the drugs have the consequence of making them fatter.”
The overall aim of treatment is to reduce the burden of diabetes and improve the patient quality of life, whilst reducing the costs. He cited evidence that suggests with early intervention and reducing glucose levels down to almost normal levels the burden of diabetes related complications can be reduced, but not completely resolved. However, he warned that there was evidence to suggest that if this treatment was performed later and with the wrong agents it may actually cause additional damage. “If lipid lowering and blood pressure lowering treatment is added to glycaemic control then this can have a profound effect on cardiovascular outcomes,” added Wilding. “The take home message is that early intervention works and is most effective for all the risk factors.”
The evidence shows that the more obese the patient becomes their lipid control and blood pressure worsens. In Wilding’s institution in Liverpool, they demonstrated that if a patient is a diabetic with a BMI >35, their coronary artery disease risk is the equivalent to someone ten years older due to increased risk factors. However, studies show that patients who lose modest amounts of weight (eg two stones/28lbs) are associated with the highest amounts of reduced mortality.
According to Wilding, there is a trade-off between the side effects of therapy and a patient’s quality of life. The evidence shows that if you gain weight and have lots of hypoglycaemia your quality of life gets worse, whereas if you lose weight and reduce your hypoglycaemia, your quality of life improves. Therefore, he argued, there should be a greater focus on the need to reduce weight and improve the quality of life.
The Look ahead study that is examining lifestyle management has reported weight loss and lipid reduction, although it does not indicate successful weight loss long term. Such studies demonstrate that lifestyle management does have a place.
Wilding then examined drug use for weight loss and looked at the Xenical in the Prevention of Diabetes in Obese Subjects (Xendos) study, which showed orlistat therapy reduced the incidence of diabetes beyond the result achieved with lifestyle changes only, an effect that was especially evident in patients with baseline impairment of glucose tolerance.
“Diabetes results in significant morbidity and mortality, and we need to manage all the risk factors not just glucose”, concluded Wilding. “Obese patients do less well so we need to combat the obese population.”