Diabetes Information

About People Types & Causes Insulins Medications Complications

Medications

Changes In Type 2 Treatment

Treatment goals in Type 2 diabetes are more stringent today than previously. Current goals include a fasting plasma glucose of 110 mg/dL or less, glucose readings 2 hours after eating of 140 mg/dL or less, and a HbA1c of 7% or less.

Modifying the diet and increasing activity levels are the healthiest and most effective tools available to treat diabetes because poor food choices and lack of activity are the primary causes for insulin resistance and Type 2 diabetes. Whenever diet and exercise are not enough to achieve these goals, medication or insulin should be added as needed to keep glucose levels as normal as possible. If one injection of insulin a day or one medication is not controlling the blood sugars, one or both should be increased. The conventional approach to treatment has been to start one medication, and increase the dosage to a maximum until it no longer controls the blood sugar. Once this happens, one or two other medication are added or basal insulin is added at bedtime.

Preserving the internal production of insulin as long as possible is essential for good control, but so far no therapy has been found that will accomplish this task. At this time, diabetes remains a progressive disease that requires additional therapy in the form of more medication or more insulin as time passes.

Someone with Type 2 diabetes usually has both impaired beta cell activity and insulin resistance. Because this disease tends to worsen in both areas, today's approach is to treat Type 2 with small to moderate doses of various medications that work in different ways to deal with both problems. Combinations of a sulfonylurea plus metformin, or a sulfonylurea plus Precose, or a glitazone with metformin is common today in pursuit of treatment goals.

For example, if someone with Type 2 has high morning blood sugars but normal post-meal readings, metformin alone might be the only medication needed. If they have normal morning blood sugars, but high post-meal readings, Prandin taken before each meal will help. If someone always eats a high carbohydrate breakfast, Starlix, Prandin, or Precose might be used before that meal only. As diabetes progresses, different medications would then be combined at lower doses to provide benefit from their combined effects.

An indicator of treatment when a person is diagnosed with Type 2 is the HbA1c reading. A treatment goal is to have the HbA1c less than the lab's upper limit for normal (usually 6%) and always under 7%. People often have an HbA1c of 9% or over when diagnosed. To lower the HbA1c by more that one or two points, more than diet and exercise is usually needed. Medications, such as a sulfonyluria with either metformin or a glitazone, will likely be needed.

Keeping the blood sugars normal is the goal of treating Type 2 diabetes just as it is for Type 1 diabetes. Due to the slow onset of the disease, people with Type 2 often do not perceive that they feel bad when their blood sugar is running 150 or even 250 mg/dl (11.1 or 1 3.9 mmol). But damage is being done by these high blood sugars and the goal is to bring as many pre and post-meal readings as possible into the normal range.

Medication Choices

Five different classes of oral agents are now available for combining with each other and insulin to achieve blood sugar control in Type 2 diabetes.

• The oldest class, the sulfonylureas, have been used for 50 years in the United States.
• Another class, the biguanide metformin, has been used in Europe since 1957, although this and
• another class, the alpha-glucosidase inhibitors (Precose) were both introduced into the United States in 1995.
• A fourth class, called glitazones (Avandia and Actos), was first introduced in 1997. The first glitazone drug that was introduced, Rezulin, had to be taken off the market because of serious side effects and deaths, but other glitazones have shown none of this severe toxicity.
• The fifth class, called meglitinides, became available in 1998 and includes repaglinide (Prandin) and nateglinide (Starlix).
• Amylin
• DPP-4
• GLP-1

Each class works by a different mechanism, so drugs from different classes can conveniently be combined to achieve good control in individuals who have various degrees of insulin resistance and insulin production. The sulfonylureas and meglitinides stimulate the pancreas to produce more insulin, while Symlin and acarbose work on the digestive system to slow the entry of glucose into the bloodstream after meals. Metformin decreases glucose production by the liver. Avandia and Actos work at the cell level to enhance glucose uptake. GLP-1 agonists also slow food absorption and ------------------------.

On average, a single oral agent will work for 5 to 7 years to control blood sugars, although this time interval is shortened when today's stringent targets are used to determine "control". The wide choice of medications allows treatments to be tailored to individual blood sugar problems and patterns, and extends the time during which medications alone can be used to achieve control. When insulin use is needed, selective use of these medications with insulin can achieve control using smaller doses.

Insulin

Although no one likes to start insulin, a relative insulin deficiency is the reason glucose levels rise and even mild glucose elevations have been linked to ----- cardiovascular disease. Of all the current medications used to treat diabetes, insulin is the most cardio protective when it is used early and --------- keep glucose levels normal

Used drug combinations has delayed or reduced the need for insulin in many people with Type 2 diabetes. Some people who previously needed small doses of insulin have been able to stop using insulin, or reduce their insulin doses, through judicious use of these five different classes of drugs. However, the average HbA1c value for all people with diabetes is still too high at 9.7% (target < 7%), so most people with Type 2 would have better control simply by adding insulin to their current diabetes medications.

Even though today's medications lessen the need for insulin, insulin use would rise dramatically if everyone who could benefit from it were actually using it. Only a small percentage of people with type 2 achieve an ideal HbA1c level of 7% or less, and insulin is more effective than any of the drugs at lowering blood sugars.

For any individual, choosing among several medication combinations may make it possible to control the blood sugar. Factors such as cost, number of doses per day, whether a drug is included in the person's health insurance formulary, and the risk of side effects help determine which medications are worth a try.