General Guidelines for
Treatments
Treatment for type 2 diabetes generally follows
certain stages that depend on the amount of residual
insulin and ability to control blood glucose levels:
Healthy lifestyle habits
are the cornerstone of diabetes treatment. A healthy
diet, weight control, and exercise are essential for any
treatment program. Many type 2 diabetics can control
their condition with diet and exercise alone for years.
If they cannot, then
medication is introduced. Most often a single oral agent
that stimulates or preserves any residual insulin is the
first choice. (Some physicians are recommending a very
aggressive initial approach for newly-diagnosed patients
who have type 2 diabetes. Knowing that many patients
have had diabetes for years prior to diagnosis, these
physicians believe that physicians should not wait to
initiate treatment with one or more medications.)
Some patients may be able
to control their glucose levels with a single drug. One
study reported, however, that after three years, half of
the patients needed more than one agent, and at nine
years, only 25% could remain on a single drug. In fact,
according to a 1999 survey, 90% of diabetes specialists
reported that they prescribed three or more medications
for their patients.
Eventually, natural
insulin may completely fail; in such cases patients then
require insulin replacement. Some people may even need
to start off with insulin. Such patients may include
those with severe hyperglycemia, those with signs of
autoimmune diabetes, and women during pregnancy.
Treatment
Goals & Intensive Control of Blood Glucose Levels
Major studies have now reported that, as in type 1
patients, rigorous control of blood glucose levels can
help reduce the risk for complications in type 2
diabetics, including retinopathy, kidney and nerve
damage. Even short-term control of blood glucose may
improve their quality of life. (It may also help prevent
impotence in men) It is not clear, however, if
controlling blood glucose has any major benefits on the
heart, and heart disease is the most serious
complication in type 2 diabetes. Studies are mixed on
the effects of intensive glucose control, with some even
reporting some harm. Of particular concern is weight
gain from insulin therapies, a major problem and health
risk in most patients with type 2 diabetes. Newer
insulin-sensitizing medications may pose less of a risk
for weight gain, however, and new weight loss drugs are
also proving to be helpful in offsetting weight gain
from other drugs. Until more is known, at this time
patients should still aim for the following test
results:
Fasting plasma glucose
concentrations below 110 mg/dL.
Glycolated hemoglobin
(HbA1c) levels of less than 7%. Type 2 diabetics with
normal or low HbA1c levels have the lowest risk for
complications. According to one study, a 1%
reduction in people with elevated glycolated hemoglobin
levels lowers the risk for complications by 21%.
Patients should discuss all options with their
physicians.
Medications
Used for Treatment of Type 2 Diabetes
Oral Agents that Use Patients' Insulin Stores
There are now many oral medication for type 2 diabetes
with different mechanisms of action that might benefit
specific patients. Most agents for these patients are
aimed at using or increasing sensitivity to the
patient's own natural stores of insulin:
Sulfonylureas (examples
include but are not limited to glyburide, glipizide, and
glimepiride). Stimulate insulin secretion.
Meglitinides (repaglinide,
nateglinide). Stimulate insulin secretion. These newer
agents are better than sulfonylureas in controlling
glucose spikes after meals.
Biguanides (metformin).
Increase tissue sensitivity to available insulin. Such
agents may have beneficial effects on cholesterol, blood
pressure, and clotting factors. Does not cause weight
gain or hypoglycemia.
Thiazolidinediones (pioglitazone
and rosiglitazone). Reduce insulin resistance. These
agents all improve cholesterol levels, including HDL
levels (the so-called good cholesterol), and may reduce
the risk for blood clots. These effects should reduce
heart disease risk. They can cause swelling from fluid
build-up and weight gain.
Alpha-glucosidase
inhibitors (acarbose and miglitol). Slow intestinal
absorption of carbohydrates. Have only modest effects
and have gastrointestinal side effects.
Combinations of these agents are often used to increase
effectiveness.
Insulin
Replacement Eventually many patients lose their
insulin stores and require insulin replacement, which
may be initiated in combination with oral agents. Some
forms of insulin analogues may be beneficial for
patients with type 2 diabetes. These include rapid-or
long-acting insulin derivatives that mimic the normal
insulin response. The possible adverse effects of
insulin on weight gain and the heart are troublesome,
however. In one report, metformin achieved the lowest
mortality rates (8%) compared to insulin (28%), a
sulfonylurea (16%), and a thiazolidinedione (14%).
Treating
Special Populations
Different goals may be required for specific
individuals, including pregnant women, very old and very
young people, and those with accompanying serious
medical conditions. Treating children with diabetes type
2 depends on the severity of the condition at diagnosis.
Until recently, insulin was the only approved medication
for treating children. In January 2001, however,
metformin became the first oral agent approved by the
Food and Drug Administration for that purpose, although
even before the ruling some pediatric diabetes
specialists had recommended using this and other oral
medications.
Measures
for Preventing Complications
Taking any necessary treatments or preventive
measures for heart disease and stroke is also essential.
This includes controlling high blood pressure (which is
also a risk factor for kidney disease) as well as
unhealthy cholesterol levels. |
