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Permalink Reply by Melitta on February 22, 2011 at 8:34pm

Hi Silverhill2570: I have not heard of using Victoza in LADA to preserve beta cells. LADA researchers in Japan used Avandia in combination with insulin to successfully preserve beta cells (and that was in human trials). And there are human studies, none of this mouse model business, that demonstrate that exogenous insulin preserves beta cell function in people with Type 1/LADA. The best summary of results that I have is "Beta Cell Protection and Therapy for LADA" (Cernea, Buzzetti, and Pozzilli, Diabetes Care, Nov 2009). Kobayashi et al (2002 and 2006) are direct human studies that indicate that exogenous insulin preserves beta cell function in people with LADA, and those studies demonstrate that sulfonylureas hasten beta cell destruction. Zhou et al (Diabetes 2004) is a direct study that indicates that insulin combined with Rosiglitazone (Avandia) is most effective for preserving beta cell function in LADAs (but of course the use of Avandia is now restricted). Bruce Buckingham MD at Stanford is doing clinical studies where he initiates really, really intensive insulin therapy in newly-diagnosed Type 1s (mostly young people), and he has had tremendous success with beta cell preservation and better health outcomes. So the evidence for doing low-dose insulin to preserve beta cells is overwhelming. But that is not helpful when you go low, as you do!

There are LOTS of us here on TuD who were diagnosed with Type 1 diabetes/LADA as adults but who were initially misdiagnosed as having Type 2. Also, you may be interested in a JDRF group that meets in Berkeley once a month, it's for women with Type 1 and it's a great group run by TuD's Zoe.

Welcome!

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Permalink Reply by Silverhill2570 on February 22, 2011 at 9:29pm

Thanks, Melitta.. I am a bit concerned as Victoza is not even recommended for T1.. She had to change my diagnosis so that my insurance would cover it. I might try to get in eith Dr. Buckingham for a second opinion

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Permalink Reply by Brian (bsc) on February 23, 2011 at 5:45am

Well, both Mellita and I agree that LADA patients should move to insulin quickly when blood sugars start to degrade. But I think we differ on whether oral medications are appropriate when your blood sugars can still be well controlled without insulin. I actually think that if you move to insulin too early, you may run into difficulties such as you describe. The variation in your insulin production may actually be hard to manage and oral medications may make tight blood sugar control easier and more achievable. Both Melitta and I would agree "sulfonylureas are to be avoided."

I believe that the major controllable component in the beta cell failure in LADA patients is when your blood sugar gets too high (so called glucotoxicity). And whether you use medications or insulin to lower and tighten control does not matter, you will get most of the benefits either way. And I actually think that some of the medications for T2 diabetics will work fine with LADA.

I like to point to work by Ralph DeFronzo looking at the beta cell preservation in T2 diabetics as being relevant to LADA. His work clearly shows the problems with sulfonylureas, but it also shows that in T2 diabetics, the class of drugs called GLP-1 analogs really preserves beta cell function quite well. I see no reason to suggest that this drug will suddenly be toxic to beta cells in LADA patients. The GLP-1 analogs, both Byetta and Victoza increase the signaling to the pancreas to secrete insulin in response to eating. It will work in a LADA because you still have significant beta cell function. GLP-1s are currently being studied in conjunction with basal insulin's in T2s and your doctor may also consider that mixed regime. It would be expected that in the near future GLP-1s will be FDA approved for use with basal insulins.

The second action of GLP-1s involves slowing digestion and makes you feel hungry. While the action on the beta cells does not really work in T1, there have been a number of reports of successful use in T1s for weight and hunger management, but this has not been studied and is not an FDA approved use.

I believe that metformin may also be of use in LADA, it increases insulin sensitivity, something all diabetics can benefit from.

While Melitta and I may not totally agree on whether medications are appropriate in early LADA, we would both surely agree that tight blood sugar control is important to beta cell preservation and that initiating insulin therapy early in order to maintain tight control over blood sugars is important.

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Permalink Reply by Silverhill2570 on February 23, 2011 at 9:45pm

Thank you so much for the thorough responses. I discontinued Lantus yesterday and this afternoon, more than 36 hrs after my last 5 unit shot, I was low again. I am on a very low carb diet (basically Bernstein) and exercise regularly, but still. I am also part of a clinical trial that is testing a new drug which is supposed to neutralize antibodies.. so it seems there are so many different things that can influence my BG levels.

It is all very confusing. I guess I will try the Victoza regime and just see how it works. One question though: I was under the impression that the mechanism of action the suppression of glucagon production rather than making affecting insulin production. or both?

Also, what do you consider as "tight BG control'. I believe I am controlling tightly, but my A1C is still 5.5 .. I am sometimes wondering whether my meter is reading low

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Permalink Reply by Brian (bsc) on February 24, 2011 at 5:33am

Ok, if you really want to learn about the action of Victoza, you can read the Prescribing Information. In that information it describes the mechanism as a GLP-1 analog, namely it signals just like GLP-1 in your body. This results in "....leading to insulin release in the presence of elevated glucose concentrations." It also "... decreases glucagon secretion in a glucose-dependent manner." It "... also involves a delay in gastric emptying."

Most practioners would describe the action of Victoza as increasing the insulin secretion in response to eating and for most, that is the major effect. The suppression of glucagon will mostly be observed as an improved fasting blood sugar number. Neither Byetta nor Victoza did anything for my chronically elevated fasting blood sugars.

As to tight control, that is all relative and a personal decision. The ADA thinks 7% is all "hunky dorry" (sorry for the technical term). The American Association of Clinical Endochrinologists (AACE) says your should get below 6.5% and get as low as possible without hypos. Dr. Bernstein, who I have followed for many years suggests that you "normalize" your blood sugar to non-diabetic levels. My moderated view is that you should get your blood sugar below levels which are thought to be harmful to you beta cells (glucotoxicity). For the most part this is about 140 mg/dl. If your A1c is below 6% and you don't go above 140 mg/dl for any significant part of the day, you have tight control. Personally, I cannot keep my blood sugar below 140 mg/dl at all times, even with insulin. But I do seek to minimize those excursions.

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Permalink Reply by Melitta on February 24, 2011 at 9:04pm

Hi Silverhill and Brian (BSC): Actually, Brian, I would say I don't know enough about the T2 drugs to answer the question! Unfortunately, the studies aren't there for Victoza use in LADAs to preserve beta cell function, but maybe that is because Victoza is relatively new? But I completely agree, of course, that tight control is the goal, but that you don't want to be taking insulin if all you get are hypos, even at very low doses. Silverhill, I would just suggest that you keep careful track of your blood sugar levels, to be on top of any changes that may indicate it's time to go back on insulin (DKA is to be avoided at all costs). And if you use Victoza, as your doctor suggests, let us know how it goes. Best of luck to you.

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Permalink Reply by LiL MaMa on February 25, 2011 at 3:44am

I was just diagnosed last January 2010 and rediagnosed as a LADA this December. I am currently taking 2 units Levemir. Levemir seems to have less of a peak than Lantus and maybe you should give it a shot. If I was taking 5 units of Lantus or Levemir I would be hypo all day as well. Maybe you should try switching to Levemir and take more like 2 units or so a day and see what happens.

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