The next phase

17-The-next-phase

Diabetes affects more than 425 million people worldwide. By 2045, it is expected to rise to 625 million. It caused four million deaths across the world in 2018. And, health expenditure wise, it cost $327 billion in 2017.

Most people are aware of only two types of diabetes—type 1 and type 2. However, there exists other subtypes. Type 1 diabetes that develops later into adulthood is called latent autoimmune diabetes in adults (LADA); 2 to 12 per cent adults have this condition.

Glutamic Acid Decarboxylase (GAD) antibodies belong to a group of diabetes-associated antibodies that instruct the immune system to destroy the insulin-producing cells of the pancreas. Testing for GAD antibodies helps a doctor to diagnose the LADA variant and offer the correct treatment. A person with LADA will require insulin treatment reasonably soon after diagnosis, unlike most people with type 2 diabetes, who can be treated by various other oral drugs and injectables. Unexplained weight loss is a hallmark of type 1, rather than type 2 diabetes. GAD is not routinely tested in India.

Maturity onset diabetes of the young (MODY) is caused by a mutation in a single gene. If one of the parents has this gene mutation, there is a 50 per cent chance that their child would inherit the mutated gene. Those children will generally go on to develop MODY before they are 25. Insulin is not necessarily needed for MODY patients. Common type of MODY are HNF-1 alpha, HNF-4 alpha, HNF-1 beta and glucokinase. Testing blood for pancreatic antibodies, and urine or blood for C-peptide, is the method to test for MODY.

The US Food and Drug Administration has recently approved Medtronic's insulin delivery device, the MiniMed 670G, that measures glucose level every five minutes and delivers insulin as required. This machine mimics the normal pancreas in sensing glucose fluctuations. Another exciting device is the smart watch by Apple, in association with Dexcom, that can measure blood glucose on a real-time basis.

In the past five years, smart devices have created a paradigm shift in the way blood glucose fluctuations are monitored. Wearables like Fitbit can monitor your sugar level and sleep pattern on real time basis, and alert the patient when there is a sugar spike or drop due to lack of sleep or walking. Also there are applications like One Drop that can measure blood glucose via smartphones and alert the doctor about the fluctuating sugar levels of his diabetic patients. A more sophisticated device of Medtronic checks sugars for 72 hours and plots a graph whereby we can detect where the spikes occur. In the pipeline is GLP-1 agonist (semaglutide), an incretin hormone therapy in oral form which can be taken once weekly. It may eventually replace insulin therapy in the next decade. All these developments point to a big change in the way diabetes is going to be managed.

Joseph is consultant in internal medicine and diabetology, VPS Lakeshore Hospital, Kochi.

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