Diabetes Treatment and Guidelines

Okay, so assuming you finally know your Diabetes status, supposing it turns out to be positive, how should you go about treating it? What is the best course of action open to you? What would treatment involve and what would you need to do or refrain from doing to ensure that treatment is successful? All these questions and more will be answered in this article.

So here goes.

Generally since diabetes is referenced by an above normal presence of blood sugar (200 mg/dl or more-random plasma Glucose test or 126 mg/dl or more- fasting plasma glucose test), it is the aim of diabetes treatment to ensure that whether through medication, exercise, surgery, dietary adjustments, etc. or a combination of all these, blood sugar level is regularized and brought back to normal. However such treatment must make sure at the same time that the opposite doesn’t happen-that blood sugar does not fall to abnormally low levels (hypoglycemia).

Accordingly, the monitoring of blood sugar is also an essential aspect of diabetes treatment. The first thing to note therefore, assuming you are diagnosed with diabetes is that diabetes treatment equates to diabetes management. For now strictly speaking, whether for Type 1(especially for Type 1) or Type 2 (depending on your take on reversal), there is no cure.

The second thing to note is that treatment would generally involve some life style changes. These changes will involve a combination of some or all of the following; dietary adjustments, exercise and the taking of diabetes medication like insulin and metformin.

Type 1 diabetes is treated with insulin, exercise and a diabetic diet. Type 2 on the other hand is treated first with weight reduction, a diabetic diet and exercise. And secondly in cases where this would not be enough, thereafter with diabetes medication or insulin therapy and Blood Sugar monitoring. As such training in self-management of diabetes is an indispensable part of diabetes management.

That said, it is important to note that treatment must be tailored to individual needs thereby catering to individual diabetic differences. Such treatment should therefore take into cognizance and address psycho-social, medical and lifestyle issues.

For the vast majority of people with Type 1 diabetes, insulin is the only form of medication they will need to take. For people with Type 2 diabetes however, available medication vary and depending on their circumstances, they may or may not need to take one or more of these drugs. Let’s take a deeper look into treatment for Type 2 diabetes.

Healthy eating

Though there is no specific diabetes diet, since our aim is to reduce blood sugar, it is best to reduce the intake of carbohydrates, animal products, sugar and fats. Instead one should center his or her diet around vegetables, fruits and whole grains.

Foods with a low glycemic index (foods that don’t raise your blood sugar quickly), typically high in fiber foods, can be helpful in assisting one to reach a stable blood sugar level.

Regular exercise

Here what is important is to incorporate regular exercise into our daily routine. Your doctor taking into cognizance your medical history would be able to suggest a balanced regimen for you. One which at once would be adequate, whilst not being strenuous.

A 30 minutes daily combination of aerobic, stretching and strength training exercise is suggested and has been found to be more effective than either type of exercise (aerobic and strength training) alone. Where you have been inactive for long, it is best to first start slowly before gradually building things up.

Blood Sugar Monitoring

Keeping your blood sugar within the target or desired range means that you must regularly monitor your blood sugar level. Your doctor should be able to give you a rough number of how many times a day you should take your blood sugar reading. Most people check their (blood) sugar level before most meals as well as before or after engaging in other forms of treatment such as exercise or the taking of medication. Illness and alcohol consumption is also known to affect blood sugar levels so one should watch out for these.

Medication

Whilst diet and exercise alone is sufficient for some people to enable them attain their target blood sugar levels, others may require medication. And though previously, insulin was the only diabetes medication available, today the number of diabetes medicine has greatly increased.

Commonly prescribed diabetes medicine today include insulin, metformin, januvia, actos, Victoza and Byetta. Lets look at some of these in detail.

Sulfonylureas; assists your body to secrete more insulin. The following drugs fall into this class, namely; glipzide (Glucotrol), glyburide (DiaBeta, Glynase) and glimepiride (Amaryl). Side effects may include weight gain and low blood sugar.

Metformin is the first drug of choice generally prescribed in diabetes cases of Type 2. This drug by improving the sensitivity of the bodies tissues to insulin, enables the body to use insulin more effectively. However since Metformin won’t usually lower blood sugar enough on its own, it is advised that concerned individuals should couple its uptake with weight loss and more physical activity. Side effects common to Metformin are nausea and diarrhea but these usually disappear as the body adjusts to it.

Meglitinides

Working like sulfonylureas, these medications encourage the body to secrete more insulin. They differ from Sulfonylureas however in that they act faster and don’t stay active in the body for as long. With these class of drugs too comes an associated risk of weight gain and hypoglycemia. However this latter risk is less than for that associated with Sulfonylureas.

DPP-4 inhibitors

DPP-4 inhibitors help to lower blood sugar levels. Although their effect is rather modest, they don’t however cause weight gain. These type of drugs include linagliptin (Tradjenta), Saxagliptin (Onglyza) and Sitagliptin (Januvia).

Thiazolidinediones or glitazones are another set of medication used in the treatment of Type 2 diabetes. Like Metformin, they increase the body tissues sensitivity to insulin. This said though, they have been associated with increased risk of weight gain, heart failure, stroke and fractures. As such they are not first choice recommendation for diabetes treatment and in fact rosiglitazone a variant has been suspended from use in Europe by medical authorities precisely because of these difficulties.

Other classes of medication available for diabetes treatment include SGL T2 inhibitors and GLP-1 inhibitors. A feature of SGL T2 functioning is that sugar is excreted out through the urine, whilst GLP-1 works by slowing digestion and thus the amount of sugar released at any one time into the blood stream.

Having stated the above, it should be noted that insulin may also be prescribed for some type 2 sufferers of diabetes. These insulin types are; Insulin aspart (Novolog); Insulin Lispro; insulin isophane (Humulin N, Novolin N); Insulin glulisine (Apidra); Insulin determir (Levemir) and Insulin glargine (Lantus).

Ordinarily insulin is required to be injected because the digestive process may disrupt the workings of insulin taken orally. Apparatus used for insulin injections include needle and syringe or insulin pens.

Other means of treating Type 2 diabetes also include herbal treatment and bariatric surgery. But whatever the case and whatever form of treatment is contemplated, it is paramount you seek the advice of and work with a health care professional before taking it.

Diabetes Type II Oral Medicine

Diabetes type II affects millions of Americans. Besides affecting the pancreas’ ability to secrete insulin and the body’s reduced capacity to use glucose, diabetes can cause problems with kidney, eyes, and peripheral neurovascular system. Furthermore, diabetics are classed in the high risk group for myocardial infarction and stroke. The following are commonly prescribed oral medicine for diabetes type II.

Metformin (Glucophage®):

  • decreases hepatic (liver) glucose production
  • decreases intestinal absorption of glucose
  • mproves insulin sensitivity (increases uptake of glucose into cells)

Dosage:

oral – 500mg twice a day and increase by 500mg per week as needed for glycemic control. Max 2550 mg/day

extended release tablets: 500mg daily and increase to 2000mg daily (may be divided into 1000mg 2x a day).

Common adverse reaction:

  • nausea
  • vomiting
  • diarrhea
  • flatulence
  • weakness

Contraindicated with serum creatinine >1.5 mg/dL or Cr Clearance Sulfonylureas

Stimulate secretion of insulin from pancreas beta cells.

Second generation

glyburide (Diabeta®,Micronase®,Glynase®): 2.5mg 30 minutes before breakfast and increase every 2 weeks up to 20 mg

glymepiride (Amaryl®) 1-2 mg with first meal and increase to 8mg/day titrating every 1-2 weeks.

glypizide (Glucotrol®, Glucotrol XL®). 2.5mg 30 minutes before breakfast or dinner and increase every 2 weeks up to 40 mg. Used more often in the elderly due to shorter half life and less risk of hypoglycemia

chlorpropramide (Diabenese) has longest half life of the list four.
Potential adverse effects: hypoglycemia, nausea, skin rash, abnormal liver enzymes.

Hypoglycemia risk may increase with concurrent use with salicylates, sulfonamides, fibric acid derivativies (e.g. gemfibrozil), and warfarin.

Hypoglycemia can be seen up to 24 hours after dose especially longer acting sulfonylureas.

Other notes: May use with insulin, glucophage, and TZD’s. Some studies have shown worse outcome when patient with MI are taking sulfonylurea.

Thiazolidinediones (TZD’s)

Benefits:

  • Acts on the liver, muscle and adipose tissue to increase insulin sensitivity and decrease glucose production. Helps the body utilize glucose from muscle and fat.
  • Pioglitazone more than rosiglitazone improves lipid panel (raises HDL , lowers triglycerides with minimal LDL elevation)
  • May preserve pancreas beta cell function.
  • May be used alone or with sulfonylurea, metformin,or insulin but usually not started as a monotherapy.

Risks

  • Weight gain due to increase fat cells and fluid retention
  • Worsening heart failure
  • Risk of MI
  • Bone fractures from decrease bone mineral density
  • Eczema
  • Macularedema especially in those with peripheral edema
  • Liver toxicity

♦ Cardiac risk seems to be higher in rosiglitazone.

♦ There is concern about concurrent insulin and TZD’s worsening heart failure.

Rosiglitazone (Avandia®) 4mg in single or divided doses. Increase to 8mg prn after 8-12 weeks. With sulfonylurea limit to 4mg.

Pioglitazone (Actos®): 15-45 mg daily. With combo therapies, decrease sulfonylurea or insulin dose prn to avoid hypoglycemia. Heart failure patients start at 15mg and monitor closely for 2-3 months before up titrating dose.

References:

Uptodate 2009, Sulfonylurea use in diabetes, David McCullock MD et al.

UptoDate 2009, Thiazolidinediones in the treatment of diabetes mellitus, David McCullock MD et. al.

Lexi-comp

Pre Diabetes and Obesity – New Study Supports Red Wine and Supplements

Pre diabetes and obesity are associated with type 2 diabetes. In fact, it is likely that pre diabetes will soon be classified as a health condition and not just a precursor of the health problem which is type 2 diabetes.

A recent study from Austria showed that several red wines contained rosiglitazone, a natural compound that is being marketed by the drug firm Smith-Cline. In fact, the levels of rosiglitazone were higher in the wines than the recommended therapeutic dose contained in the pills used to treat type 2 diabetes.

These beneficial effects were seen in red wine only. Additionally, the high levels of this protective compound were not seen in all red wines. As background, the researchers note that these wines have shown the ability to prevent the development of type 2 diabetes to some extent. The molecular reactions and pathways involved in this protection are not fully understood at this time.

Obesity and pre diabetes both have problems with cellular inflammation. These wines contain substantial amounts of ligands. Ligands help the body reduce inflammation, thin the blood and prevent clots as well as assist in cholesterol transport and metabolism. Ligands are “sticky” molecules. Ligands attach to the circulating cholesterol which assist the cholesterol in its journey to the liver where it is metabolized.

Red wine should not be considered an alternative to standard therapy when it comes to treating pre diabetes, obesity and type 2 diabetes. The same can be said for prevention of these conditions. No one knows what the effects of alcohol would be in the presence of these ligands and polyphenol antioxidants. in their study, the researchers did find that all the red wines had some of these protective compounds.

As for rosiglitazone, there have been some legal issues and even lawsuits regarding its use. This does put a cloud over the use of rosiglitazone in large patient populations.

The study seems to make the case for some wines and that elusive “something” that seems to extend life. The beneficial effects of wine have been touted as the major contributor to the French Effect. The French Effect is the association of longevity with a high-fat diet. This association is perplexing as it defies conventional thinking. It does appear that with studies and research findings such as the ones we have discussed, we are a little closer to understanding the beneficial effects of red wine. It is fair to say that some wines have been shown to contain compounds that positively impact on some health conditions. Undoubtedly, we will be hearing more about wine in the near future.