Do people with Type 1 diabetes take medications for Type 2 diabetes?
The other day, Myra came to my clinic for her initial assessment for Diabetes Self-Management Education. As we were going through her list of medications, I discovered that she was taking liraglutide (Victoza), but her diagnosis was clearly Type 1 diabetes.
Myra stated that her endocrinologist had prescribed the medication. He informed her that this was becoming more common. I had heard that patients with Type 1 diabetes were being prescribed GLP-1 non-insulin injections for their Type 1 Diabetes, specifically liraglutide.
I had also heard about SGLT2 inhibitors were being used for Type 1 diabetes, but I had heard about an increased incidence of diabetic ketoacidosis (DKA) with these medications for Type 1 and Type 2 diabetes patients. Since inquiring minds want to know, I decided to investigate both.
Liraglutide for Type 1 diabetes in the news
In August, 2015, Novo Nordisk made a decision not to pursue liraglutide for Type 1 diabetes with the Federal Drug Administration (FDA). This decision came after the second trial for the FDA approval was completed. In the trial, researchers compared the addition of liraglutide to insulin therapy with a control group on standard insulin therapy. Novo Nordisk concluded that the results were not quite good enough, and decided not to pursue the FDA approval for liraglutide for Type 1 diabetes.
Benefits of liraglutide in Type 1 patients
In the study, when taking liraglutide, Type 2 patients saw a lower A1C, significant weight loss, and decreased number of episodes of hypoglycemia. Conversely, Type 1 patients taking liraglutide did not fare as well with A1C reduction, showing only a slight reduction in A1C (0.5% reduction compared with 0.3% reduction in control group).
There was not much of an effect on episodes of low blood glucose or hypoglycemia, but a continuous glucose monitor was not used in the trials. CGM use may have given a better picture as to what was going on with blood glucose. This could have shown whether or not hypoglycemia is less of a problem in patients taking liraglutide for Type 1 diabetes.
Type 1, weight loss and liraglutide
Liraglutide did have a significant effect on weight loss for Type 1 patients. In the trial, patients lost almost 10 pounds, while the control group taking insulin gained 2 pounds. Still, this was not enough reason for the company to seek FDA approval for a Type 1 indication. (1)
When is it appropriate to add liraglutide for Type 1 diabetes?
In my research, I learned that 40% percent of those with Type 1 diabetes also have metabolic syndrome (a group of risk factors that raises your risk for heart disease and other health problems such as stroke). Liraglutide takes care of 3 things related to metabolic syndrome, including weight, diabetes and blood pressure. (2)
The positives and negatives of liraglutide for Type 1 diabetes
You could have less episodes of low blood glucose, need 25% less insulin to get in your target ranges, and experience a drop in blood pressure as well as weight, by adding liraglutide to your regimen. With all of the benefits, you might want to try it for your Type 1 diabetes. Have a conversation with your endocrinologist as to whether or not you could benefit.
On the other hand, you are talking about another daily injection on top of your insulin injections. Also, because liraglutide is not FDA approved for Type 1 diabetes, it will be costly for the patient in most cases. Knowing that insurance will not cover it, you will want to check in to the cost of the medication with your insurance company.
What about SGLT2 Inhibitors for Type 1 diabetes?
SGLT2 inhibitors were being watched as a possible method for obese patients with high blood pressure and Type 1 diabetes as a way to smooth out blood glucose, and avoid highs and lows. This year, initial trial results came in that suggest that SGLT2 inhibitors used in Type 1 diabetes patients may increase the incidence of DKA (Diabetic Ketoacidosis).
The study involved the SGLT2 drug, canagliflozin (brand name Invokana) in an 18-week, phase 2 study. Infections and insulin pump failures certainly contributed to the increased incidence of DKA when Type 1 patients took canagliflozin. With a 300 mg dose of canagliflozin, patients had a greater than 9% incidence of DKA. At the very least, SGLT2 inhibitors should only be used in Type 1 patients who are being monitored regularly for signs of DKA by their physician. Again, the drug will not be covered by insurance, since it is not approved for Type 1 diabetes. (3)
In closing, my opinion is that liraglutide should be considered as an add on therapy for those with Type 1 diabetes if cost is not a factor. However, I do not believe that benefits of SGLT2 inhibitors outweigh the risks of DKA.