Adjusting Doses of Exenatide (Byetta) Untilwe have a once-weekly dose of Byetta, it wiU be necessary to fo cus dosing on the times of day when overeating or snacking occurs.
This means starting with the 5 meg prefiUed syringe (orange label) and injectingabout 1 hour beforetimes of snackingor overeating oc cur.
Study the packageinsert carefuUy to learn how to inject with this specialdevice,which the manufacturer refers to as a pen. (A video tu torial is avaUable on the manufacturer'sWeb site,www.byetta.com.) If you overeat only at one meal, inject about 1 hour before that
208 Treatment
meal. If 5 meg helps partiaUy, the dose can be increased to 10 meg by either injecting two 5 meg doses or 1 dose from the 10 meg (blue la bel) pen. If the eating problem occurs several times daUy, 5-10 meg should be injected 1hour prior to eachtime of the daywhen the prob lem eating usuaUy occurs.The maximum daUy dosageof exenatide is 20 meg.
MY PREFERENCE
If we ever get a once-weekly dose of exenatide or if Januvia helps overeating, I wiU certainlyconsiderthem because of their ease of use (assuming, also, that they are as effective).
In the meanwhUe, I prefer the pramlintide (SymUn) because the amounts injected can be ad justed in smaU increments and multiple daUy doses are faciUtated, even though that is contrary to instructions on the package insert.
Also, the pramlintide is much more likely to work for people with minimal or absent beta ceUs.
Afterreading the draft of the aboveparagraph, I haveprescribed for a few patients a new product that stimulates the intestines to secrete two hormones, GLP-1 and cholecystokinin (CCK).
We've already dis cussed GLP-1.
CCK, like amylin, works directly upon the brain to bring about satiety.
Although this newproduct isdouble-barreled,it is not as effective as injected pramlintide.
The new product contains pinolenic acid, a polyunsaturated fatty acid that's derived from pine nuts.
It is sold as a supplement caUed Natural Appetite Control, by the Life Extension Foundation.
It is worth trying for people who distrust products approved by the FDA, but so far I'veseenno appetite reduc tions after minimal trials.
Dosing is 1-3 softgels about 30 minutes be fore times of anticipated overeating or snacking.
The cost is $28 per bottle if purchased singly, $19 per bottle if purchased in groups of four.
Toorder, phone (800) 544-4440 or visitwww.lifeextension.com.
Of all the medications mentioned in this chapter,the IMs certainly work for more people than the others.
If it turns out that they remain effective after years of use by the same individual, I wiU certainly caU them miracle drugs.
Recent studies in animals have shown IMs to foster beta ceU regen eration.
I'm sure that this won't cure diabetes, but it may further en hance the abUity of diabeticsto control and normalize blood sugars.
How to Curb Carbohydrate Craving or Overeating 209
CAN ANY OF THESE TREATMENTS PERMANENTLY STOP OVEREATING?
1 have seen patients using autohypnosis, low-dose naltrexone, and evenjust low-carbohydrate dietswho,after one year, found that they no longer had cravings for carbohydrates or excess food, even when they discontinued hypnosis or naltrexone.
This is probably akin to some studies of depressed patients treated with certain antidepres sants: after a period of time, the antidepressants may no longer be needed.MetaboUc brain scans sometimes showan apparently perma nent normalization of brain function in selected regions.
For aU we know, this may apply as weU to the incretin mimetics.
One of my pramlintide patientsfound that it ceased workingafter 2 months of use.
She discontinued it for one week and restarted at a lower dose.
The lowerdoseis stillworking after2V2 months.
In any event, the improvement in blood sugars and concomitant weightlossare major incentives to give these methods a try.
IF THE STOPPER ON THE SYMLIN VIAL IS TOO HARD
Some Symlin users have complained that the stoppers on some of theirSymlin vials have beenso hard that the needle of their insuUn sy ringe is duUed after one fiUing with Symlin.
They also have com plained that on some vials, the needle actuaUy becomes permanently bent when one attempts to puncture the vial.
Amylin Pharmaceuticals is planningto come out with an improved stopper,but approvalof this product by the FDA may delaythe release by several years from the time of this writing.
The company is also planning to come out with a Symlin pen simUar to the pen used for Byetta.
This is not reaUy a solution to the problem, since the pen wiU only inject fixed doses instead of the variable doses that we seek.
Thisleaves us with twooptionsfor circumventing the problem.The first is to puncture the stopper in the very center, where the rubber is thinnest.
The needle should be perpendicular to the surface of the stopper and should not puncture it at an angle.
If this technique does not solve the aforementioned problems, then it wiU be necessary to
210 Treatment
transfer your Symlin to empty vials that are more suited to use with insulin syringes.
Empty, sterUe insulin vials are avaUable at no charge from most pharmacies.
They are also avaUable from EU LUly and Company.Your physician can prescribe these empty vialstogetherwith a 5 cc syringe with a IVi-inch,23 gauge needle for transferring the Symlin from the original vialto a new 10ccinsulinvial.
The technique for transferring the SymUn is very simple.
Puncture an empty vial with the 23 gauge needle and draw out 5 cc of air.
Inject half the airinto the SymUnvial.
With the vial upside down and the needleweU below the surfaceofthe Uquid, draw out about 2.5ccof SymUn.
Then injectthe restof the air into the Symlin vial and drawout the remaining2.5 cc of Symlin.
You now can inject the 5 cc of Symlin into the empty, sterUe vial.
If you wish, you can repeat the above procedure with a second 5 cc Sym Un vial, transferring its contents to the same empty 10 cc insuUn vial that you used previously.
You can,forexample,transferthe contents of ten Symlin vialsto five 10cc insulin vials.
UPDATES ON FORTHCOMING APPETITE SUPPRESSANTS
Anyone can purchase a subscription to Obesity Meds and Research News at www.obesity-news.com, or by phoning (703) 960-5513 or faxing (703) 960-7462. This is the best update source that I know of for news on upcoming and newly approved medications.
14 Using Exercise to Enhance Insulin Sensitivity
Strenuous, prolonged exercise is the next level of our treatment plan after diet, and should ideaUy accompanyany weight-loss program or treatment for insulin resistance (as in type 2 dia betes). Before we go into our specific recommendations for exercise, aU of which should be approved by your physician prior to putting them into practice,it's important that you understand the benefits ex ercise can bring.
WHY EXERCISE?
WhUe many peoplemay begin exercising out of a senseof responsibU- ity , the way chUdren eat vegetables they don't like , the main rea son they keep exercising is that it feels good.
Whether it's the intense competition of a fast and furious basketbaU game, or cycling alone in the countryside,exercise bringsmany rewards , physical, psycholog ical, and social.
People who aren't diabetic and exercise strenuously and regularly tend to Uve longer, are healthier, look healthier and younger, have lower rates of debUitating and incapacitating Ulnesses such as osteo porosis, heart disease, high blood pressure, memory loss of aging, and the Ust goes on.
OveraU, people who exercise regularly are better equipped to carry on day-to-day activities as they age.
Many type 1 diabeticshave been Ul for so long with the debUitating effects of roUer-coaster blood sugars that they are often depressed about their physical health.
Numerous studies have established a link between good health and a positivemental attitude.
If you're a type 1
212 Treatment
diabetic,asI am, strenuous exercise wiU not improve your blood sugar control as it wiU for type 2s (which we'U discuss shortly), but it can have a profound effect on your self-image.
It's possible, if you keep yourbloodsugars normal andexercise regularly andstrenuously, to be in betterhealththan yournondiabetic friends.
Also, it'sbeen my expe rience that type 1 diabetics who engage in a regular exercise program tend to take better care of their blood sugars and diet.
Think of exercise as money in the bank , every 30 minutes you put into keeping in shape today wUl not onlyleave youbetter off right now, it wiU pay continuing dividends in the future.
If going up the stairs yesterday leftyouhuffingandpuffing, in awhUe you'll bound up the steps.
Your strength wUl likely make you feel younger, possibly more confident.
There is evidencethat exercise actuaUy does make you look younger: even the skinof those who exercise regularly tends not to ageas rapidly.
After working out for a few months, you'U look better, and people wUl mention it.
With this kind of encouragement, you may be more likelyto stick to other aspects of our regimen.
Although most of us who engage in bodybuUding exercise can ex perience increases in muscle mass and strength, the degree to which we respond is in part geneticaUy determined.
With very simUar exer cise regimens, somepeople wiU show dramatic increases in both mus clebulk and strength; others wUl showneither.
Most of us Ue between these two extremes.
There areeven people who gain strength but not large muscles, andothers who can buildlarge muscles without getting much stronger.
If you don't develop big muscles or great strength, you wiU stiU enjoy the other benefits from the weight training de scribed here.
It has longbeen known that strenuous exercise raises the levels of serum HDL (good cholesterol) andlowers triglycerides in the blood stream.
Recent studies suggest that bodybuUding exercise (anaerobic rather than aerobic exercise) also lowers serum levels of LDL (bad cholesterol).There is even evidence that atherosclerosis (hardening of the arteries) may be reversible in some individuals by such major im provements in serum Upid profiles.
I'm weU over seventy, I exercise strenuously on a daUy basis, I don't eat fruit, I've hadtype 1diabetes for sixty years, and I have two eggs for breakfast every day.
Where's my cholesterol?
It'sin averyhealthyrange that nondiabeticsone-third my age rarely attain (page 131).
Part of thatisdueto my low-carbohydrate diet, but part of it is due to my daUy exercise program.