Category: General

Injectable drugs are essential in the management of diabetes. This includes various forms of insulin and a relatively new class of molecules called GLP-1RA analogs.
For insulin, we now have short-acting (e.g., Aspart, Lispro, Glulisine) and ultrashort acting analogs (e.g., FiAsp), which act much faster than traditional human insulin and control the glucose levels after meals. We also have modern insulins like Degludec and U300 Glargine, which act beyond 24 hours). Although not available for clinical use, once-weekly insulin (ICODEC) is also available in research.

GLP-1RA is a class of injectable medicines in diabetes that are available as once-daily and once-weekly injections. They stimulate the pancreas to produce more insulin and suppress glucagon production. Once weekly injections called Dulaglutide (Trulicity) and once-daily injections called Liraglutide (Victoza) have heart and kidney protection in addition to lowering glucose levels. One of these molecules, called Semaglutide, is available as a once-weekly injection and for daily oral use. Tirzapatide is a new molecule in research that combines the actions of GLP-1 and GIP. It produces more glucose-lowering and weight loss than GLP-1RA.

Some injections combine both a GLP-1RA and long-acting insulin. They are called IDegLira (Xultophy) and IGlarLixi (Soliqua). IDegLira is available in India.

Author
Dr. Mathew John

Type 2 diabetes mellitus is a disease where multiple defects in insulin production and action or reduction in GLP-1RA result in high blood glucose levels and lead to significant complications. We have several drugs to treat Type 2 DM, which addresses many of the above defects and gives the patient reasonable overall metabolic control. Most people with diabetes are first started on oral medicines before injectable medications. The older oral medicines include Metformin, Sulphonylureas(e.g Glimepiride), Pioglitazone and DPP4 inhibitors.

The new drugs are mainly of two groups:

1.Semaglutide (RYBELSUS) is a new oral diabetes medicine that acts similar to GLP-1. The levels of GLP-1 are reduced in diabetes. GLP-1 increases insulin production from the pancreas and reduces the production of glucagon. Glucagon is a hormone that raises blood glucose.

2.GLIFLOZINS or Sodium-Glucose cotransporter 2 (SGLT2) Inhibitor are a group of medicines that act by flushing out glucose through the urine and reducing blood glucose. As a result, they have kidney and heart protection benefits, especially in people with previous kidney and heart disease. The drugs in this group are Empagliflozin, Canagliflozin, and Dapagliflozin.

Author
Dr. Deepa G

It is well known that diabetes is one of the most common causes of developing kidney disease. But most often, it is thought that it is the diabetes medicines that are responsible for the development of kidney diseases. This is not true. Not only are diabetes medicines safe, but some medications even protect your kidneys. High blood glucose, uncontrolled hypertension, and smoking are responsible for increasing the risk of kidney disease. But once a person develops kidney disease, doctors may adjust the dose of many medications used. This is because many drugs are excreted out of the body by the kidney, and the blood levels of these drugs may increase in kidney disease. Therefore, some medications may need to be stopped or dosages adjusted according to the kidney functions of that person. (E.g., Pain killers (NSAID), Antibiotics).

Some of the newer classes of diabetes medications also prevent the progression of diabetic kidney disease. The most prominent among these are SGLT2 inhibitors, whose latest studies show they help treat diabetic kidney disease. The common drugs in this group are empagliflozin, dapagliflozin and canagliflozin. In addition, GLP-1 receptor agonists, another newer group of medicines too, can prevent the progression of diabetic kidney disease. The common drugs in this group are Liraglutide and Dulaglutide. Finally, a new drug class named Finerenone was recently approved for treating kidney disease in people with diabetes.

Author
Dr. Tittu Oommen

Medicines are used to bring blood glucose levels to near normal in people with diabetes. For type 1 diabetes, insulin is the primary option, but for type 2 diabetes, various options, including oral and injectable drugs, are available. Type 1 diabetes is due to the destruction of the beta cells of the pancreas that produces insulin. In type 2 diabetes, various reasons are responsible for the elevated blood glucose levels: this includes reduced insulin production, reduced insulin action, reduced output of GLP-1 (a molecule that stimulates insulin production), and decreased urinary loss of glucose (due to increased activity of a protein called SGLT2). In addition, there are various other reasons, including inflammation and brain-related reasons for type 2 diabetes.

The various drugs used in diabetes act by correcting these abnormalities: reduced insulin production is improved by sulphonylureas (e.g. Glimepiride, Gliclazide) and insulin; reduced insulin action is enhanced by Metformin and Pioglitazone; GLP-1 is improved by DPP4 inhibitors (e.g. Vildagliptin, Sitagliptin, etc.) and GLP-1RA (e.g. Liraglutide, Dulaglutide) and SGLT2 action is reduced by SGLT2 inhibitors (Empagliflozin, Dapagliflozin, etc).

Author
Dr. Mathew John

Delayed puberty is treated with hormone therapy. For example, boys might get a course of treatment with testosterone, and girls with low doses of estrogens. The endocrinologist may also suggest medicines like hCG or FSH to boys. Sometimes doctors prescribe a short span of hormone replacement therapy to see whether they can trigger puberty. After treatment ends, the child’s hormones usually take over to complete the process of puberty. If they don’t, the doctor will discuss long-term sex hormone replacement.
Using testosterone and estrogen is safe in children. However, hormone treatment has to be supervised by an endocrinologist. Hormone replacement therapy is safe and essential for the child’s physical and emotional well-being. The duration of treatment for delayed puberty depends on its cause.

At 14 years, it can be upsetting for a child not to grow and develop physically as quickly as their peers. An endocrinologist is often able to detect signs that puberty has started. Boys can start puberty at a wide range of ages beginning between 11 and 14, so we consider puberty delayed when it has not begun by age 14. The earliest sign of puberty in boys is an enlargement of the testicles, followed by growth of the penis and pubic hair. The growth spurt usually starts a year or so after the genitals enlarge, generally by age 15. Only later, hair develops over the face and the chest.
For boys who don’t show any signs of puberty by 14, it should be evaluated by an endocrinologist. Fortunately, by far, the most common cause is constitutional delayed puberty. This is a normal variant of growth. These boys are generally healthy and will eventually go through puberty if given enough time. In most cases, it is inherited from one or both parents.
The physical exam is often enough, and the key finding is that the penis and testicles do not enlarge by age 14. Sometimes investigations are done to find out if there are actual disorders of male hormone production. Also, An x-ray of the hand and wrist to determine the bone age is often ordered, to look for the delay in bone maturation. Rarely imaging tests such as MRI and Ultrasound are asked to determine the exact nature of delayed puberty.

Author
Dr. Tittu Oommen

Girls generally attain puberty between the ages of 10 and 14. But in some children, these changes can normally occur earlier too. The first sign of puberty in girls is that their breasts begin to develop. This is followed by the appearance of pubic hair. In addition, some girls may notice more hair on their legs and arms. Around two years after beginning puberty, girls usually have their first menstrual period. After that, girls go through a growth spurt – from the time their periods start, girls grow 5 to 7.5cm (2 to 3 inches) annually over the next year or two, then reach their adult height.
Most commonly, especially in girls, early puberty is due to the brain sending signals earlier than it should. There is no other underlying medical problem or trigger. This also can often run in families. Less often, early puberty stems from a more serious problem in areas in the brain responsible for the timing and occurrence of puberty (Pituitary and Hypothalamus. This could be due to a tumour or trauma. Thyroid or ovarian problems also can trigger early puberty.
Girls who show signs of puberty before the age of 8 should consult an endocrinologist for evaluation. To diagnose early puberty, the doctor may order blood tests to look for high levels of sex hormones. In addition, X-rays of your child’s wrist and hand can show whether the bones are maturing too early. Rarely, imaging tests such as MRIs and ultrasound studies are done to rule out uncommon causes of early puberty, such as a tumour in the brain or ovary.

Author
Dr. Mathew John

The onset of puberty below eight years in girls and below nine years in boys is called precocious puberty. The endocrinologist should see all kids with suspected precocious puberty. Some of them turn out to be normal puberty that started earlier than expected. On the other hand, some kids with early puberty may turn out to have diseases of the pituitary, the hypothalamus or the gonads( testes and ovaries) or even the adrenals.
Early-onset of puberty will bring both emotional and physical problems. The biological concern includes early bone growth stoppage, leading to short adult height. In addition, kids with early puberty are highly self-conscious about the changes occurring in their bodies. This may lead to low self-esteem and increase the risk of depression and substance abuse. The early onset of menstrual periods in girls is also a concern to parents.
Medicines called GnRH analogues (e.g. Leuprolide, Triptorelin) are commonly used to stop the production of gonadotropins and hence arrest the progression of puberty. When used early and at an appropriate age, these drugs help to improve the final height of kids with precocious puberty. They are generally safe and have very few adverse effects.

In boys, puberty generally starts between ages 11 to 14. However, it could start anytime after nine years of age. The first sign of puberty in boys is the enlargement of the testes. However, this is rarely noticeable from the outside. Later the pubic hair starts to appear.
Gradually the penis starts becoming more prominent, and thicker pubic hairs start appearing. Later the underarm hairs begin to grow, and the voice deepens. It is common to have acne at this stage. At this stage, growth spurts occur and boys grow distinctly faster. Later, hair develops over the face and the chest. Most boys would complete the pubertal growth by 18 years of age.
If you notice any signs of puberty below nine years in a boy, it merits a visit to an endocrinologist. The investigations are directed at the causes of increased androgen (male hormone) production. Increased androgen production could be from the testes (directly or triggered by the pituitary ) or the adrenal glands.

Author
Dr.Mathew John

Puberty is a time when the boy or girl becomes sexually mature. Puberty is an exciting phase for kids. Although the physical aspect of puberty triggers curiosity, the psychological aspects are also equally exciting. It is the stage when the appropriate hormones start acting slowly and steadily. As a result, boys gradually become men, and girls are on their way to becoming women.
It starts at between the ages 10 and 14 for girls and ages 11 and 16 for boys. Since the range for starting puberty is quite broad, it is not unusual to have a kid start and progress in puberty, but another kid of the same age not having any signs of puberty. However, these age ranges are not strict, and normal puberty in a small number of kids can start below this age.
There is a small gland in the head called the pituitary responsible for producing gonadotropins that start puberty. This gland is regulated by an area of the brain called the hypothalamus responsible for deciding the timing of puberty. The gonadotropins act on the testes (in boys) and ovaries (in girls) and produce hormones -testosterone (in boys) and estrogen (in girls). These hormones lead to most of the changes that we see externally in boys and girls in puberty.

Author
Dr. Mathew John