Endocrine Abstracts

Introduction: Insulin is not an optimal treatment in obese type 2 diabetic patients with insulin resistance. We often introduce it as a last resort hoping to improve the metabolic control of our patients. However it is not always effective, and tends to increase body weight, worsen the global cardiovascular risk and cause hypoglycemias. New drugs such as the GLP-1 agonist receptors can be a better alternative and sometimes allow withdrawal of insulin.

Clinical case: A 59 year old female patient had morbid obesity (BMI 41 kg/m²) and type 2 diabetes mellitus diagnosed 17 years ago, chronically poorly controlled (HbA_1C > 8% in the last 10 years) with metformin 850 mg TID and insulin in escalating doses up to 36 units of 75NPH/25R premix TID. She also had hypertension, chronic coronariopathy with anterior AMI diagnosed five years ago and successive heart failure with preserved ejection fraction and paroxystic atrial fibrillation. Her treatment included Atenolol 50 mg BID, Olmesartan 40 mg, Amlodipine 10 mg, Hydrochlorothiazide 25 mg, Doxazosine 4 mg and acenocumarol. She was admitted in Internal Medicine because of decompensated heart failure in the context of a respiratory infection. Her HbA1c was 8.6% and eGFr CKD-EPI 82.2 ml/min, with LDL-cholesterol 72 mg/dl. On discharge she was offered treatment with Liraglutide but chose Dulaglutide 1.5 mg/week. Metformin was maintained and the insulin dose was reduced to 20-20-14 units. Four months later she had reduced the dose to 19-19-13 because of mild hypoglycemias and her HbA1c was 6.1%. She had lost 9 kg of body weight. After three months her dose was 12-12-6 with HbA_1C 5.8% and LDL-cholesterol 56 mg/dl. Sixteen months after discharge she maintains a body weight loss of 10 kg, insulin was withdrawn while maintaining adequate glycemic control, her HbA_1C was 6.8%, and her antihypertensive treatment was reduced (Olmesartan 20 mg, Bisoprolol 2.5 mg substituted for Atenolol 50 bid, and Hydrochlorothiazide withdrawn). Moreover, the patient was quite satisfied with her evolution.

Conclusions: The new therapeutic arsenal for type 2 diabetes mellitus, particularly the SGLT2 inhibitors and the GLP-1 receptor agonists, have improved our ability to achieve metabolic control in obese patients with marked insulin resistance, and in many cases may avoid the introduction of insulin and even allow its withdrawal in patients such as ours. We must also consider the positive results of trials like EMPA-REG OUTCOME, CANVAS and LEADER in secondary cardiovascular prevention.