Care of Patients with Type 2 Diabetes

Diabetes (a disease-causing high blood sugar) is a chronic, lifelong condition that can lead to a variety of serious complications. These complications include heart attacks, strokes, kidney failure, leg amputation, impotence and blindness. Good control of blood glucose (BG) can help prevent these complications. 

Type 2 diabetes occurs in people who are generally overweight or inactive and have a genetic predisposition to develop diabetes. Insulin is a hormone made by the pancreas to help our body utilize sugar (glucose).  Patients with type diabetes are insulin resistant, i.e. their pancreas makes insulin, but their organs (liver, muscles etc) do not respond to it. Over time, the amount of insulin left in the pancreas is depleted and then blood glucose may become more difficult to control.  Often several medicines and ultimately insulin injections are needed to keep blood sugars under control, especially after meals.  Early treatment and aggressive weight loss can help prevent this downhill course in most individuals.
Depending on the stage and severity of diabetes, your doctor will recommend a treatment plan to keep you healthy and reduce the risk of these complications.  A balanced and healthy diet is very important and a lower intake of high fat or high “carb” food is recommended.  Blood glucose should generally be checked 2-4 times a day depending on the severity of diabetes. Target blood glucose levels (BG) are shown in table 1. A blood test called Hemoglobin A₁C is used to determine average sugar glucose control over the last 3 months and the goal HBA1C is < 6.5 or 7.

Targets For Patients With Diabetes:

Once a year, a complete examination of the eyes is recommended.  The urine should be checked for protein (microalbumin) once a year and the feet should be examined for nerve damage.  Patients with diabetes often have high blood pressure and high cholesterol (or triglyceride/ blood fat) levels, and therefore may have to take several medicines to control all three conditions.  Even a slight increase in blood pressure (above 130/85) or LDL-cholesterol (above 100 mg/dL) requires treatment in diabetic patients. ACE inhibitors or ARBs (blood pressure medicines which reduce the pressure in the kidneys) are prescribed for most diabetics (even those without high blood pressure) and help prevent kidneys from diabetic damage.  Patients with diabetes who are over the age of 40 should consider taking STATINs.  These medicines lower cholesterol and other harmful fat levels and reduce the risk of heart disease and strokes (even when the blood fat levels are not very high) by preventing “hardening of the arteries (atherosclerosis)”, particularly those arteries, which supply oxygen-rich blood to the heart itself (coronary arteries).

Medications for Diabetes

Metformin (Biguanides):

This is the first medicine used in most cases and works on the liver to reduce sugar levels.  It may cause some weight loss but may also cause stomach upset in some. It should not be taken if kidney function is compromised and should be withheld for 48 hours after surgeries or CT scans. 

SGLT-2 Inhibitors:

This class of medications (e.g. Invokana, Farxiga, Jardiance, Steglatro) work in the Kidneys and help excrete some sugar through the urine. They may lower the blood pressure, cause some weight loss and do not cause low blood sugar.  They are also beneficial for the heart and kidney functions. Local yeast infections may occur and rare cases of DKA have been reported. 

GLP-1 analogs (Bydureon/Victoza/Trulicity/Ozempic/Rybelsus):

These agents slow the absorption of the carbs and reduce appetite. Many patients lose weight and some may complain of nausea in the first weeks of use. Very rarely, a serious complication called pancreatitis (severe abdominal pain) may occur. In animal studies, a rare form of thyroid cancer (called medullary thyroid cancer) was seen rarely. GLP-1 analogues cause weight loss and reduce heart-related complications in patients with diabetes.

Mounjaro (Trizepatide) is perhaps more effective because it works on both GLP-1 receptors & a related compound called GIP.

Actos (Pioglitazone):

Actos improves insulin resistance and lowers blood fat levels in 

many patients. If used early, it may slow down the deterioration of the insulin-producing capability of the pancreas. It can cause fluid retention and should 

not be used if a patient has congestive heart failure.

Sulfonylureas:

They stimulate the release of insulin from the pancreas. Therefore they are supposed to be taken before a meal (either once or twice daily). Because they may deplete existing insulin stores in the pancreas, they should be avoided if blood sugars are not too high. They can cause severe hypoglycemia.  Examples: Glimepiride, Glipizide and Glyburide.

DPP-4 Inhibitors (Januvia/Onglyza/Tradjenta/Alogliptan):

These are often used with other medicines, have few side effects & do not cause hypoglycemia (low BG). They are more effective in lowering BG peak after meals.

Meglitinide (Repaglinide & Nateglinide):

These work like sulfonylureas but for a shorter period of time (~ 2-4 h). Therefore, the risk of hypoglycemia & weight gain is lower. However patients often have to take a dose of these medications before each meal. 

Cycloset (Bromocriptine):

Cycloset improves your body to respond to insulin by lowering insulin 

resistance, usually present in those with type 2 diabetes. When taken in the morning (within 2 hours of waking up) it promotes improves insulin sensitivity throughout the day by a mechanism involving an increase in dopamine action in the brain 

Insulin:

Insulin is the most effective agent to lower BG & if BG levels are really high, or diabetes has been present for >6-8 years, insulin production from your pancreas may be too low and therefore “pills” may not be able to keep your BG under control (particularly after meals) and you may have to add insulin to your regimen.  Your doctor will recommend the best combination depending on the severity of your diabetes (see article on insulin therapy).

Diabetes is a chronic disease.  By taking charge, you can control it and prevent all of the complications of diabetes. American Diabetes Association (www.diabetes.org) has many publications and other tools that may help you control your diabetes. Good luck!!

This information is for general knowledge & is not a substitute for medical advice your doctor recommends.