Diabetes: Therapies - Medical Essentials
Medline Plus tells us that before the discovery of insulin in 1921, everyone with type 1 diabetes died within a few years after diagnosis. Although insulin is not considered a cure, its discovery was the first major breakthrough in diabetes treatment.
Today, healthy eating, physical activity, and taking insulin are the basic therapies for type 1 diabetes. The amount of insulin must be balanced with food intake and daily activities. Blood glucose levels must be closely monitored through frequent blood glucose checking. People with diabetes also monitor blood glucose levels several times a year with a laboratory test called the A1C. Results of the A1C test reflect average blood glucose over a 2- to 3-month period.
Healthy eating, physical activity, and blood glucose testing are the basic management tools for type 2 diabetes. In addition, many people with type 2 diabetes require oral medication, insulin, or both to control their blood glucose levels.
Adults with diabetes are at high risk for cardiovascular disease. Managing diabetes requires keeping blood glucose levels under control – and also managing blood pressure and cholesterol levels through healthy eating, physical activity, and use of medications (if needed). By doing so, those with diabetes can lower their otherwise increased risk of heart disease or stroke. Aspirin therapy, if recommended by the health care team, and smoking cessation can also help lower risk.
People with diabetes must take responsibility for their day-to-day care. Much of the daily care involves keeping blood glucose levels from going too low or too high.
Getting the sugar / insulin balance wrong can create a crisis condition.
When blood glucose levels drop too low—a condition known as hypoglycemia—a person can become nervous, shaky, and confused. Judgment can be impaired, and if blood glucose falls too low, fainting can occur.
A person can also become ill if blood glucose levels rise too high, a condition known as hyperglycemia.
People with diabetes should see a health care provider who will help them learn to manage their diabetes and who will monitor their diabetes control. Most people with diabetes get their primary care from their GP. Often, having a team of providers can improve diabetes care. A care team can also include:
an endocrinologist with special knowledge of diabetes
a dietitian
a nurse or nurse practitioner
a physiotherapist
a podiatrist (for foot care)
an ophthalmologist or an optometrist (for eye care)
and other health care providers, such as cardiologists and other specialists.
The goal of diabetes management is to keep levels of blood glucose, blood pressure, and cholesterol as close to the normal range as safely possible. Medline Plus quotes strong evidence that keeping blood glucose levels close to normal reduces the risk of developing major complications of type 1 diabetes and keeps the risk reduced.
The United Kingdom Prospective Diabetes Study, completed in 1998, showed that intensive control of blood glucose and blood pressure reduced the risk of blindness, kidney disease, stroke, and heart attack in people with type 2 diabetes.
FIRST AID for hyper and hypoglycaemia: We have seen far too little mention in most information about diabetes concerning first aid. The authorised UK First Aid Manual advises that sugar should be given if a diabetic person is in crisis but still conscious and the cause is unclear. This will rapidly correct hypoglycaemia and will do little harm in hyperglycaemia. The next step is to dial 999 without delay. If the person in crisis knows what is needed and just needs help to use their kit – help them.
Hyperglycaemia comes on gradually. Symptoms can include thirst, vomiting and excessive urination. Signs of the condition can include a fruity sweet odour on the breath, rapid breathing, rapid and weak pulse, warm dry skin and drowsiness.
Hypoglycaemia happens rapidly. The person may feel hungry. The pulse is rapid and strong, the skin pale and cold with sweating. Seizures are common, and there is a rapid loss of consciousness.
MEDICAL ESSENTIALS:
BBC Health tells us that although diabetes can’t be cured, it can be managed and kept under control. Anyone diagnosed with diabetes should seek treatment immediately to prevent associated illnesses.
The fasting blood glucose test is the usual tool for diagnosis and most reliably done in the morning. This tests for a high level of glucose in the blood after an 8 hour fast. A diagnosis can also be made based on one of the following test results, confirmed by retesting on a different day:
A high blood glucose level 2 hours after drinking a solution containing glucose dissolved in water. This test is called the oral glucose tolerance test (OGTT).
A high random (taken at any time of day) blood glucose level along with the presence of diabetes symptoms.
TREATMENT
BBC Health tells us that the type of treatment depends on the type of diabetes.
In both types, dietary measures play a crucial role. Specially trained dieticians can offer invaluable advice on suitable foods – see our section on diet.
Treating type 1 diabetes:
Type 1 is treated with insulin and by eating a healthy diet. Insulin can’t be taken by mouth because the digestive juices in the stomach destroy it. This means that for most people it has to be given by injections. Most people find giving the injections simple and relatively painless, since the needle is so fine.
How often someone needs to inject depends on what their diabetes specialist has recommended, and which type of insulin they’re using.
Treating type 2 diabetes:
Type 2 may have been considered the ‘milder’ form of diabetes in the past, but this is no longer the case. For many people, type 2 diabetes can be controlled by diet alone. Medication in tablet form is used when diet doesn’t provide adequate control.
BBC Health reminds usagain that it is possible to minimise the risk of strokes, heart, vascular and kidney disease and other serious complications by keeping diabetes under tight control. They stress the vital importance of checking glucose levels at home regularly as instructed, and attending hospital check-ups where blood glucose, blood pressure, kidney function, eyes and feet will be examined. Any problems detected can then be treated early, rather than later when problems may be more difficult to treat. They also remind that while uncontrolled diabetes is a common cause of blindness, treatment can prevent blindness in 90 per cent of those at risk.
DRUG TREATMENTS
Staying with the information provided by BBC Health: FOR TYPE 1 DIABETES insulin is given at regular intervals throughout the day, usually two to four times.
Each injection may contain one, or a combination of different types of insulin, which act for a short, intermediate or longer period of time.
Injections can be given using either a traditional needle and plastic syringe, or with an injection pen device, which many people find more convenient.
An automatic insulin pump is available, which means that fewer injections are needed. The needle is sited under the skin, and connected to a small electrical pump that attaches to a belt or waistband and is about the size of a pager. Inside is a reservoir of fast-acting insulin which is delivered continuously at an adjustable rate.
Inhaled insulin has recently become available for treating people with a proven needle phobia or people who have severe trouble injecting.
Insulin was first used to treat diabetes in 1921. Under normal circumstances, it’s made by beta cells that are part of a cluster of hormone-producing cells in the pancreas.
The hormone regulates the level of glucose in the blood, preventing the level from going too high. Insulin enables cells to take up the amount of glucose they need to provide themselves with enough energy to function properly. It also allows any glucose left over to be stored in the liver.
Most insulin used today is ‘human insulin’, although some people still use insulin from cows and pigs. ‘Human insulin’ is a product of genetic engineering, where bacteria bred in a laboratory are given a gene that allows them to produce insulin.
FOR TYPE 2 DIABETES The different types of medication in tablet form work by one of these methods:
- helping the pancreas to make more insulin
- increasing the use of glucose and decreasing glucose production
- slowing down the absorption of glucose from the intestine
- stimulating insulin release from the pancreas
- enabling the body to use its natural insulin more effectively
Over time, if a careful diet combined with oral medication are not sufficient to keep the diabetes under control, insulin injections may be recommended.
The Senior Alliance is grateful to Diabetes UK for its stance since 2003 against drug rationing by the National Institute of Clinical Excellence (NICE) which could compromise the care of people with diabetes. The Diabetes UK website tells us that restrictions direct doctors to deny glitazone drugs to some people with diabetes.
Glitazones can provide an alternative to insulin injections for those with Type 2 diabetes who need to improve their blood glucose control.
Suzanne Lucas, Director of Care at Diabetes UK is quoted as saying that “Diabetes is serious and if not well controlled can devastate lives. Doctors and patients need to have access to the treatments that are best for them. Today’s ruling will deny that. Diabetes is costing the NHS millions of pounds a day. Much of that is spent on treating the long-term effects of the condition, many of which could be prevented with early, effective treatment. NICE needs to look at the long-term picture rather than basing decisions on trying to make small financial savings today.”
Diabetes UK would urge manufacturers and regulatory bodies to look more closely at the full range of treatment options for glitazones and make them available where they are safe and effective. The charity is also urging doctors to put their patients health first when interpreting the new guidelines.
The ruling could also leave people with diabetes facing a choice between their health and their livelihood. Glitazones can provide an alternative to insulin injections for those with Type 2 diabetes who need to improve their blood glucose control. Denying access will limit their options and potentially open them to discrimination which could see people such as those who drive for a living or those who work offshore losing their jobs.
ALTERNATIVE METHODS FOR USING INSULIN
From the Diabetes Exercise and Sports Association website we get the following simple information: Injection has been the standard means of self-administering insulin, but alternative insulin–delivery methods have emerged. The various options provide an array of choices for people with diabetes, with each method appealing to different patients based on their preferences and the specific nature of their disease. These alternative delivery methods include:
Insulin pumps: A lightweight device the size of a pager holds insulin that flows through a tube and needle inserted into the patient’s abdomen. The patient wears this device day and night, occasionally removing it for activities such as
athletics or showering. Insulin pumps continuously deliver basal doses of insulin maintaining the proper glucose (blood sugar) level. The pump also allows the patient to release varied doses of insulin if the glucose becomes too high. Patients who use insulin pumps have to take an active role in managing their care. They must commit to glucose monitoring several times a day and keeping a close watch on carbohydrate consumption.
Insulin pens: A device that resembles a pen and has a cartridge of insulin attached. Patients turn a dial to set the dosage amount and press a plunger to deliver the medicine, usually in the abdomen, upper arms, thighs or buttocks.
It is extremely important that patients using insulin pens ensure that they
properly mix the insulin before injecting the medication. Recent research indicates that many patients are not properly mixing their dosages, which results in insulin that is absorbed too quickly. This increases the chance of episodes of low glucose (hypoglycemia).
Insulin jet injectors: A high-pressure mechanism that sends a fine spray of insulin through the skin. No needles are involved, but some patients find the high-pressure air to be painful. We note that others don’t.
Inhaled insulin: An inhaler, similar to the device used by people with asthma, delivers powered insulin through the mouth. The medication travels to the lungs, where it is absorbed into the bloodstream. U.S. and European regulators approved the first brand of inhaled insulin in late January 2006. Find out if you can get this, and if it could work for you. Some people, especially those with type 1 diabetes, will still need to inject long-acting insulin. Whichever type you have, it may or may not be right for you. In general, the U.S. Food and Drug Administration described it as the biggest advance in insulin therapy since discovery of the hormone in the 1920s.
glucose monitoring: The “Take Control of Your Diabetes website (see Useful Organisations) reports on the development of continuous glucose monitoring, a revolutionary technology they say will change the lives of people with diabetes on insulin.
NEW DRUG TREATMENTS
Diabetes UK’s website tells us that:
1. A new treatment for Type 2 diabetes based on a hormone discovered in the Gila lizard is now available in the UK.
Byetta (Exenatide) is a synthetic copy of the hormone found in the Gila lizard that can be used as an add-on treatment for people with Type 2 diabetes. It works in three different ways:
It helps the body to produce more insulin when it is needed.
It reduces the amount of glucose being produced by the liver when it is not needed.
It reduces the rate at which the stomach digests foods and empties. This means that the rate at which glucose from food is released into the blood is reduced.
“Managing blood glucose levels, along with blood pressure levels, is central to reducing the risk of heart attacks, blindness, strokes, kidney disease and amputations in people with Type 2 diabetes," said Cathy Moulton, Care Advisor at Diabetes UK.
“This is an exciting time, as any new drug that helps people with Type 2 diabetes and is safe and effective is to be welcomed. New treatments provide more options to ensure the most effective treatment for any individual.”
Byetta (Exenatide) is one of the first in a new class of drug to help people with Type 2 diabetes manage their blood glucose levels. Although it is injected, it is not an insulin. It must be injected twice daily and has been shown to shown to reduce blood glucose levels and may also help weight management. It is used in combination with metformin, and/or sulphonylurea tablets.
2. A new drug to treat Type 2 diabetes is now available in the UK. Januvia (Sitagliptin) is an add-on treatment for people with Type 2 diabetes. It is a DPP-4 inhibitor which works by increasing the levels of hormones in the body called incretins. These hormones are released throughout the day and levels are increased at meal times. They work in the body in two ways:
Produce more insulin only when needed.
Reduce the amount of glucose being produced by the liver when it is not needed.
Diabetes UK welcomes any advances that help improve quality of life for people with diabetes, says Simon O’Neill, Director of Care, Information and Advocacy Services at Diabetes UK.
“In some cases, Type 2 diabetes can be managed through lifestyle adjustments such as eating a healthy, balanced diet and taking regular physical activity. When managing the condition in this way is not possible, Diabetes UK recognises that a wide choice of treatment options, including Januvia (sitagliptin) in combination with metformin or glitazone tablets, can help.
People with diabetes should have as wide a choice as possible of effective treatments for their condition. Good blood glucose control is essential for people with diabetes to improve wellbeing and protect against long-term damage to the eyes, kidneys, nerves, heart and major arteries.”
Januvia (Sitagliptin) is taken in tablet form once a day with or without food. It is an add-on treatment suitable for use with either Metformin or a Glitazone. It is currently not licensed as mono-therapy, triple-therapy or as an add-on medicine with insulin.
