Antidiabetic Drugs

Archive for the ‘Type 2 diabetes’ Category

There are certain complications that occur more often in people with type 2 diabetes than in people without this condition. A major problem associated with type 2 diabetes occurs when excess sugar in the blood begins to clog small blood vessels and leads to circulation problems — blood cannot travel freely to where it needs to be.

Poor circulation can lead to tissue damage, eventually contributing to eye disease (diabetic retinopathy), kidney damage (nephropathy), and nerve cell damage (neuropathy). Too much blood glucose can also speed up the process of hardening of the arteries (arteriosclerosis), increasing your risk of developing a heart attack and stroke.

Although your risk of developing complications is affected by some factors that you can’t control — namely, your age, race, and genetic makeup — there are things you can do right now to manage your risk of developing complications from type 2 diabetes. The greatest risk factor, one that almost all type 2 diabetes complications are associated with, is excess sugar in the blood.

You can work to achieve healthy blood sugar levels and significantly decrease your likelihood of developing type 2 diabetes complications by sticking to a healthy diet and exercise regimen, and by properly following any prescribed treatment and medication plans.

If you need help keeping your blood sugar under control, ask your doctor if medication can help.

Here is a quick list of the key things you can do to keep your blood sugar levels under control.

* Test your blood sugar. Ask your doctor or healthcare professional when and how often to perform a blood sugar test.

* Record your blood tests, medicines, and daily events. Review the record with your doctor or healthcare professional at each office visit.

* Take your medication as prescribed by your doctor or healthcare professional, even if you are feeling well.

* Eat healthy foods. See a dietitian to create a meal plan that is right for you.

* Exercise. If you have not been active, start slowly. Good activities include walking and swimming. Talk to your doctor or healthcare professional about an exercise program that is right for you.

Important Tips:

* Stay at a weight that is right for you. Ask your doctor or healthcare professional what you should weigh.

* Treat low blood sugar symptoms quickly with some form of sugar.

* If you are a smoker, stop. Talk to your type 2 diabetes care team about ways to quit smoking.

* Learn more about type 2 diabetes and type 2 diabetes self-care. Ask your doctor or healthcare professional to suggest a dietitian and a diabetes educator to help you manage your diabetes.

* Seek support from family and friends or join a type 2 diabetes support group. Call your local hospital or health department to find a support group.

* Reward yourself for staying in control. When you know you are doing a good job of sticking to your treatment program, reward yourself by doing something you enjoy!

To manage setbacks:

* Identify your setbacks when it comes to blood sugar control. Decide now how you will handle these events next time. Talk to a healthcare team for ideas.

* If you’ve slipped, admit it and move on. Learn what you can from your experiences.

* Don’t be too hard on yourself. A setback is not the end of the world.

* Seek assistance. Ask for a little help from friends and family or your healthcare team when you are down or need someone to talk to.

All people with type 2 diabetes have to work to keep the amount of sugar in their blood as near to normal as possible. This is called “being in control.” Studies have shown that good glucose control may prevent or delay complications of type 2 diabetes such as heart disease, kidney disease, or blindness.

Controlling your blood sugar levels can be an ongoing challenge. Many different factors affect your blood sugar levels, including diet, activity, stress, and overall health. Knowing how much to eat, how much to exercise, and how much medication and/or insulin to take can be difficult. Keep in mind that your type 2 diabetes care team is available for support.

Making Blood Sugar Control More Manageable

When you have type 2 diabetes, it is easy to get caught up in the day-to-day actions that are required to manage your condition. Sometimes all of the “shoulds” and “should nots” can feel overwhelming. To make your daily efforts more manageable, it may be helpful to think about all your reasons for controlling your blood sugar. You may want to consider posting a list of these reasons where you will see it often.

There are other approaches you can take that might make the steps along the way easier. Try Glucophage XR. For example, if you plan to increase your physical activity, start by taking a 15-minute walk 3 times a week. Then try walking longer or more often. Remember, a big part of the process is learning what works for you. Your healthcare team can help you construct a manageable diabetes care plan.

In addition to exercise, diet, and weight loss, some people with type 2 diabetes need medication to keep their blood sugar levels under control. If you require medication to help control your blood sugar, you may want to ask your doctor or healthcare professional if Glucophage XR may be right for you.

Treatment of type 2 diabetes serves two main purposes. In the short term, it may provide relief from the immediate symptoms of high blood sugar. In the long term, good control of sugar may prevent or delay complications of type 2 diabetes, such as heart disease, kidney disease, and blindness.

Type 2 diabetes may be treated with diet, exercise, and weight loss. This is particularly true for people who have been recently diagnosed. Many people also require oral medications or injected insulin to help control their blood sugar.

The treatment suggested by your doctor or healthcare professional will depend on several factors, including:

* how long you have had type 2 diabetes

* how high your blood glucose levels are

* your overall health

* other medication you may be taking

To help make your treatment work best for you, you will work closely with a team of healthcare professionals. This healthcare team typically consists of your doctor, a dietitian or nutritionist, and nurses, as well as a foot doctor (podiatrist) and eye doctor to check for signs of developing complications. Together, your healthcare team will develop a treatment plan that is right for you.

Along with the care provided by your healthcare team, you can make a difference in the success of your type 2 diabetes treatment plan. You should closely follow your healthcare team’s recommendations for diet, exercise, weight loss, and treatment.

Here are some important things you can do:

* Modify your diet and exercise regimens to carefully follow the recommendations outlined by your doctor or healthcare professional.

* If your doctor or healthcare professional has prescribed medication for your diabetes, always take it as instructed.

* You should monitor your blood sugar as prescribed by your doctor or healthcare professional to see how well you are managing your diabetes.

It is important for you to be an active participant in managing your type 2 diabetes.

When a person is suspected of having type 2 diabetes, there are several different types of blood tests that may be used to diagnose the disease, including the fasting glucose test, the oral glucose tolerance test, and the random glucose test. Of these, the fasting glucose test is the preferred method because it is highly accurate and simple to perform.

This section provides information on commonly used tests to diagnose type 2 diabetes. Only your doctor or healthcare professional can determine if you have type 2 diabetes.

Fasting Glucose Test

Diabetes is most often diagnosed using a fasting glucose test. For this test, you will be asked to go without eating for 10 to 16 hours, usually overnight, before a blood sample is drawn. The test will measure the amount of glucose in your blood. If your glucose level is equal to or greater than 126 milligrams per deciliter (mg/dL) on two or more fasting glucose tests performed on different days, you have type 2 diabetes.

This chart shows how the fasting glucose test is interpreted.

Oral Glucose Tolerance Test

In some instances, an oral glucose tolerance test may be performed to diagnose type 2 diabetes. When taking this test, you will usually be asked to eat a diet that is high in carbohydrates for 3 days. Before the test, you will have to fast for 10 to 16 hours, usually overnight. When you go to the office or laboratory, you will first have a fasting blood sample drawn. You will then be asked to drink a sweet liquid that contains glucose. Samples of your blood will be taken 5 times over a period of 3 hours. Your doctor or healthcare professional will give you specific instructions prior to having a glucose tolerance test.

In a person who does not have type 2 diabetes, the glucose (sugar) levels in the blood will rise and then fall quickly. In someone with type 2 diabetes, blood glucose levels will often rise higher than normal and will not drop as fast. If your blood sugar level is above 200 mg/dL at 2 hours, you may have diabetes. Your doctor or healthcare professional will either repeat the test or perform a fasting glucose test on a different day to confirm the diagnosis.

After an oral glucose tolerance test, if the blood glucose levels are somewhere between those of a person without type 2 diabetes and a person with type 2 diabetes, a person is said to have impaired glucose tolerance. Although people with this condition may not have type 2 diabetes, they are at increased risk of developing it. If you have impaired glucose tolerance, your doctor or healthcare professional may recommend that you lose weight and exercise to help manage your risk of developing type 2 diabetes.

This chart shows how the oral glucose tolerance test is interpreted.

Random Glucose Test

When symptoms of diabetes are present, a blood sample that is taken in a non-fasting state (otherwise known as a random blood sample) may be used to test for type 2 diabetes. In this case, a glucose (sugar) level of greater than 200 mg/dL accompanied by symptoms of hyperglycemia suggests a person may have type 2 diabetes. However, the result must be confirmed on another day by performing a fasting glucose test or an oral glucose tolerance test.

If you have been diagnosed with type 2 diabetes and diet and exercise no longer control your blood sugar, treatments are available that may help you lower your blood sugar levels. One such treatment is Glucophage XR. Ask your doctor or healthcare professional if Glucophage XR is right for you.

Type 2 diabetes often has no symptoms. If symptoms are present, they often develop gradually and go unnoticed until problems occur. In fact, many people have type 2 diabetes and don’t even know it. Early diagnosis and treatment for type 2 diabetes is important. See your doctor or healthcare professional immediately if you experience any of the following symptoms:

* Extreme thirst

* Frequent urination

* Extreme hunger

* Unexplained weight loss

* Unexplained fatigue

* Blurry vision

* Tingling or numbness in the hands, feet, or legs

* Itchy skin

* Frequent infections of the skin, gums, vagina, or bladder

* Slow healing of cuts and scrapes

If you learn that you have type 2 diabetes and diet and exercise are not enough, treatments are available that may help you control your blood sugar levels. One such treatment is Glucophage XR. Ask your doctor or healthcare professional if Glucophage XR may be right for you.

Although type 2 diabetes can occur in anyone, you are at greater risk for developing this disorder if you:

* Have a family member who has type 2 diabetes

* Are overweight

* Are over 65 years of age

* Are of African-American, Hispanic/Latino, American-Indian, Asian-American, or Pacific-Islander descent

* Have high blood pressure

* Have very high cholesterol or triglyceride levels

* Are not very physically active (get less than 30 minutes of exercise 3 days a week)

* Are a woman who developed type 2 diabetes while pregnant (a condition called gestational diabetes)

* Are a woman who has experienced an unexplained miscarriage or stillbirth or had babies weighing 9 pounds or more at birth

Take advantage of our interactive type 2 diabetes risk assessment tool.

If you are at risk for developing type 2 diabetes, there are several things you can do that may manage your risk, such as exercising regularly, eating healthy foods, and watching your weight. Your doctor or healthcare professional can work with you to develop a program that’s right for you.

If you have been diagnosed with type 2 diabetes and your doctor or healthcare professional has recommended that you control your blood sugar levels with medication in addition to eating healthy foods and exercising regularly, ask him or her if Glucophage XR is right for you.

Until the beginning of the 20th century, type 2 diabetes was fairly rare. It now affects more than 14 million Americans. Healthcare professionals believe that type 2 diabetes has become so common because increasing numbers of people are eating more, exercising less, and becoming overweight. In addition, people are living longer, so there are more people than ever before over the age of 40, and thus more people at risk for developing type 2 diabetes.

Some people may be more likely to develop type 2 diabetes because they have various risk factors, such as their genetic make-up, body type, and activity level.

People who carry a genetic trait for type 2 diabetes and who are overweight may develop type 2 diabetes more rapidly. In these people, extra body fat may cause cells to become resistant to the effects of insulin (called insulin resistance). When this happens, the pancreas attempts to compensate by producing more insulin. Eventually, the pancreas may not be able to keep up with the body’s demand for increased levels of insulin, causing an abnormal increase in blood sugar levels. This condition is called impaired glucose tolerance, which can potentially lead to type 2 diabetes, hypertension, and heart disease.

Fortunately, there are steps you can take that may help manage your risk of developing type 2 diabetes. Some people are able to avoid type 2 diabetes by making changes to their lifestyle, such as eating less and exercising more regularly. It is also important to look at other type 2 diabetes risk factors that you may have. Ask your doctor or healthcare professional how to manage your risk factors.

If you have been diagnosed with type 2 diabetes and diet and exercise cannot adequately control your blood sugar, effective medication is available. Glucophage XR is a convenient and effective way to help lower high blood sugar levels. See your doctor or healthcare professional to find out if treatment with Glucophage XR may be right for you.

Assessing care

Pharmacists can assess the general efficacy of care in people with diabetes. One approach is to use a written Diabetes Patient Assessment Questionnaire. This survey documents whether the patient has seen certain specialists, has undergone various evaluations (dilated pupil exam, foot exam, etc.), or has received appropriate counseling (on nutrition, exercise, self-monitoring of blood glucose). Patients indicate the types of treatment they are receiving, their latest blood glucose values, and related information. Such questionnaires provide a wealth of information that the pharmacist can use in determining whether certain aspects of diabetes management need attention, perhaps by other members of the health care team. The very act of asking a patient to complete the document shows that the pharmacist is informed about diabetes and is a valuable participant in the management of the disease.

Ideally, patients receiving treatment for diabetes should see the appropriate health care professional for regular evaluations. A list of standards for care appears in Table 8. In reality, however, many patients do not undergo the recommended quarterly or annual exams. Surprisingly, less than 25% of patients with diabetes have A1C levels evaluated each year, while only 40% perform daily blood-glucose self-monitoring. Only half of patients undergo an annual eye exam or annual foot exam, and although a daily low-dose aspirin tablet is a standard of diabetes care, only 20% of patients take aspirin regularly. Pharmacists should consider maintaining a checklist of these evaluations and asking patients about their status.

Educating patients

Patients who understand the concepts of insulin resistance and insulin sensitivity are better able to manage their diabetes. Formal diabetes education has been shown to greatly improve quality of life and metabolic control, and significantly reduce the rate of acute complications, yet only 40% of people with diabetes receive such education. Also, under the constraints of the current health care system, some physicians may be unable to allow adequate time during a visit to fully address the concerns of a patient who has a chronic disease. With proper training, pharmacists can play a key role in providing patient education.

The basics of diabetes management should be emphasized at every opportunity. Patients must be reminded that drug therapy is an adjunct to, not a substitute for, lifestyle modifications. While taking medication, patients should still attempt weight loss through a calorie-controlled diet and regular aerobic exercise. Smoking cessation is important as well, and pharmacists can describe the effectiveness of various smoking cessation strategies. Even reminding patients to wear a Medic Alert tag identifying them as having diabetes can be a lifesaving step.

More specific diabetes education can also be provided by community pharmacists. For example, patients treated with insulin or sulfonylureas need to understand the need to monitor for signs of asymptomatic hypoglycemia, a common adverse effect of treatment with these agents. Daily self-monitoring of blood glucose is important. Pharmacists should be familiar enough with the supplies and equipment involved in blood glucose monitoring to train patients in their proper use. ADA-recommended levels for blood glucose control appear in Table 4.

Adherence is an issue with any medical treatment, but the complexity of some diabetic regimens makes adhering to the treatment a particular challenge. Simplicity, whenever possible, can help with treatment adherence. For example, patients are more likely to take medications that require only once-a-day dosing as opposed to treatments requiring multiple doses throughout the day.Adherence is also compromised by treatment side effects. Pharmacists can teach patients to anticipate these unwanted effects and provide strategies for managing them. For example, the weight gain associated with use of many antidiabetic agents may be mitigated through careful diet and exercise, and avoiding starch in the diet may reduce the abdominal discomfort and flatulence associated with use of alpha-glucosidase inhibitors.

For some patients, cost may be a factor in their decision to fill prescriptions. Newer medications usually cost more than older products, especially those such as the sulfonylureas for which generic equivalents are available. Fortunately, many states now require insurance companies to cover the costs of diabetes supplies, including drugs, monitors, and injection equipment.

Many patients are afraid to inject themselves with insulin. Should insulin become necessary, pharmacists can allay fears about the injection and can offset concern about weight gain by emphasizing the long-term benefits of good glycemic control.

Common sense, empathy, and accurate information are invaluable resources for pharmacists seeking to educate their patients. In learning about their disease, patients will want to focus on how the information applies specifically to them. Encouraging patients to participate actively in determining their own treatment plans and goals can further boost adherence.

Making referrals

Pharmacists should maintain an up-to-date file of health care professionals in the area who specialize in all aspects of diabetes care. If a patient is found to need a certain evaluation, for example, a dilated pupil exam, the pharmacist can quickly provide the necessary contact information. To ensure that the patient adheres to the guidelines, pharmacists can offer to call and make appointments on the patient’s behalf. Building a referral network also serves to identify the pharmacist as a skilled member of the diabetes care team. Physicians and therapists will be more likely to refer their patients to the pharmacy that has built a reputation for providing knowledgeable care and a full line of diabetes products and devices.

Training

To increase chances of success, pharmacists should undergo training in diabetes management. There are many educational opportunities and materials available. One program, Pharmacy Partners in Diabetes Care, is co-sponsored by Washington State University College of Pharmacy, CoMed, and Lifescan, Inc. Enrollees learn all aspects of diabetes disease-state management: treatment assessment, blood glucose monitoring skills, advanced consultation techniques, nutrition, and exercise. The intensive course, which offers nearly 90 hours of continuing education credits, also includes training in reimbursement strategies (www.lifescan.com).

The National Certification Board for Diabetes Education conducts a program to train certified diabetes educators (CDEs). In recent years, pharmacists have become the fastest-growing group of health care professionals applying for CDE certification. For more information, access www.ncbde.org.

Professional organizations, including the National Community Pharmacists Association (NCPA, www.ncpanet.org) and the American Pharmaceutical Association (APhA, www.aphanet.org), offer several CE-accredited programs. By meeting NCPA standards, a pharmacy can establish itself as a Certified Diabetes Care Center. Courses are held at least twice a year at the NCPA’s annual convention and at the Rx Expo. Presented by the National Institute for Pharmacist Care Outcomes (NIPCO), the program provides 16 hours of American Council on Pharmaceutical Education (ACPE)-approved continuing education.

Improving outcomes: Pharmacy-based programs to improve adherence with diabetes care have been shown to improve outcomes and reduce health care costs. In Asheville, North Carolina, pharmacies are reimbursed by the city for diabetes self-management services provided to municipal employees. When this program began, surveys indicated that only one third of patients maintained blood glucose readings in the normal range. After 14 months, two thirds of patients had achieved glycemic control (measured as a mean A1C level of 6.2%, significantly lower than the recommended target of 7.0%) and reduced lipid levels. Estimates show that the city saved more than $20,000 in costs of managing diabetes in the first year.

A 1997 University of Kansas study found that patients who received diabetes self-management services in the community pharmacy setting showed a 22% improvement in blood glucose readings and a significant reduction in diabetes-related symptoms. Such services reduced annual medical costs by $4,300 per patient. Similarly, a report from Corpus Christi, Texas, found that pharmacy-based diabetes management reduced the need for hospital stays and reduced average hospital stays by 26%. Overall cost savings were estimated to be $4,000 for each patient. Such results are encouraging and demonstrate the positive impact that pharmacists can have on the lives of patients with diabetes.

Conclusion

Insulin resistance is a major health concern. In addition to being a leading risk factor for type 2 diabetes, it is associated with hypertension, dyslipidemia, obesity, and cardiovascular disease. Making lifestyle changes can reduce insulin resistance and help prevent the onset of diabetes. For those patients with type 2 diabetes, treatment with insulin-sensitizing drugs, such as the TZDs and biguanides, can improve glycemic control and prevent some of the adverse consequences of the disease. Adherence with both lifestyle and medication regimens is very important and should be actively supported by all members of the health care team.

Pharmacists can increase awareness of the underlying pathophysiology and clinical implications of insulin resistance. Pharmacists also play a vital role in counseling patients with type 2 diabetes on strategies that reduce their risk of hyperglycemic complications, and in providing support, education, and guidance. By understanding the disease and its management, pharmacists can contribute to improved outcomes and help to reduce the impact of this worldwide epidemic.

Another class of agents considered to have mild insulin-sensitizing properties is the biguanides. The most commonly used drug in this class is metformin. Metformin decreases hepatic glucose production, decreases intestinal absorption of glucose, and to a lesser extent enhances glucose uptake by peripheral tissues. This agent can also produce beneficial changes in the lipid profile by decreasing triglycerides, LDL cholesterol, and total cholesterol (-16%, -8% and ­5%, respectively), but it has no significant effects on HDL cholesterol. Metformin is effective either as monotherapy or in combination with a sulfonylurea or insulin. When used as monotherapy, metformin does not appear to cause weight gain and in some cases is associated with weight loss. Gastrointestinal side effects, such as nausea, dyspepsia, and diarrhea, are commonly associated with metformin therapy (reported in up to 50% of patients). Lactic acidosis is a rare but serious concern, especially in patients with renal dysfunction. Metformin is contraindicated in patients with renal disease, congestive heart failure, sepsis, or metabolic acidosis, and should be used with caution in the elderly, especially those with compromised renal function. Recommended dosing for metformin and the TZDs are shown in Table 7.

Combination therapy

As diabetes progresses, patients frequently require a combination of agents to address the various metabolic abnormalities present in diabetes and to treat complications. It is not unusual, for example, for a patient to take a sulfonylurea to boost insulin secretion, a TZD to reduce insulin resistance and hyperglycemia, an ACE inhibitor for control of hypertension, and a statin for management of hyperlipidemia. The alert pharmacist will be aware of the patient’s multiple prescriptions and will be prepared to give advice about proper dosing, potential interactions, and management of side effects.