Living With Type 2 Diabetes

Diabetes self-management education is an integral component of medical care. Among adults with diagnosed diabetes, 12% take both insulin and oral medications, 19% take insulin only, 53% take oral medications only, and 15% do not take either insulin or oral medications.

Traditionally, information regarding diabetes would be obtained from a family physician . However, with access to the internet so widely available now , people are able to educate themselves through websites . This information can be beneficial, but care must be taken to ensure the information is medically sound . Several of the external links below provide information about diabetes and its management, including self-management.

Exercise

In September 2007, a joint randomized controlled trial by the University of Calgary and the University of Ottawa found that "Either aerobic or resistance training alone improves glycemic control in type 2 diabetes, but the improvements are greatest with combined aerobic and resistance training than either alone." The combined program reduced the HbA1c by 0.5 percentage point. Other studies have established that the amount of exercise needed is not large or extreme, but must be consistent and continuing. Examples might include a brisk 45 minute walk every other day.

Theoretically, exercise does have benefits in that exercise would stimulate the release of certain ligands that cause GLUT4 to be released from internal endosomes to the cell membrane. Insulin though, which no longer works effectively in those afflicted with type 2 diabetes, causes GLUT1 to be placed into the membrane. Though they have different structures, they both perform the same function of increasing intake of glucose into the cell from the blood serum. Exercise also allows for the uptake of glucose independently of insulin, ie by adrenaline.

Antidiabetic drugs

There are several drugs available for type 2 diabetics—most are unsuitable or even dangerous for use by type 1 diabetics. They fall into several classes and are not equivalent, nor can they be simply substituted one for another. All are prescription drugs.

One of the most widely used drugs now used for type 2 diabetes is the biguanide metformin; it works primarily by reducing liver release of blood glucose from glycogen stores and secondarily by provoking some increase in cellular uptake of glucose in body tissues. Both historically, and currently, the most commonly used drugs are in the Sulfonylurea group, of which several members (including glibenclamide and gliclazide) are widely used; these increase glucose stimulated insulin secretion by the pancreas and so lower blood glucose even in the face of insulin resistance.

Newer drug classes include:

Testosterone treatment is very efficient to reduce insulin resistance without digestive problems (a very common side effect of other anti-diabetes drugs)
Thiazolidinediones (TZDs) (rosiglitazone, pioglitazone, and troglitazone -- the last, as Rezulin, was withdrawn from the US market because of an increased risk of systemic acidosis). These increase tissue insulin sensitivity by affecting gene expression
α-glucosidase inhibitors (acarbose and miglitol) which interfere with absorption of some glucose containing nutrients, reducing (or at least slowing) the amount of glucose absorbed
Meglitinides which stimulate insulin release (nateglinide, repaglinide, and their analogs) quickly; they can be taken with food, unlike the sulfonylureas which must be taken prior to food (sometimes some hours before, depending on the drug)
Peptide analogs which work in a variety of ways:
- Incretin mimetics which increase insulin output from the beta cells among other effects. These includes the Glucagon-like peptide (GLP) analog exenatide, sometimes referred to as ''lizard spit'' as it was first identified in Gila monster saliva
- Dipeptidyl peptidase-4 (DPP-4) inhibitors increase Incretin levels (sitagliptin) by decreasing their deactivation rates
- Amylin agonist analog, which slows gastric emptying and suppresses glucagon (pramlintide)

Oral drugs

Diabetes mellitus type 2 is tightly associated with hypogonadism.

A systematic review of randomized controlled trials found that metformin and second-generation sulfonylureas are the preferred choices for most with type 2 diabetes, especially those early in the course of the disease. Failure of response after a time is not unknown with most of these agents: the initial choice of anti-diabetic drug has been compared in a randomized controlled trial which found "cumulative incidence of monotherapy failure at 5 years to be 15% with rosiglitazone, 21% with metformin, and 34% with glyburide". Of these, rosiglitazone users showed more weight gain and edema than did non-users. Pioglitazone and rosiglitazone may also increase the risk of fractures.

For patients who also have heart failure, metformin may be the best tolerated drug.

The variety of available agents can be confusing, and the clinical differences among type 2 diabetics compounds the problem. At present, choice of drugs for type 2 diabetics is rarely straightforward and in most instances has elements of repeated trial and adjustment.

Injectable peptide analogs

DPP-4 inhibitors lowered A1c by 0.74%, comparable to other antidiabetic drugs. GLP-1 analogs resulted in weight loss and had more gastrointestinal side effects, while DPP-4 inhibitors were weight neutral and increased risk for infection and headache, but both classes appear to present an alternative to other antidiabetic drugs.

Insulin preparations

If antidiabetic drugs fail (ie, the clinical benefit stops), insulin therapy may be necessary – usually in addition to oral medication therapy – to maintain normal or near normal glucose levels.

Typical total daily dosage of insulin is 0.6 U/kg.

For men, plasma glucose [mmol/liter–5)x2] x (weight [m)–height For women, [(fasting plasma glucose [mmol/liter–5)x2] x (weight [m)–height initial insulin regimen are often chosen based on the patient's blood glucose profile. Initially, adding nightly insulin to patients failing oral medications may be best. Nightly insulin combines better with metformin than with sulfonylureas. The initial dose of nightly insulin (measured in IU/d) should be equal to the fasting blood glucose level (measured in mmol/L). If the fasting glucose is reported in mg/dl, multiply by 0.05551 to convert to mmol/L.

When nightly insulin is insufficient, choices include:

Premixed insulin with a fixed ratio of short and intermediate acting insulin; this tends to be more effective than long acting insulin, but is associated with increased hypoglycemia.. Initial total daily dosage of biphasic insulin can be 10 units if the fasting plasma glucose values are less than 180 mg/dl or 12 units when the fasting plasma glucose is above 180 mg/dl". More recently, a randomized controlled trial found that although long acting insulins were less effective, they were associated with reduced hypoglycemic episodes.

Antihypertensive agents

The goal blood pressure is 130/80 which is lower than in non-diabetic patients.

ACE inhibitors

The HOPE study suggests that diabetics should be treated with ACE inhibitors (specifically ramipril 10 mg/d) if they have one of the following :

hypertension
hypercholesterolemia or reduced low high-density lipoprotein cholesterol levels
cigarette smoking
microalbuminuria

After treatment with ramipril for 5 years the number needed to treat was 50 patients to prevent one cardiovascular death. Other ACE inhibitors may not be as effective.

Hypolipidemic agents

Gastric bypass surgery

Gastric Bypass procedures are currently considered an elective procedure with no universally accepted algorithm to decide who should have the surgery. In the diabetic patient, certain types result in 99-100% prevention of insulin resistance and 80-90% clinical resolution or remission of type 2 diabetes. In 1991, the NIH (National Institute of Health) Consensus Development Conference on Gastrointestinal Surgery for Obesity proposed that the body mass index (BMI) threshold to consider surgery should drop from 40 to 35 in the appropriate patient. More recently, the American Society for Bariatric Surgery (ASBS) and the ASBS Foundation suggested that the BMI threshold be lowered to 30 in the presence of severe co-morbidities. More debate has flourished about the role of gastric bypass surgery in type 2 diabetics since the publication of The Swedish Obese Subjects Study. The largest prospective series showed a large decrease in the occurrence of type 2 diabetes in the post-gastric bypass patient at both 2 years (odds ratio was 0.14) and at 10 years (odds ratio was 0.25).

A study of 20-years of Greenville (US) gastric bypass patients found that 80% of those with type 2 diabetes before surgery no longer required insulin or oral agents to maintain normal glucose levels. Weight loss occurred rapidly in many people in the study who had had the surgery. The 20% who did not respond to bypass surgery were, typically, those who were older and had had diabetes for over 20 years.

In January 2008, The Journal of the American Medical Association (JAMA) published the first randomized controlled trial comparing the efficacy of laparoscopic adjustable gastric banding against conventional medical therapy in the obese patient with type 2 diabetes. Laparoscopic Adjustable Gastric Banding results in remission of type 2 diabetes among affected patients diagnosed within the previous two years according to a randomized controlled trial. The relative risk reduction was 69.0%. For patients at similar risk to those in this study (87.0% had type 2), this leads to an absolute risk reduction of 60%. 1.7 patients must be treated for one to benefit (number needed to treat = 1.7). [http://medinformatics.uthscsa.edu/calculator/calc.shtml?calc_rx_rates.shtml?eer=27.0&cer=87.0 Click here to adjust these results for patients at higher or lower risk of type 2 diabetics.

These results have not yet produced a clinical standard for surgical treatment of diabetic patients, as the mechanism, if any, is currently obscure. Surgical cure of Type 2 diabetes must be, as a result, considered currently experimental.