The Circle of (diabetic) Life

In the early days of medicine the ancient physicians recognised a condition that was characterized by excessive drinking and passing large quantities of urine and they called it diabetes. It didn't take them long to recognize that there were actually two varieties of this condition, one where the patient’s urine tasted sweet (Mellitus, from the latin for honey) and one where the patient’s urine tasted of nothing much (Insipidus - it tasted insipid!).

Later, they realised that the presence of glycosuria and the accompanying osmotic diuresis were actually consequent upon hyperglycaemia. Ever since then, our aim in treating diabetes (mellitus) has been to control hyperglycaemia and thereby to control osmotic symptoms in the first instance and risk of complications in ­the long term.

At the beginning of the modern era of diabetology this was first with the use of insulin and later, for patients with type 2 diabetes, with the first oral hypoglycaemics - the biguanides, later the sulphonylureas and more recently with glitazones, glinides, DPP-IV inhibitors etc.

How ironic then that the latest class of oral hypoglycaemic takes us back to the beginning by intentionally inducing glycosuria - the SGLT2 inhibitors. Any day now, if you practice in the UK, you can expect the launch of Dapaglifozin, a first-in-class novel oral hypoglycaemic for (initially) the treatment of type 2 diabetes. By inhibiting renal tubular glucose reabsorbtion it induces glycosuria, lowers blood glucose and therefore HbA1c by ~0.5-1% and induces a small weight loss. It also induces an osmotic dieuresis in the region of ~400ml/day and increases the risk of uro-genital candidiasis (a bit like having uncontrolled diabetes).

Will it be any good? Well, of course, only time will tell if it will reduce macro- and micro- vascular complications, decrease MI and stroke rates and ameliorate premature mortality.

Many of us will still recall the days of routine urine testing for patients on oral hypoglycaemics. Back then, glycosuria was bad and its absence was a sign of good control. Now, the tables will be turned and perhaps glycosuria will be associated with good metabolic control, but one thing’s for sure, I’ll not be tasting!

Dr Turner has recently updated Diabetesbible's advice on driving. Click here to read more. 

Tags for this article: new therapeutics

The author - Dr Jeremy Turner

Jeremy Turner A consultant diabetologist and endocrinologist in Norfolk, and author of Diabetes Bible

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My blog expresses my personal views on the rapidly advancing field of diabetes. It is aimed at fellow physicians and is not offering medical advice to readers. I will not respond to requests for clinical advice. If you have health concerns please contact your GP or specialist.

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