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infarction or nonfatal stroke in patients with type 2 diabetes and car- References:
diovascular disease,8 showed significant resolution of NASH,9 and also 1. Diabetes Control and Complications Trial (DCCT): Results of
reduced the risk of clinically important kidney outcomes and death Feasibility Study. The DCCT Research Group. Diabetes Care 1
from cardiovascular causes among patients with type 2 diabetes and January 1987; 10 (1): 1–19
chronic kidney disease. 10 2. American Diabetes Association; Implications of the United
All those results were obtained in significantly less time than the Kingdom Prospective Diabetes Study. Diabetes Care 1 January
eight years of the duration of the UKPDs trials. More is coming with 2003; 26 (suppl_1): s28–s32
the addition of other novel agents like the SGLT2 inhibitors. 3. Pioglitazone and cardiovascular outcomes in patients with insulin
The early medications that remain in use today, in many instanc- resistance, pre-diabetes and type 2 diabetes: a systematic review
es, are still helpful. They have their own set of side effects that, over and meta-analysis. Liao et al, bmjopen-2016-013927
the years, we have learned how to meander around to deliver care for 4. Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes,
patients. In many situations, they optimize the effect of the newer ones. Marso et al, N Engl J Med 2016;375:311-322
Our newer agents also are not free of side effects. We need to remain 5. A Study of Tirzepatide (LY3298176) in Participants With Heart
observant of when to start them, when to stop them and who would Failure With Preserved Ejection Fraction (HFpEF) and Obesi-
be the better candidates for them. We also need to educate the patients ty: The SUMMIT Trial, ClinicalTrials.gov ID NCT04847557
about the side effects of these medications so they will not let them 2024-07-22 )
escalate into significant decompensation, which in some circumstances 6. Tirzepatide for Metabolic Dysfunction–Associated Steatohep-
have created controversy, especially these days, where the media easily atitis with Liver Fibrosis Loomba et al. 2024 N Engl J Med
grabs a fact and brews it into a superlative distortion of reality. 2024;391:299-310
Burping, nausea and vomiting are some of the most common side 7. Tirzepatide for the Treatment of Obstructive Sleep Apnea and
effects of GLP-1 and GLP1-GIP agonists. It can range from mild to Obesity, Malhotra et al, 2024N Engl J Med 2024;391:1193-120
severe and is often accompanied by a persistent sensation of abdominal 8. Semaglutide and Cardiovascular Outcomes in Patients with Type
discomfort and bloating. These drugs have demonstrated kidney benefits 2 Diabetes, Marso et al, N Engl J Med 2016;375:1834-1844
in patients with type 2 diabetes, but in rare cases, kidney damage has also 9. A Placebo-Controlled Trial of Subcutaneous Semaglutide in
Thinking Outside the Box Delivered happened when using them, especially if nausea, vomiting or diarrhea 10. Effects of Semaglutide on Chronic Kidney Disease in
Nonalcoholic Steatohepatitis, Newsome et al, N Engl J Med
leads to severe dehydration. To minimize chances of dehydration due to
2021;384:1113-1124
gastrointestinal causes, it is recommended to begin these agents at a low
Outcomes in Type 2 Diabetes dose and gently adjust them to meet the patient’s needs. Patients are more Patients with Type 2 Diabetes, Perkovic et al, N Engl J Med
2024;391:109-121)
likely to have nausea when they first start treatment or after increases in
the dose. For most people, these side effects resolve uneventfully. Rapid
By William Trigoso, MD, FACE, and Tina Copple, DNP, FNP-BC, CDCES escalation of the dose may lead to rapid escalation of symptoms and side
effects. Constipation is less common than diarrhea and nausea, but it
I n the race against Type 2 diabetes complications, insulin has been the blow of type 2 diabetes was achievable. In the coming years, we can still occur as a side effect of these medications. Adequate hydration William Fernando Trigoso, MD, FACE, is a physician and
Our common sense kept telling us that the task of softening
the main protagonist.
ameliorates this in a significant manner. The presence of severe epigastric
Glucagon, or its related peptides, were a good explanation of
to overcome it. The development of thiazolidinediones finally gave us
Heredia in Lima, Peru, trained in Internal Medicine at the
the alert for the presence of pancreatitis. Patients should be made aware
the physiopathology of the disease but never considered part of the became more aware of the mechanisms of insulin resistance and ways pain or severe abdominal discomfort, although infrequent, should raise surgeon who graduated from the Universidad Peruana Cayetano
armamentarium to fight this disease. straightforward evidence that we could significantly improve cardio- of this to seek immediate consultation with a physician. Michael Reese Hospital in Chicago, IL., and earned his fellowship
With a limited understanding of the complex physiopathology of vascular outcomes.3 Blurry vision or visual defects should also be communicated to in Endocrinology and Metabolism at the University of Wisconsin Hospital.
type 2 diabetes, during the 1970s and 1980s, we developed medica- It was only when we turned or eyes away from insulin, looking into the physician since progression of diabetic retinopathy or retinal vein Dr. Trigoso is board certified in Internal Medicine, Endocrinology,
tions to potentiate the action of insulin within the body. Our main different domains, that we were able to re-discover the action of glu- occlusion, although infrequently, has been reported as a potential side Diabetes and Metabolism, Clinical Lipidology, and Clinical Bone
goal was to improve glycemia, with the hope of preventing complica- cagon-like peptide hormones and unveil their secrets, like the incretin effect. Densitometry and Neck Ultrasound. He is a fellow of the American
tions, and hoping to improve the quality of life of the person. During effect, the regulation of hepatic glucose production and its effects in Although only seen in rats, medullary-thyroid carcinoma has been College of Endocrinology and member of the American Association of
the 1990s, metformin revolutionized the management of type 2 dia- feeding behaviors and its repercussions in weight reduction. A new era added to the label warning and potentially may happen in association Clinical Endocrinologists, American Diabetes Association, National Lipid
betes. It was a game changer that gave us the confidence that made had begun, and we started to see significant improvements in glycemia with multiple endocrine neoplasia syndrome type 2. In any case, a Association and International Society for Clinical Bone Densitometry. Dr
us believe that we could match the results of the Diabetes Control and weight reduction and a decrease in insulin use among the sufferers good examination of the thyroid is always warranted in every patient. Trigoso is the Vice-President of Diabetes and Glandular Disease Clinic in
and Complications Trial (DCCT)1 published a few years earlier. This who also demonstrated greater patient satisfaction. These days, the big challenge is to make these medications available San Antonio, a 100% group member of BCMS and TMA.
study proved beyond a doubt that in people with type 1 diabetes, The long-awaited favorable outcomes begin pouring in one by one. to the population at large. The main barrier is the prohibitive cost and
aggressive glycemic control led to the prevention of complications. Liraglutide showed a significant amount of improvement in cardiovas- economic toxicity of these medications. Large segments of the popu- Tina Copple, DNP, FNP-BC, CDCES, received her Doctorate of
To our dismay, after eight years, the results of the United King- cular death.4 Tirzepatide demonstrated reduction in the risk of heart lation, especially in the lower economic strata, are at substantial risk of Nursing Practice at The University of Alabama at Tuscaloosa and
dom Prospective Diabetes Study (UKPDS) showed barely positive failure,5 significant resolution of MASH6 and significant reduction of developing metabolic diseases, which lead to becoming type 2 diabet- Master of Science in Nursing, Family Nurse Practitioner at The
outcomes in the prevention of microvascular complications and a the apnea hypopnea index (AHI) in persons with moderate-to-severe ics and suffering complications. This is even more pronounced among University of Texas Health Science Center. She is a Certified Diabetes
non-significant trend in the improvement in cardiovascular compli- obstructive sleep apnea and obesity.7 Semaglutide decreased the pri- minorities with limited access to insurance or to third-party payers Care and Education Specialist, Certified Diabetes Educator Clinical Lipid
cations.2 mary composite outcome of cardiovascular death, nonfatal myocardial willing to cover this category of medications. Specialist and Certified Clinical Densitometrist (CCD).

14 SAN ANTONIO MEDICINE • December 2024 Visit us at www.bcms.org 15