Diabetes: The All-We-Need-To-Know Handbook
How to Spot Diabetes?
First thing’s first, we need to be sure we have diabetes before we take the necessary steps towards managing it. How? It’s always best to consult with our doctor about any fears or suspicions we might have.
Our doctor might also suspect diabetes if we happen to have a family history or any other risk factors. Another warning sign of possible diabetes is sweet-smelling urine, which is a clear indicator that our blood sugar levels are overly high.
One reason why they may be high in the first place is that our pancreas may not produce sufficient amounts of insulin (type I diabetes), or if our body does not react accordingly to insulin (type II diabetes).
If we do decide to get diagnosed (or if our doctor thinks it’s necessary), then we start with 3 tests. In most cases, the doctor will want to redo a test if it shows high amounts of blood glucose. This is so that they can be absolutely sure of the results. The 3 tests are:
- Fasting glucose test – This test is taken in the early morning on an empty stomach. An indication of diabetes would be a level of 126 mg/dL or possibly higher.
- OGTT (oral glucose tolerance test) – What we do is drink a glucose-containing beverage, then having our sugar levels checked at every half an hour to an hour for up to three hours. If it happens to be 200 mg/dL or even higher at two hours, then this might be an indication that we have diabetes.
- The A1c test – This is basically a blood test which shows our average blood glucose levels for the previous two to three months. A level which is 6,5% or maybe higher might indicate we have diabetes.
Moreover, our doctor might want us to do a ZnT8Ab (zinc transporter 8 autoantibody) test. This is also a blood test which is used for helping determine if the patient has type I diabetes instead of any other type.
The main goal of such a test is to achieve a diagnosis which is as accurate as possible and thus act with timely treatment.
T1D and T2D Treatment Facts
If one wishes to prevent any further complications of this disease, then maintaining control over one’s blood glucose (sugar) levels is one of the primary goals.
- T1D (Type 1 Diabetes) is managed mostly with insulin, but also with exercise and dietary changes.
- T2D (Type 2 Diabetes) may be managed either with insulin or non-insulin medications, dietary changes or weight reduction.
The choice of type 2 diabetes medications can vary depending on a number of factors, including:
- The side effects and effectiveness of the medication.
- The underlying health status of the patient in question.
- Medication compliance issues.
- Cost to the healthcare system or the patients themselves.
Type 2 Diabetes medications may have a different way of reducing one’s blood sugar levels. For example, they might:
- Increase the excretion of glucose.
- Increase one’s sensitivity to insulin.
- Decrease the absorption of carbs from one’s digestive tract.
- Do their job through some other mechanisms.
The patient often uses type 2 diabetes medications in combination. There isn’t just one method to deliver insulin. There are:
- An insulin pump
- Prefilled pens
A crucial part of every diabetes care plan is proper nutrition. However, there isn’t such a thing as ‘one specific diabetes diet’, which can be recommended for all diabetes patients without exception. One important and active area of study when it comes to treating diabetes is the transplantation of the pancreas.
Which Specialists Treat T1D and T2D?
Those would be the endocrinologists. That means these are doctors whose specialty is dealing with endocrine disorders. They usually take on diabetes cases as well. But those diagnosed with diabetes may also be treated by primary care specialists, including family practice specialists and internists.
What is Diabetes Treatment?
Like we mentioned previously, the main goal when it comes to treating either type I diabetes or type II diabetes is the proper and constant management of one’s blood glucose levels.
That means they need to stay within the normal range as much as possible, with some minimal and rare excursions to high or low levels.
The treatment for type I diabetes is:
- T1D diet
- And, of course, insulin
The treatment for type II diabetes is:
- T2D diet, weight reduction, and exercise.
- If these measures fail in controlling one’s blood sugar levels, then oral medications are prescribed.
- And if that method fails as well, then that can only mean initiation of insulin treatment.
Adhering to a diabetes diet represents one of the most crucial aspects when it comes to managing blood glucose for those with diabetes. When one wants to consider the ideal diabetes diet, then one must also take certain aspects into consideration as well.
Namely, we are referring to the amount of carbs which one consumed. But also, the amount of protein, fat, and fiber which the food contains.
Further considerations are the glycemic load and glycemic index. The foods which have a low glycemic load and low glycemic index are the ones which raise one’s blood sugar at a much slower pace than those which happen to be high on the scale.
The glycemic load takes the average portion size into account, while the glycemic index, known as GI for short, is a standardized measurement.
When it comes to planning a diet for those diagnosed with type I diabetes, then the amount of insulin administration coupled with the timing of the meals must play a key role. We will talk more about a diet for those with diabetes further below.
Every ADA diet needs to be:
- Low in simple sugars, fat, or cholesterol
Additionally, one’s daily intake of calories must be equally and proportionally divided into three basic meals (with snacks for the young ones with T1D).
The ADA has lifted the ban it once had on simple sugars for those with type I diabetes. This, in the past 2 years. The new rules state that small amounts of simple sugars are permitted, as long as they are taken it together with a complex, properly balanced meal.
Exercise and Weight Reduction
Both of these are extremely important when it comes to treating type II diabetes. Exercise and the weight reduction which is sure to follow are both useful for increasing one’s sensitivity to insulin. We’ll talk more about exercise further below.
Which, as a positive result, helps one also take better control over their blood glucose elevations, something which should never be underestimated. A diet for type II diabetes should be all about eating foods which are low on the GI scale. Such examples include:
- Brown rice
- Whole wheats
- Steel-cut oatmeal
Type 2 Diabetes Medications
All of the information below strictly applies to patients who are not breastfeeding or pregnant. At this time, the only proven method for controlling the disease for women who happen to be pregnant or breastfeeding is the usual diet plus exercise plus insulin method.
If someone is currently taking any of the upcoming medications (or are planning to in the near future), then the best thing to do is consult with their diabetes healthcare professional.
The same goes for those who are planning on getting pregnant or have already become pregnant while taking any of the medications we are about to discuss. Type 2 diabetes medications are meant to:
1. Increase one’s pancreas’s insulin output
2. Decrease the amount of liver-released glucose
3. Increase one’s cells’ response (sensitivity to insulin)
4. Decrease the intestine’s carbohydrate absorption
5. Slow down the emptying of one’s stomach. What this does is delay both the small intestine’s absorption and digestion of nutrients.
When choosing the best treatment for type 2 diabetes, one should carefully consider:
1. Each medication’s magnitude of change in blood glucose control
2. Any other medical conditions which co-exist. Examples include, but are not limited to high cholesterol and high blood pressure.
3. Any number of abnormal or harmful side effects (results) stemming from the chosen therapy.
4. Some other therapy-related contraindications. This means any medications or treatments which may prove potentially hazardous.
5. Issues which may have an effect on the patient who adheres to taking medications. Such can be the dosing frequency, the timing of the medication and some others.
6. Costs to the healthcare system and the patient.
Any of the drugs preferred may offer more than just one benefit. For instance, they can control one’s cholesterol and lower their blood glucose.
And, when compared to managing the many chronic complications all related to poorly-managed diabetes, one would realize that the cost of therapy using such drugs is rather small. Diabetes can be managed through various combinations of different medications, as we stated prior.
The newer medications permit the ‘tailoring’ of one’s individual treatment options to suit their personal needs. It’s also quite essential to understand that not every single diabetes patient might benefit from certain drugs, as it only makes sense that not every medication is suitable for every individual patient out there.
That’s why it’s so important for patients diagnosed with type 2 diabetes to consult with and work closely with their diabetes healthcare providers.
This is so they can create the perfect drug treatment plan which is ideal for them personally. That means a plan which not only provides the most benefits but also minimizes any adverse effects and risks.
Once more, we cannot stress enough how very important it is for those with diabetes to stick to a proper diet and exercise routine. Remember, regardless of any prescribed medications, preventing and controlling one’s diabetes starts with healthy life choices and a healthy lifestyle in general.
Meglitinides (Starlix and Prandin)
These are a specific class of medications which do their job through promoting the secretion of insulin coming from the pancreas. Nateglinide (Starlix) and repaglinide (Prandin), unlike the longer-lasting sulfonylureas in one’s body, last for a much shorter time.
In fact, they have peak effects within just an hour. It is for this reason that they are prescribed to be taken 3x a day, before each meal.
Due to the fact that these medications have the ability to cause an increase in the circulation of insulin levels, they may lead to hypoglycemia. However, many sources suggest that they cause it on a less frequent basis than sulfonylureas do.
A 3-month study saw that Prandin was able to drop fasting blood sugar values by 61 mg/dL. As for blood sugar values post-meals, it was 100 mg/dL. And since one takes it directly before a meal (because it is short-lasting), it makes it predominantly beneficial for lowering one’s post-meal blood sugar.
It also doesn’t decrease one’s fasting sugar levels in the same degree.
It can be used together with certain other medications (metformin, for example). Doing so in the past has bared witness to some impressively positive results. It significantly improved the control of blood sugar in 83 type 2 diabetes patients.
Warnings concerning pregnancy, interactions with other drugs, possible side effects and dosage, among others are:
- Our healthcare professional needs to be aware of all of the medications we are taking at the time of taking Prandin, as it can interact with certain ones.
- The usual pre-meal starting dose is 0.5 mg, which we can increase to 4 mg. But make sure never to exceed the maximum dose, which is 16 mg a day.
- All those with liver or kidney abnormalities need to use this drug with caution.
- Since the main role of this drug is to increase one’s insulin levels, it may also cause abnormally low glucose levels. A severe case of hypoglycemia may lead to symptoms such as tremors, sweating, confusion, seizure and even coma.
- Additionally, this drug is associated with joint and muscle aches, headaches, and, in some individuals, sinus infections.
- Nursing mothers or pregnant women should avoid using this drug.
- When it comes to the elderly, the dosage may need some adjusting. This is because the older one is, the slower they tend to eliminate (metabolize) medications.
There’s no need to get into the details since this drug essentially has the same interactions and side effects as Prandin. The key benefit it offers is its starting dose of 120 mg needs no adjustment. In other words, it remains constant.
Another plus to Starlix is that it is relatively safe to use for those with kidney disorders or an impaired function of their kidneys.
If one looks at the medical history of dealing with type 2 diabetes, one would easily realize that the main goal has been to increase the pancreas’s output of insulin. The class of drugs which does this is named sulfonylureas.
As for the older versions of these drugs, there are tolbutamide and Diabinese (chlorpropamide). But they aren’t used anymore become they have become associated with a heightened risk of cardiovascular complications.
The new generation of these drugs include:
- Glucotrol (glipizide)
- DiaBeta (glyburide)
- Amaryl (glimepiride)
And, in the case of these drugs as well, their useful ability to lower one’s blood sugar levels can lead to unwanted results such as hypoglycemia. Furthermore, as their name suggests, these medications contain sulfa, which means patients which happen to be allergic to it should avoid them.
A class of drugs which have a long history of usage in both Canada and Europe, called biguanides, are known to decrease the glucose amount which one’s liver produces. Back in the year 1994, FDA approved the biguanide drug called metformin in the treatment of type II diabetes.
- This drug has the unique ability to decrease the liver’s glucose production.
- Metformin, if used by itself, is unlikely to cause hypoglycemia, since it does not increase one’s insulin levels. Another good side of this drug is that it usually suppresses one’s appetite, which may also lead to weight loss.
- Metformin may be used together with insulin or some other drugs, as well as by itself.
- Patients who have any sort of kidney impairment would do best to stay away from this drug. As for those with liver impairment, caution is advised.
Metformin’s ‘predecessors’ had come to be associated with lactic acidosis. This is a serious condition which indicates a possibly hazardous buildup of acid in one’s blood. This being the result of the drug’s accumulation along with its breakdown products. When it comes to this regard, metformin is considered much safer.
Still, most experts on the subject recommend that one should discontinue metformin at least 24 hours before any type of surgical procedure, or one which includes the injection of dyes intravenously. An example of the latter being some kidney x-ray studies.
The reason is that these dyes may cause an impairment of one’s kidney function but may also cause a buildup of this drug in one’s blood. After these procedures are over and the individual is normally urinating, it is safe to restart using metformin.
Invokana (Canagliflozin) and Farxiga (dapagliflozin)
The FDA approved both these drugs, the first one back in March of 2013 and the second in January of 2014.
Their role is improving one’s glycemic control, particularly for patients diagnosed with type 2 diabetes.
Both these medications, which one takes orally, belong to a group called SGLT2 (sodium-glucose cotransporter 2) inhibitors.
What they do is block the reabsorption of sugar by the kidneys. Which leads to an increase in sugar excretion, resulting in reduced blood sugar levels.
Clinical trials which involved more than 10.000 patients using Invokana discovered an improvement not just in their fasting sugar but also in their HbA1c (hemoglobin A1c) levels.
As for Farxiga, 16 clinical trials witnessed an improvement in those same levels involving more than 9,400 patients.
Warnings, Precautions, and Side Effects:
- Both of these drugs have similar side effects, which can include UTIs (urinary tract infections) and vaginal yeast infections.
- Each of them can be used either by itself or combined with some other medications such as insulin, sulfonylurea, metformin, and pioglitazone.
- Farxiga has shown contraindications for those who have a history of bladder cancer.
- Because there is a dehydration risk, the elderly, those taking diuretics or those with renal problems should use them with caution.
Thiazolidinediones: Actos (pioglitazone) and Avandia (rosiglitazone)
This group of drugs can lower one’s blood sugar by heightening the cells’ sensitivity to insulin. In other words, they improve the target cell response when it comes to insulin.
In the U.S., the first drug of this type was Rezulin (Troglitazone). But back in 2000, the FDA took it off the market due to its dangerously toxic effects on one’s liver.
Similar, yet much safer drugs, such as Avandia (rosiglitazone) and Actos (pioglitazone) have taken its place in the U.S. An extensive number of studies have all failed to link either of these two drugs with any liver-related issues.
They both work through heightening the cells’ responsiveness (sensitivity) to insulin. They also cause an improvement in the sensitivity of one’s fat cells and muscles to insulin. To put it simply, these two drugs are both effective in lowering type 2 diabetes patients’ blood sugars.
- Both are taken once a day, and both act within 1 hour of their administration.
- It takes up to 6 weeks for them to cause a decrease in blood glucose levels and up to twelve weeks for the maximum benefits to be evident.
- Both were approved as first-line diabetes therapies and can also be used together with other drugs. Both may be used by individuals who happen to be taking insulin or other oral drugs at the same time.
Warnings, Contraindications, Side effects and Precautions
Many have linked Avandia (Rosiglitazone) to an increased risk of stroke or heart attack. In fact, experts have had long debates on the severity of such concerns. Then, on the 23rd of September, 2010 the FDA significantly restricted the use of this drug for those with type 2 diabetes.
Any reports of liver issues have been substantially milder (and, more importantly, reversible once one discontinues using the drug). Still, most healthcare professionals prefer to monitor blood tests for any possible liver damage (about every 2 months) in the 1st year of therapy.
But even this recommendation was recently removed. Indeed, when it comes to thiazolidinedione drugs, the two biggest contraindications involve heart failure and liver disease.
Moreover, in patients already with heart failure symptoms, fluid retention can be particularly concerning. Other unwanted side effects are weight gain (usually ranging from 3-8 pounds, but can be 12-15 pounds as well in some cases).
The majority of such weight gain is mostly fluid, but body weight can also be an occurrence. It is largely dependent on the doses taken, with more doses equaling more weight gain. It is particularly pronounced when it comes to insulin-taking individuals.
Puffiness and edema (ankle swelling) may also arise as a problem caused by fluid retention. In which case, one can control it by either reducing the dosage or taking a diuretic. Aldactone (spironolactone) works better than Lasix (furosemide).
And even though there is plenty of controversy surrounding this subject, patients with heart failure or symptomatic heart failure should avoid these two drugs altogether.
A more recent concern is the connection between these two drugs and slightly more frequent fractures of the arms and legs’ distal long bones.
But it doesn’t mean fractures of the spine or hip, which are usually more worrisome. At present, the data is insufficient and much more research is needed on the effects and side effects.
But let us look at a positive side now. Both Avandia and Actos have shown to improve cholesterol patterns when it comes to people diagnosed with diabetes. The triglycerides decrease more often than not, and the good HDL cholesterol levels increase.
Furthermore, some studies have shown that Actos may be superior to Avandia when it comes to changing one’s lipid profiles.
And we all know how beneficial this can be for type 2 diabetes individuals already dealing with an increased risk of heart disease.
As more data are available, it is also becoming clearer, and clearer drugs from the thiazolidinedione class may directly benefit one’s large blood vessels and heart.
In prediabetic cases, they may even prevent one’s progression to diabetes. They do this by decreasing any clotting factors and reducing any inflammation as well.
This medication’s main role is decreasing the intestine’s carbohydrate absorption. Enzymes in one’s small intestine, before being absorbed into one’s bloodstream, need to break down carbs into sugar particles, such as, say, glucose.
And one of these enzymes involved in the carbohydrate process is named alpha-glucosidase. And if this enzyme is inhibited, carbohydrates cannot break down so quickly, which also delays the absorption of glucose.
The alpha-glucosidase inhibitor which is available here in the U.S. goes by the name of (Precose) acarbose. Many clinical trials which involved over 700 participants discovered a connection between Precose and a reduction of HbA1c (hemoglobin A1c) values.
And yet, Precose by itself has not shown any impressive results, at least not when compared to some other anti-diabetic medications.
Since the main area, it works on is in our intestine, it can contribute to the effects of anti-diabetic drugs which work elsewhere (sulfonylureas, for instance).
As a matter of fact, multiple clinical studies have witnessed an improvement in blood glucose control in those who were treated using both a sulfonylurea and Precose, in comparison to those which only used a sulfonylurea.
This is why Precose is either used in combination with a sulfonylurea or by itself.
- It should be taken 3x daily at the beginning of one’s meals. The dosage can vary from 25-100 mg before the meal. The maximum dose one should take is 100mg 3x a day.
Side Effects of Precose and Warnings
Due to the way it does its job, this particular drug may have some serious gastrointestinal-related side effects. The most common symptoms, which have been reported by as much as 75% of those who have taken this drug, are the following:
- Abdominal pains
For these very reasons, this drug should be administered starting with a low dose, and then proceeding to increase it over the course of a few weeks. This, of course, will depend on how each individual patient reacts to the drug itself.
Any gastrointestinal-related symptoms caused by this drug have a tendency to subside during a few weeks’ time. However, certain individuals have reported constant and persistent symptoms and problems.
If one takes greater doses, liver tests may show some abnormalities, albeit all of which reversible.
This drug was the first in the class which is made of anti-hyperglycemic, injectable medications which are meant to be used together with insulin. This applies to both, those with type I or type II diabetes. Symlin’s active ingredient, pramlintide, represents a synthetic analog of the human amylin.
This is a neuroendocrine hormone which occurs naturally. It helps control glucose after a meal by being synthesized by beta-cells in the pancreas. Much like the case with insulin, those with diabetes also happen to be deficient in amylin.
In some cases, amylin is completely absent. What it can do is improve one’s glycemic control, particularly when used with insulin. But it can also offer the one taking it certain benefits which one cannot realize only with insulin.
According to specific data, pramlintide can reduce any blood sugar spikes which may occur after a meal. It can also reduce any glucose fluctuations throughout one’s day. It can even increase one’s feeling of fullness (satiety).
Which can lead to a potential loss of weight. On top of all that, it may also lower one’s insulin requirements at mealtime. It can also improve one’s HbA1c levels more than the sole usage of insulin can. It is administered three times a day before each meal through injection for:
- Type I diabetes as an addition to insulin therapy during mealtime. This goes especially for those who fail to achieve their desired sugar control in spite of using optimal insulin therapy.
- Type II diabetes as an addition during one’s mealtime insulin therapy for all those which fail to achieve their optimal sugar control regardless of their insulin therapy. It can be used by itself or in combination with metformin or a sulfonylurea agent.
Side Effects of Pramlintide and Warnings
Despite all the good things it can do, when combined with insulin, pramlintide has been linked to an increased danger of severe hypoglycemia induced by insulin. This goes particularly for those diagnosed with type I diabetes. This severe hypoglycemia can occur within three hours of injecting of the pramlintide.
The main side effects of these drugs are the following:
- Nausea – But the good news is that it can be reduced if one steadily and gradually increases the dose.
- Severely low levels of blood glucose (hypoglycemia). In order to avoid this, one’s mealtime insulin dose should be halved after starting with this drug. Some brief clinical studies which lasted up to 6 months had reported weight loss. To be precise, more than 6 pounds, which was associated with pramlintide treatment.
Most people will certainly be surprised to find out the true origins of this drug. The source is the saliva of a venomous lizard called the Gila Monster! The explanation is a simple one. Scientists had discovered that this small animal could survive long periods without consuming anything.
Then they found a substance in the saliva of this creature which explained why. The role of this substance was to slow down the stomach-emptying process, which in turn makes its host feel more satiated for longer periods of time.
This specific substance bared a keen resemblance to a gut hormone which can naturally be found in us humans. They call it GLP-1 (glucagon-like peptide-1). The problem is that this substance is broken down by an enzyme called DPP-IV.
So, the main goal here was to make a substance similar to GLP-1, without the breakdown part. Such efforts had ended up developing exenatide, or Byetta. Exenatide represents the first in the class of incretin mimetic drugs meant for treating type 2 diabetes.
Indeed, it shares quite a number of therapeutic properties with the naturally-produced GLP-1. It even mimics its natural physiology when it comes to self-regulating blood glucose.
What this drug namely does is slow the emptying of one’s stomach as well as the release of glucose coming from one’s liver. Thus, it can successfully regulate the delivery of nutrients for absorption by one’s intestine. It even regulates our hunger by working centrally in our brains.
This drug is primarily used as an additional treatment for all those with type 2 diabetes who were unsuccessful in controlling their blood sugar with the help of sulfonylurea, metformin, or a combination of the two.
Byetta can also enhance the pancreas’s insulin release. The secretion of one’s insulin usually happens strictly when one’s blood glucose is high. Naturally, it decreases as soon as our sugar levels return to normal.
Additionally, this drug also has the ability to suppress the liver’s glucose release, as well as slow down the stomach-emptying process, slow down one’s nutrient absorption (including carbs), and can even reduce one’s food intake.
Just like pramlintide, this drug is also taken through injections. The only difference is that in this case, it needs to be twice a day. This most often means before one’s breakfast and dinner.
It is available in the form of a disposable pen or two doses. The main point here is to start slow, at least for a month, and then gradually but surely move up to a higher dose. This of course, only if one sees they need it and can tolerate it well.
Another similarity exenatide shares with pramlintide is that its main side effect is nausea. This is most probably due to its stomach-emptying effects.
And since this drug is sensitive to certain temperatures, one would do best to store the pens at 36 F to 46 F. However, there has been a recent change concerning this recommendation. It is now advised for one to refrigerate any unopened pens.
And once they have been opened, it’s all right to leave them at room temperature. One’s risk of hypoglycemia remains with exenatide. This applies particularly if it is taken in combination with a sulfonylurea.
One’s healthcare professional may decide to decrease one’s dose of any other drugs during the evaluation period of response to this drug. Most patients, much like with pramlintide, experience some amount of weight loss taking this drug.
This makes exenatide ideal for the average type II diabetes patients who also happen to be overweight or even obese. The FDA is, at the moment, considering the approval of a longer-lasting form of exenatide.
The idea of this new form is less frequent injections, but the same (or at least similar) side effects and benefits.
This drug, especially if one combines it with the right exercise program and diet, can cause an improvement in the blood glucose (sugar) of type 2 diabetes adult patients. It’s an injectable medicine, like some of the previously-discussed ones. Here are some more facts on it:
- It is not insulin, and there needs to be more studies and research to make sure whether this drug is effective and safe to use in combination with insulin.
- It is not meant for those with DKA (diabetic ketoacidosis), or for those diagnosed with type I diabetes.
- Even though the first study which was conducted on adolescents with type II diabetes witnessed similar pharmacokinetics compared to those seen in adults with type II diabetes, this drug has yet to be approved for the use in minors.
- Much like exenatide, this drug also belongs in the same class of medications which have been named GLP-1 receptor agonists. These have the ability to enhance the pancreases release of insulin after a meal.
Bydureon (Long-acting exenatide)
Just like its name clearly states, Bydureon represents a form of exenatide which is loner-acting, and so one injects it only once per week.
Back in April of 2014, the FDA had approved this drug as an injectable monotherapy for type 2 diabetes adults. It shares very similar side effects and the same acting mechanism as Liraglutide.
In fact, 8 clinical trials which involved more than 2000 participants diagnosed with type II diabetes witnessed an improvement in their HbA1c. All thanks to using this drug. Like we mentioned, it can be used as monotherapy, or combined with glimepiride, insulin, metformin, and pioglitazone.
However, a word of caution. Those diagnosed with type I diabetes should not use this drug. The same rule applies to those who happen to have a family (or personal) history of MTC (medullary thyroid cancer). Or even those at risk of multiple endocrine neoplasia syndrome type 2, since it can be a predisposition to MTC.
Back in September of 2014, the FDA had approved an injectable monotherapy drug meant for type 2 diabetes adults called Trulicity (dulaglutide).
These three drugs (dulaglutide, liraglutide, and albiglutide) all belong to the same class of GLP-1 receptor agonists. Which only means they also share most of the side effects.
6 clinical trials which involved more than 3,300 type 2 diabetes patients witnessed an improvement in one’s HbA1c level by using this drug.
It too can be used on its own in the form of monotherapy, or one can combine it with prandial insulin, metformin, thiazolidinedione, and sulfonylurea.
- The same rules apply here as well: this drug is neither meant for those with type I diabetes, nor for those with family or personal history of MTC (medullary thyroid cancer). As well as those at risk of multiple endocrine neoplasia syndrome type 2 (a potential predisposition to MTC).
- Trulicity (Dulaglutide) is not intended for use as a first-line treatment for those with type 2 diabetes who cannot manage with exercises and a proper diet.
Linagliptin, Saxagliptin, Sitagliptin (DPP-IV Inhibitors)
Like we had briefly discussed, our body can break down GLP-1 through an enzyme named DPP IV. So the logical step here is to either create a synthetic version of GLP-1 (one which resists the breakdown, such as exenatide) or to hinder this specific enzyme, to begin with.
Since we already talked about the what the first approach yielded, let’s take a look at the second one: a new group of drugs called DPP IV inhibitors. What this group does is allow for the native GLP-1, which is already circulating in our blood, to do so for a longer period than it normally would.
Quite a number of companies are currently working on this new class of drugs.
- The FDA, back in 2006, had approved the first kind in this group called Januvia (sitagliptin). One can use it together with certain other drugs, but those with improper kidney function should have their dose adjusted accordingly.
- A second drug belonging to this class, called Onglyza (saxagliptin) was approved back in August of 2009.
- And yet a third one, Tradjenta (linagliptin) was FDA-approved and joined this group of drugs back in 2011.
As for the side effects these drugs may bring, they are rather alike to those of exenatide. The difference here is that these drugs are taken orally. And while exenatide has shown results in weight loss, these drugs have yet to show any for now.
Type 2 Diabetes Medication Combinations
There are 5 relatively new medication combinations on the market for treating type 2 diabetes. Those are:
- Janumet (a combination of various doses of metformin/sitagliptin);
- Avandamet (a combination of various doses of metformin/rosiglitazone);
- Glucovance (a combination of various doses of metformin/glyburide);
- Actoplusmet (a combination of various doses of metformin /pioglitazone);
- Metaglip (a combination -in pill form- of various doses of metformin/glipizide).
The main benefit of these 5 combination drugs is that one doesn’t need to take so many pills. Which should hopefully also improve one’s compliance.
All of them work well, but a large number of healthcare professionals choose to go with the individual medications (in order to optimize the dosage) prior to continuing with these combination drugs. This is also to make sure the patient in question has become stable and tolerant of these drugs.
Treating Diabetes Using Insulin
For those diagnosed with type I diabetes, insulin remains to this day their main treatment option. However, that is not to say those with T2D cannot find it useful either.
Such cases include patients with type 2 diabetes who simply cannot maintain control over their blood glucose levels through oral medications, losing weight, exercising and dieting alone.
In an ideal situation, the administration of insulin is all about mimicking one’s natural pattern of healthy pancreas-secreted insulin. The problem is, though, that this natural insulin secretion process is a rather complicated one, which also makes it hard to duplicate properly.
But one should be able to manage their blood sugar through a well-balanced diet, regular exercise, multiple daily insulin injections as well as keeping a close eye on their glucose levels at home.
That way, they can assure themselves a properly treated diabetes, which will not lead to any further complications.
Up until the late 90s of the past century, insulin was mostly derived from animal sources, such as pigs or cows. But this led to a supply problem as they couldn’t meet such high demand. An additional problem was that this type of insulin, one derived from porcine and bovine sources, caused an immune reaction in some individuals.
Meaning, there was a great danger that such patients could easily become resistant to this type of animal-derived insulin. Luckily, there were certain revolutions occurring in the field of molecular biology during the 50s, 60s, and 70s of the 20th century.
So, in 1977, there was cloning of the human insulin gene. Following this, in 1982, this synthetically-made human insulin was the first drug resulting from recombinant DNA technology to receive the FDA’s approval. Nowadays, this type of human insulin has widely replaced most animal-derived varieties.
There are different kinds of insulin. They differ from each other in terms of pharmacokinetics. In other words, their duration after an injection or how much time they need before they act. That’s why we can use different regimes to achieve optimal individual blood glucose control.
The kinds of insulin which are available at this time are the following:
- Insulin which is rapid-acting, meaning it needs just 5 minutes to take effect after one has administered it. Its peak effect happens within one hour, and it lasts from two to four hours. Examples of this kind are insulin aspart, insulin glulisine, and insulin lispro.
- The regular kind of insulin usually acts within half an hour, and the effect reaches its peak at about two to three hours after its administration. It lasts ranging from three to six hours in total.
- Insulin of the intermediate-acting variety typically starts lowering one’s blood sugar two to four hours after it has been administered. It can peak ranging from four to twelve hours following, and typically lasts from twelve to eighteen hours.
- Insulin of the long-acting variety can take effect within six to ten hours. It lasts about twenty to twenty-four hours (a whole day). The two examples of this kind which are available, detemir and glargine, lower one’s sugar levels at a fairly even pace over a 24-hour period. In their case, there are no major troughs or peaks.
The Different Ways Insulin Can Be Delivered
There isn’t a growth just in the varieties of insulin available. The methods which one can use to administer them is also growing. Let us take a closer, detailed look at each one.
Prefilled Insulin Pens
Back in the 20th century, insulin was available only in an injectable form, which meant one had to carry syringes with them wherever they went. Of course, they also had to carry, the vials of insulin, needles, and alcohol swabs (for sterilization of the area before administration).
Needless to say, patients were finding it anything but easy to administer their required daily shots. Which meant that most didn’t achieve optimal blood glucose control.
Thankfully, in this modern age, there are plenty of pharmaceutical companies which offer one convenient and discreet methods for the safe delivery of insulin each day. One such method is the pen delivery system, which is offered by many manufacturers.
They look quite similar to an ink cartridge one would find in a fountain pen. So, it’s no wonder that this cartridge (which usually contains 300 units) is held inside a small device the size of a pen. One uses such cartridges for the most common insulin cumulations. The method is simple. A person dials in the insulin amount which they need to administer.
They do this by turning the pen’s bottom until they see the needed number of units in the specific window meant for viewing doses. The pen’s tip is a needle, which they need to change with each administration. The needle penetrates the skin easily through a release mechanism, safely delivering the amount of insulin required.
Once one has used up the cartridges, they, just like the needles, are disposed of. Now all one needs to do is simply insert new ones. In some of these systems, one disposes of the entire pen. Either way, this is a much less troubling or bothersome method than the traditional kind.
Those currently available on the market are about the size of a beeper or pager. This device delivers insulin continuously. It administers the programmed amount of insulin at a basal rate. But the amount needed during the course of one day may vary.
This can depend on factors like sleeping or exercise. The owner of the pump can program it to deliver an additional amount of insulin during their meals. This covers any excess demands due to eating carbs.
Thanks to their hypoglycemia minimizing effects, as well as those which enable a tight control on blood glucose, these devices are excellent at offering a flexible lifestyle. Further good news is that there are now these special sensors on the market which one can use in combination with the pump.
That way, the sensor beeps if something is amiss, and the pump can react by signaling its user and “asking” whether the programmed patterns and administration need any adjusting. This is just one more step to making the lives of those with diabetes easier.
Insulin That Can Be Inhaled
Pfizer marketed it, FDA approved it. This was back in 2006. They gave it the name Exubera. However, Exubera was poorly received which lead to its discontinuation soon after, in October of 2007.
Transdermal or Intranasal Insulin
Many have tried other way of delivering insulin. This method showed promise at the beginning, but it often led to nasal irritation or poor absorption in general. As for transmitting insulin through the skin (transdermal) using skin patches – it also yielded some rather disappointing results.
There was also insulin in pill form, but it too disappointed since the digestive enzymes found in all our guts break it down. And yet, there may be hope for oral insulin after all.
It is currently tested in one of TrialNet’s clinical trials. Its main use would be a preventive one, particularly for those at risk of progressing to overt type I diabetes.
Alternative Diabetes Treatment
There are some things we can take, like mineral and vitamin supplements, which, partnered with a healthy diet and exercise routine, can help manage our diabetes. However, one needs to keep in mind that these are by no means a replacement for any medications prescribed by our doctor.
Rather, they should be used in combination with any medications. The vitamins and minerals which have shown the most potential for treating one’s diabetes are the following:
- Vitamins B6 and B12
- Vitamin C
- Vitamin E
And as for the most potent herbal remedies for diabetes:
- Capsaicin cream
- Holy basil leaves
- Evening primrose oil
- Fenugreek leaves
It is always wise to consult with a healthcare professional before taking any of these herbal remedies.
There are other alternative therapies, such as hypnotherapy, meditation, guided imagery, yoga, and biofeedback. Sounds like a bunch of bogus?
Well, many with diabetes have attested to their soothing effects. And trust us, stress is the one thing everyone wants to manage, as cortisol has also been linked to heightened blood sugar levels (among many other negative things).
Exercise and Lifestyle Changes for Diabetes
This is such an important element in our diabetes treatment since it not only lowers our blood sugar levels but also improves the body’s insulin use. We should just make sure to consult with our doctor before starting any workout programs.
Beware: if our blood sugar happens to fall too low, we may need a carb snack 30 minutes before starting our exercise. If we feel any hypoglycemia symptoms during our exercise, best to take a break and have a carb stack.
We should wait for a quarter of an hour then check our levels again: if they are still low, have another snack. Exercising even helps prevent the disease altogether in those with prediabetes. As for diabetics, it improves their circulation and lowers their chances of stroke or heart attack.
How much is ‘just-right’? Most experts recommend no less than 150 minutes of moderate physical activity per week. We should also do strength training two times a week for even better health results.
As for the type of exercise, it’s rather an individual thing, so it’s best to ask our personal healthcare professional what works best in our case.
And remember, it’s a wise idea to wear a tag indicating we have diabetes or a MedicAlert bracelet. That way, in case we experience a serious hypoglycemic attack and cannot ask for help ourselves, anyone near us can quickly understand the problem. Same goes if we’ve been in an accident and require immediate medical attention.
One of the reasons is that they don’t mistake our condition with drunkenness. This is very important indeed, as untreated hypoglycemia can lead to seizures or a coma. Another extra tip: we should take good care of our teeth by brushing and flossing regularly. Diabetes tends to worsen gum disease.
The Diabetes Diet
Each diabetic individual knows the importance of proper nutrition. And it’s not like the only goal of a well-balanced eating plan is control over one’s glucose. Such a diet helps one achieve average, healthy body weight, and also shows promise for protecting one against the usual diabetes-related cardiovascular complications.
If one is looking for a specific diabetes diet plan, they will not find it. That is because each eating regime is tailored to suit the individual needs of each person with diabetes. This also applies to their eating habits and schedules.
Then there’s the balance with one’s oral diabetes medications and insulin intake. But there are some main principals which generally apply to all those diagnosed with diabetes.
That means more consumption of healthy foods such as fruits, beans, whole grains, non-fat dairy, lean meats, fish, poultry or vegetarian substitutes.
Many experts on this subject, including ADA (the American Diabetes Association), recommend that one’s daily calories need to be 50-60% from carbs, 12-20% from protein, and not more than 30% from fats.
Furthermore, those with diabetes may find it better to consume multiple small meals throughout their day, instead of just one or two large ones. And, despite what many believe, there aren’t a specific group of foods which are forbidden for diabetics.
They can enjoy the same meals as anyone else, as long as they pay attention to portion sizes and plan their meals in advance. Many of those with diabetes have witnessed the benefits of using certain methods for the proper following of a meal plan. Some of these are the following:
- Dividing their meal plate into imaginary lines. They divide one’s plate into halves, and then one-half if divided into fourths. Sounds complicated? It’s not once they get the gist of it, believe us. The idea is that one-fourth of their plate should contain starches/grains, the other fourth should contain protein. As for the half remaining, one should fill it with vegetables of the non-starchy variety.
- Another method they can try is an exchange list. They are a great help with one’s meal planning. This means the grouping of certain foods which have the same amount of protein, carbs, fat and calories. The ADA has published such exchange lists to help them plan their meals more easily.
- Counting carbohydrates – this should be based on the total carb intake of foods, measured in grams.
- Consulting with the GI scale – the glycemic index ranks each carb according to how it affects one’s blood glucose levels. Those who are high tend to cause sugar spikes, those which are low on this scale are ideal for regular consumption.
Hope for the Future – Pancreas Transplantation?
Like we mentioned a few times above, the ideal goal of helping patients manage their type 1 diabetes is to find an insulin therapy which mimics our natural pancreas. The closest thing we have to such therapy at this moment is the transplantation of the pancreas.
There are currently a number of approaches which experts study when it comes to this subject. This includes isolated islet cells as well as the entire pancreas. What are islets? They are these cell clusters which contain the cells responsible for the production of insulin, beta-cells.
However, one needs to be aware of the risks which transplantation carries with it. This includes both the surgical process itself as well as the following immunosuppression which lasts for quite a while. It is because of such risks that not just the pancreas, but the kidneys are transplanted simultaneously.
And yet, controversy surrounds the question of why those who are not in need of kidney transplants must go through this process if they wish for pancreas transplantation. The debate here is whether the risks outweigh the benefits and vice versa.
The truth of the matter is that one’s diabetes often relapses after the transplantation is completed. Like we mentioned prior, the selective transplantation of islet cells is proving to be a worthy alternative. Yet, the concern over the possibility of rejection is still present.
That’s why there are currently attempts to try and disguise the islets in tissues which one’s body won’t reject. This can be done, for instance, by surrounding these cells with the host’s own cells before the implantation can take place.
Researchers are doing what they can to explore artificial barriers which can surround the islet cells, and thus, hopefully protect them from rejection. All while allowing the insulin to safely enter one’s bloodstream, of course.
One can agree that the last couple of years (as well as the one which will follow) are promising and exciting times for anything related to diabetes care.
There are many new promising agents being developed as people are reading this. Many options are refined and continue to expand, as well as new alternatives which bring hope for the near future. While this research continues, one thing never changes.
And that is to achieve the best blood glucose control which one can. And no wonder, since maintaining proper control of these levels also minimized one’s chance of any severe diabetes-caused complications.
These can all include nerve damage, blindness, and kidney damage. But the cornerstone of managing one’s diabetes, no matter the new drugs which come on the market, will always be a healthy lifestyle.