Chapter 23

Type 2 is the type of diabetes most people get as adults after the age of 40. But you can also get this kind of diabetes at a younger age.

Healthy eating, exercise, and losing weight may help you lower your blood glucose (also called blood sugar) when you find out you have type 2 diabetes. If these treatments do not work, you may need one or more types of diabetes pills to lower your blood glucose. After a few more years, you may need to take insulin shots because your body is not making enough insulin.

Most people make insulin in their pancreas. If you have type 1 diabetes, your body does not make insulin. Insulin helps glucose from the foods you eat get to all parts of your body and be used for energy.

Because your body no longer makes insulin, you need to take insulin in shots. Take your insulin as your doctor tells you. The section What do I need to know about insulin? provides more information on insulin.

You need to know:

	Diabetes medicines that lower blood glucose never take the place of healthy eating and exercise.
	If your blood glucose gets too low more than a few times in a few days, call your doctor.
	Take your diabetes pills or insulin even if you are sick. If you cannot eat much, call your doctor.

Actos

Amaryl

Avandia

DiaBeta

Diabinase

Dymelor

Glucophage

Glucophage XR

Glucotrol

Glucotrol XL

Glucovance

Glynase PresTab

Glyset

Micronase

Orinase

Prandin

Precose

Starlix

Tolinase

Oral Drugs

Adults with Type 2 diabetes may or may not be treated with one or more classes of oral diabetes drugs. The oldest class, sulfonylureas (SFUs), act on the pancreatic tissue to produce insulin. The newest one is Amaryl (glimepiride) approved by FDA in 1996.

Because SFUs can become less effective after 10 or more years of use, other drugs often are needed. Another class is the biguanides, including metformin, which was approved by FDA in 1995. This drug acts by lowering cells’ resistance to insulin, a common problem in Type 2 diabetes. A third class is the alpha-glucosidase inhibitors, which include Precose (acarbose), approved by FDA in 1995, and Glyset (miglitol), approved in 1996. These drugs slow the body’s digestion of carbohydrates, delaying absorption of glucose from the intestines.

A newer class of diabetes drugs is the thiazolidinediones. They include Rezulin (troglitazone), approved in 1997, and Avandia and Actos, both approved in 1999. These drugs improve a condition that seems to be an important underlying cause of adult onset diabetes—resistance of the body to insulin.

Though they act similarly, their approved uses vary. Rezulin, for example, is approved for use in combination with sulfonyureas and metformin. It should not be used as an initial single agent therapy and should be prescribed only in patients not adequately controlled by other therapies.

FDA approved Avandia for patients with diabetes who are not taking insulin and Actos for diabetics who are not adequately controlled by diet and exercise alone. Actos is approved for use with sulfonylureas, metformin or insulin in patients who are not adequately controlled on the these agents alone.

FDA recommends regular liver chemistry tests for patients receiving a thiazolidinedione. This recommendation is based on evidence of serious and sometimes fatal liver injury in patients treated with Rezulin. Though liver disease was not seen in clinical trials of Avandia and Actos, FDA recommends liver tests for patients on any of the approved thiazolidinediones. The recommendations are as follows:

For patients on Rezulin, liver function tests should be done before the patient starts therapy, monthly during the first year of Rezulin therapy, and quarterly thereafter.

For patients on Actos and Avandia, liver function tests should be performed at the start of therapy, every two months during the first year of treatment, and periodically thereafter.

Symptoms suggesting liver problems include unexplained nausea, vomiting, stomach pain, tiredness, loss of appetite, dark urine or yellowing of skin (jaundice). If any of these symptoms occur, liver enzymes should be checked. If the patient develops jaundice, he or she should stop the drug therapy.

Another new class of oral blood glucose-lowering drugs, the meglitinides, was introduced in December 1997 when FDA approved Prandin (repaglinide). These drugs work like the SFUs. Prandin is taken two, three, or four times a day usually about 15 minutes before meals. The advantage of this medicine is that, like the short-acting SFUs, it provides convenience to patients who are not on a regular eating schedule. Also, it may reduce the potential for serious hypoglycemia (low blood sugar), the most important adverse reaction of SFU therapy. Prandin is approved for use alone or in combination with metformin.

You can inject insulin into several places on your body. Insulin injected near the stomach works fastest. Insulin injected into the thigh works slowest. Insulin injected into the arm works at medium speed. Ask your doctor or diabetes teacher to show you the right way to take insulin and in which parts of the body to inject it.

	If you use a whole bottle of insulin within 30 days, keep that bottle of insulin at room temperature. On the label, write the date that is 30 days away. That is when you should throw out the bottle with any insulin left in it.
	If you do not use a whole bottle of insulin within 30 days, then store it in the refrigerator all the time.
	If insulin gets too hot or cold, it breaks down and does not work. So, do not keep insulin in very cold places such as the freezer, or in hot places, such as by a window or in the car’s glove compartment during warm weather.
	Keep at least one extra bottle of each type of insulin you use in your house. Store extra insulin in the refrigerator.

	dizzy or light-headed
	hungry
	nervous and shaky
	sleepy or confused
	sweaty

	Aspart (Novolog)
	Insulin Glargine (Lantus)
	Lente
	Lispro (Humalog)
	NPH
	Premixed
	Regular
	Ultralente

	Sulfonylureas (SUL-fah-nil-YOO-ree-ahs). Stimulate your pancreas to make more insulin.
	Biguanides (by-GWAN-ides). Decrease the amount of glucose made by your liver.
	Alpha-glucosidase inhibitors (AL-fa gloo-KOS-ih-dayss in-HIB-it-ers). Slow the absorption of the starches you eat.
	Thiazolidinediones (THIGH-ah-ZO-li-deen-DYE-owns). Make you more sensitive to insulin.
	Meglitinides (meh-GLIT-in-ides). Stimulate your pancreas to make more insulin.
	D-phenylalanine (dee-fen-nel-AL-ah-neen) derivatives. Help your pancreas make more insulin quickly.
	Combination oral medicines. Put together different kinds of pills.

	When do I take the medicine–before a meal, with a meal, or after a meal?
	How often should I take the medicine?
	Should I take the medicine at the same time every day?
	What should I do if I forget to take my medicine?
	What side effects may happen?
	What should I do if I get side effects?

	Side effects are changes that may happen in your body when you take a medicine. When your doctor gives you a new medicine, ask what the side effects might be.
	Some side effects happen just when you start to take the medicine. Then they go away.
	Some side effects happen only once in a while. You may get used to them or learn how to manage them.
	Some side effects will cause you to stop taking the medicine. Your doctor may try another one that doesn’t cause you side effects.

	a sulfonylurea and metformin
	a sulfonylurea and acarbose
	metformin and acarbose
	repaglinide and metformin
	nateglinide and metformin
	pioglitazone and a sulfonylurea
	pioglitazone and metformin
	rosiglitazone and metformin
	rosiglitazone and a sulfonylurea

23.

Patient Teaching

Medicines for People With Diabetes

	your own response
	the place on your body where you inject insulin.
	the type and amount of exercise you do and the length of time between your shot and exercise.

	delaying or skipping a meal
	eating too little food at a meal
	getting more exercise than usual
	taking too much diabetes medicine
	drinking alcohol

	1/2 cup (4 oz.) of any fruit juice
	1 cup (8 oz.) of milk
	1 or 2 teaspoons of sugar or honey
	1/2 cup (4 oz.) of regular soda
	5 or 6 pieces of hard candy
	glucose gel or tablets (take the amount noted on the package to add up to 15 grams of carbohydrate)

	crackers and peanut butter or cheese
	half of a ham or turkey sandwich
	a cup of milk and crackers or cereal