Diabetes has officially become an epidemic. Approximately 20.8 million people in the United States (7% of the U.S. population) are afflicted with diabetes and an additional 54 million are thought to have pre-diabetes.¹

There are 3 types of diabetes; Type 1 diabetes, type 2 diabetes and gestational diabetes. Type 1diabetes commonly occurs when the body fails to produce insulin , the hormone needed for the body to use the sugar in the foods we eat. Type 2 diabetes can happen when the tissues in our bodies stop responding to insulin. It can also occur when our bodies stop producing insulin. Gestational diabetes is when diabetes occurs during pregnancy.

Type 2 diabetes is the most common type of diabetes. Diabetes is a serious disease. It can cause high blood pressure, high cholesterol, cardiovascular disease, kidney problems and blindness. It can also cause a condition called diabetic neuropathy, a disease that is responsible for a great number of limb amputations each year.

Today, there are more options than ever to treat Type 2 Diabetes. The American Diabetes Association (ADA) has established guidelines for the treatment of type 2 diabetes. Is your doctor following the guidelines? Let’s find out. The following is based on the ADA guidelines for type 2 diabetes.

 How Will My Doctor Measure My Progress During Therapy?

To find out if your diabetes treatment is working or not, your doctor will most likely look at a test called a HgA1C (‘hemoglobin A1C’) from time to time. This test will give your doctor an idea of how well-controlled your blood sugar has been over the last 3 months. The goal in a patient with diabetes is to obtain a HgA1C less than 7%. Typically, your doctor will test your HgA1C when starting therapy, then about every 3 months.  

What Happens After I Am Diagnosed?

At first, your doctor should talk to you about adopting a healthier lifestyle. This may involve such modifications as loosing weight and exercising. Diet and exercise can help lower your HgA1C by as much as 1 to 2%.³ If you need to lower your HgA1C by more than 1 to 2% or if your doctor feels you can benefit from medication therapy, you may be started on metformin (Glucophage®). Metformin can decrease your HgA1C by as much as 1.5%.³ Your doctor may choose to use another medication other than metformin if you suffer from liver disease or kidney disease.  

The ADA says that you should continue the lifestyle modifications and/or medication therapy for 2-3 months, then follow up with your doctor. During this first 3 months, your doctor may work with you to optimize the dose of this medication, if needed.  Certain patients may be started on more aggressive therapy, such as insulin , if their HgA1C is really high (greater than 10%) or if they are having troublesome symptoms.³

So It’s Been Three Months…Now What?

After about three months of initial therapy, your doctor will probably check your HgA1C. If it is less than 7%, your doctor may just continue your current therapy. If your HgA1C is still higher than 7%, further therapy is needed. If you have not yet tried metformin , your doctor may have you try it. If your initial therapy included metformin, the ADA recommends that your doctor add one of the following medications. These medications will usually lower the HgA1C by 0.5 to 2.5%.³:  

• Rosiglitazone (Avandia®)  
• Pioglitazone (Actos®)
• Glyburide (Diabeta®, Glynase®, Micronase®)
• Glipizide (Glucotrol®)
• Glimepiride (Amaryl®)
• Insulin

Which medication your doctor chooses will depend on other conditions you have.  For example, if you have heart failure, rosiglitazone or pioglitazone, may not be good choices.  If you are allergic to sulfa, glyburide and glipizide may not be good choices.

Your doctor may prescribe Metaglip® (a combination of metformin and glipizide) or Glucovance® (a combination of metformin and glyburide). This is an attractive option for patients who want to try to decrease the number of pills they take each day.

Typically, you will continue on this new therapy combination for another 3 months, then follow up with your doctor. During this 3 month period, your doctor may ‘tweak’ the doses of your medications in an effort to optimize their use.

If after this second 3 month period your HgA1C is still not less than 7%, your doctor may add an additional agent (one of those listed above), add insulin, or intensify your insulin therapy.³

Are you beginning to see a pattern here?

This cycle of trying different medications should go on until you and your doctor reach your goal HgA1C. This pattern, although the recommendations of the ADA, may be altered if you require more intense therapy, are experiencing troubling symptoms of high blood sugar or are not tolerating your medications well.  

Aren’t There Newer Medications Available For Diabetes Now?

There are newer agents available for the treatment for diabetes, however, these new agents are not listed in the general guidelines because they have less data and are more expensive than traditional agents. Currently, these agents may be reserved for patients who may have good control over their HgA1C but still experience high blood sugar after meals.  

Acarbose (Precose®) and miglitol (Glyset®) are two newer medications that generally will only lower the Hga1c by 0.5-0.8%.⁴ These medications are more expensive, nearing $100 for a month’s supply in some cases.²

Two other medications, repaglinide (Prandin®) and nateglinide (Starlix®), are effective at lowering the HgA1c by as much as 1.5%.⁴ They are even more expensive, however, at approximately $130 to $250 for a month’s supply.²   

 Exenatide (Byetta®) is a new injection that can lower the HgA1C by approximately 0.5-1%. It does have a high incidence of stomach upset, however. Currently, it is only approved for use in combination with certain other medications. ⁴

Pramlintide (Symlin®) is another new injection that is approved for use in combination with insulin . It only lowers the HgA1c by about 0.7%.⁴

Finally, new insulin products appear on the market from time to time. The newest insulin to hit the market is Exubera®. Exubera® is the first inhaled insulin. In trials, it has been shown to control blood sugar much like short-acting insulin. There are some questions, however, as to how effective the inhaler is during certain conditions.

For example, having a chest cold may affect how the inhaled insulin is absorbed and thus affect blood insulin levels and blood sugar control. There is also some concern about how Exubera® has been shown to decrease lung function over time. For these reasons, many doctors are hesitant to prescribe the new insulin.

What Side Effects Can These Medications Cause?

All of the medications used to treat diabetes have the potential to cause side effects. Different people are able to tolerate different drugs differently. For example, one person may tolerate metformin well at its highest dose while others may experience stomach upset at even the lowest doses.  

Perhaps the most common side effect with these medications is stomach upset. Just about all of them can cause some degree of stomach upset. Some are worse than others. In fact 45% of patients taking either acarbose or migitol discontinue these medications due to side affects such as stomach upset.

Hypoglycemia (low blood sugar) is another common side effect for some of these medications.  Metformin, acarbose and migitol are less likely to cause this than other agents. ⁴  Low blood sugar can be dangerous. If blood sugar drops low enough, it can result in a loss of consciousness or worse.

Weight loss is a side effect of many diabetes medications.  Metformin , acarbose , miglitol , and exenatide can all cause weight loss. ⁴  Some of the weight loss associated with these agents may be due to the stomach upset they can cause.  On the other hand, other drugs such as glipizide , glyburide , glimepiride , pioglitazone and rosiglitazone have been shown to cause weight gain in some people. ⁴  

Rosiglitazone and pioglitazone have been known to cause edema (swelling). ⁴ This is one of the reasons these medications are not recommended in patients with heart failure. Sometimes, more fluid build up in the body can put more work on your heart.

New data also suggests that rosiglitazone may increase the risk of heart attack and stroke. Although the evidence is not conclusive, preliminary data is raising some eyebrows and causing concern.

Lactic acidosis is a rare, but serious side effect of metformin. When it occurs, it is fatal in nearly 50% of cases. ⁴ Nausea, vomiting, abdominal pain and a rapid pulse are all symptoms of lactic acidosis. If you experience any of these symptoms while taking metformin, seek medical attention promptly. Lactic acidosis is more likely to occur in people who have poor kidney function.

How Do I Get the Most Out of My Therapy?

Being successful with your diabetes therapy will take some dedication on your part. You must be dedicated to taking your medications exactly as your doctor prescribes them. You should feel comfortable talking with your doctor about your preferences and not be afraid to ask questions of your doctor or pharmacist if there is something you do not understand about your therapy. It is important that you feel empowered with regard to the management of your diabetes and your health in general. Unsure where to start? Try visiting the American Diabetes Association website at www.diabetes.org.

REFERENCES

1. American Diabetes Association. Diabetes statistics. Total prevalence of diabetes & pre-diabetes. Available at http://www.diabetes.org/diabetes-statistics/prevalence.jsp.   Accessed January 17, 2007 .

    

2.  Red Book, 2006 edition, CD-Rom. Montvale, MJ; Thompson PDR .

    

3. Nathan DM, Buse JB, Davidson MB , et al. Management of hyperglycemia on type 2 diabetes algorithm for the initiation and adjustment of therapy. Diabetes Care 2006;29:1963-72.

    

4. Drug Monographs at Clinical Pharmacology. Available at http://www.clinicalpharmacology.com. Accessed January 17, 2007 .