SAT-161 TREATMENT OF DIABESITY WITH DIET AND NEWER ANTIGLYCEMIC MEDICATIONS IN PLACE OF INSULIN: EFFECT ON DIABETIC KIDNEY DISEASE

Abstract

Type 2 diabetes is the result of several years of prediabetes and the metabolic syndrome. The goal of treatment is weight loss to reduce insulin resistance, and to reduce the need for glucose-lowering medications including insulin. Long term data from the Diabetes Control and Complications trial showed that tight HbA1C correction does not lead to better cardiovascular disease (CVD) outcomes, yet tight control does correct microvascular complications. Recent reports suggested that insulin therapy does not treat the biochemical components of metabolic syndrome, whereas the oral antihyperglycemic medications especially metformin, the incretin mimetics (GLP-1 receptor agonists) and the sodium-glucose co-transporter-2 (SGLT2) inhibitors do indeed correct this. Weight loss correction also needs a caloric deficit but this becomes hard with insulin therapy which often causes weight gain. Standards of Medical Care in Diabetes by American Diabetes Association stated that SGLT2 inhibitors and GLP-1 RA should be considered for patients with type 2 diabetes, established atherosclerotic CVD and chronic kidney disease (CKD) who require another drug or cannot tolerate metformin to attain target HbA1C as these agents appear to reduce risks of CKD progression, CVD events, and hypoglycemia. We treated patients of type 2 diabetes and obesity with combined low-carbohydrate diets and intermittent fasting, along with metformin and newer antiglycemic agents, stopping of insulin therapy wherever feasible. The associations between weight loss, improvement in renal function and treatments were reported using correlation coefficient r and probability p value where significant. Total of 60 patients were reviewed between February 2014 and July 2019 in our outpatient clinic. Mean age was 62.5 years with male to female ratio 3:2. The observed average weight loss was 10.74kg, with 13.2kg and 7.06kg loss for male and female patients respectively. Estimated glomerular filtration rate (eGFR) has improved by 3.13ml/min/1.73m2 and proteinuria was reduced by 12.4 units on average, in terms of albumin creatinine ratio. Mean HbA1C reduction was 0.7%. Mean reduction in insulin therapy was by 16 units with a maximum 202 units in one patient. Clinic blood pressure measurement during the follow-up period was largely unchanged. Weight reduction seems to improve eGFR (r 0.2, p 0.0012, 95% CI from 3.6716 to 13.4304). Combined use of SGLT-2 inhibitor and GLP-1 RA seems to have effect on improvement in eGFR (p 0.01) regardless of weight loss.View Large Image Figure ViewerDownload Hi-res image Download (PPT) It seems possible to control blood sugar in type 2 diabetes by combining metformin, SGLT-2 inhibitor and or GLP-1 RA with intermittent fasting and low-calorie diets avoiding extra-insulin therapy, with resultant improvement in renal function (eGFR and proteinuria) along with weight loss. Therefore, oral antihyperglycemic agents with proven cardiovascular benefit and renal protection should be considered earlier to achieve the treatment goals where drug-specific effects are important on the basis of patient factors.