This week I had the pleasure of seeing a really nice 46 year old Hispanic male who is fairly new to the office.  He came back in to see me in follow up on his diabetes.  To give you a bit of background history, the patient came to see me about 6 months ago, just not feeling very well. Based on his symptoms of fatigue, history of elevated blood sugar and family history, lab work was completed.He saw us initially with a Hemoglobin A1c of 12.3% in June (normal should be 4.9%-5.6%).  This means he had an average blood sugar over the previous three months of about 310 mg/dL (normal should be < 110 mg/dL).

Past Medical History include:  Diabetes Mellitus – type II (not on any medications when initially seen), Hypertension (high blood pressure), Dyslipidemia (elevated cholesterol) and a non-specific heart arrhythmia.

Medications: None

Surgeries: Knee & shoulder arthroscopies

Family History: Father Diabetes, Stroke, Heart Disease, Hypertension, Elevated Cholesterol

Social History: Non-Smoker, Limited Alcohol Use

He related to me that he had been on metformin before, however, had some significant diarrhea and was not interested in using this medication EVER again.   A previous doctor had tried Victoza© (liraglutide), a GLP-1 inhibitor, but he didn’t use it for very long as he didn’t really see much change with this medication.

After getting his labs back, we had a very long conversation about the need to either fix his diet dramatically, or he may be looking at using 3-4 oral medications or even insulin to control his blood sugar.

When I see average blood sugars (HbA1c) stay over 6.5%  (or greater than 140 mg/dL), the risk for retinal, kidney and nerve damage is significant and often irreversible after 4-5 years.  Most physican’s are affraid to lower the HbA1c to less than 7.0% with medications due to low blood sugar events, and so the diabetes community has “settled” with 7.0% as being effective.  However, it still isn’t low enough.  I saw this happen with my father and with other members of me family.  I’ve seen it happen over and over with my patients over the last 15 years when they have not lowered their blood sugar and reduced the high insulin loads that occur in response to those high blood sugar levels.  It has been my experience that HbA1c can be very safely lowered to the normal range, as low as 5.2-5.6% without symptomatic low blood sugars, with the correct diet and careful use of medications.

So, my patient, above, committed to change.  I was worried that diet alone would not be able to lower these levels enough to be effective so we discussed tight carbohydrate restriction, the addition of methlyated folate and chromium and a re-trial of a low dose of Victoza© (liraglutide), which he had at home.

I didn’t see him for about three months.  When he followed up this week I was amazed.  I was amazed because I rarely see more than 1.5% drop in HbA1c with the addition of Victoza© (liraglutide).  The additional 4.5% of drop with diet was dramatically impressive.

When we talked, he told me that all he has done differently is use the Victoza© (liraglutide) and cut his carbohydrate intake to less than 10 grams per meal (Yes, he did admit to occasionally cheating).

You can see the dramatic results:

	June 2015	September 2015
Glucose	258	103
HbA1c	12.3%	6.3%
Urine Creatinine (Random)	208	72
Total Cholesterol (mg/dL)	219	218
Triglycerides (mg/dL)	137	117
HDL-C (mg/dL)	38	37
LDL-C (mg/dL)	154	158
LDL-P (nmol/L)	2172	1691
Small dense LDL-P (nmol/L)	1289	419
TSH (mU/L)	1.75

As you can see, a dramatic change in his blood sugar has occurred in a three month interval.  Not only that, we see a significant change in his cholesterol profile.

Some might argue that this is the Victoza© (liraglutide) doing this.  I can tell you, in the 15 years I’ve been doing this and in the 5 years that Victoza© (liraglutide) has been available in the U.S., I have never seen a drug reduce blood sugar or cholesterol this dramatically.

Previously, we looked at LDL-C for heart disease risk, however, I have multiple patients that have had heart disease with normal LDL-C ( <100 mg/dL).  LDL-C is just a summation of all the particles. The LDL particle is actually made up of three sub-types and it is specifically the small dense particle that causes the vascular risk. You can see a dramatic normalization of the small dense particle LDL with no change in LDL-C and minimal change in Total Cholesterol in the patient’s labs when he reduces his carbohydrate intake.  This is a pattern I see every single day. When serial carotid ultrasound studies are completed, I see reduction in blockage and reduction in the vascular wall thickening.   I will be very interested to see the vascular studies on this patient and I will await his results as he tightens up his diet even further.

All in all, he has dramatically brought his diabetes under control with carbohydrate restriction and if he continues this lifestyle, he has reduced his risk for retinal damage, reduced his risk for kidney damage, reduced his risk for nerve damage and essentially added 20 years to his life.

(Disclosures:  Dr. Nally has no vested interest, monitary or otherwise, in Novo Nordisc or it’s products including liraglutide.)