Control of type 2 diabetes
David Kinshuck, Pat Lamb, Urmila Griffiths (Pat & Urmila: diabetes specialist nurses, Good Hope Hospital. Last edit 2011)
Important pages for type 2 diabetes
Extra pages for type 2 diabetes using insulin
- embrace your diabetes
- take control
- what is happening in type 2 diabetes
- factors combine causing type 2 diabetes
- pattern of progression
- slowing down progression
- testing your sugar level
- do you need tablets, and if so what?...a protocol
- common drugs (this page)
- less common drugs (separate page)
- type 2 diabetes and insulin
- weight and bariatric surgery
- cholesterol, HDL, triglyceride
- UKPDS Study
- typical medication
- Joslin type 2
We are learning more about diabetes all the time, and it is becoming clear the harder you work to control your diabetes when it is diagnosed the more benefit you will get in the long term. Complications from diabetes will be prevented or delayed (NEJM 08) (UKPDS 08).
Type 2 diabetes is a progressive condition. It is not a 'mild' form of diabetes. The exercise you take and the food you eat need to balance the remaining natural insulin your body makes. This page is designed to give readers an idea how decisions are made concerning their care, but remember every patient is different and advice can vary.
Your diabetes nurse can teach you the basics, and reading up is helpful. But there is special educational program that has proven very helpful, a DESMOND course. Your doctor must allow you to attend such a course. The course teaches you how to take control of type 2 diabetes, and patients who have attended the program have better diabetic control and fewer problems.
Birmingham meeting 2012: Patients only take half their oral medication. Fixed dose combination tablets would help a little. 10% compliance with multiple drugs.
There are four particular problems.
- First, there is a shortage of insulin.
- Second, there is insulin resistance.
- Third, there may genes
These factors work together to contribute to type 2 diabetes. The factors may be controlled by genes. So your children or brothers and sisters may be affected, and they should take precautions (exercise, healthy diet, not becoming overweight, and not smoking).
You may have inherited this condition from your parents. Alternatively, a few people may have had pancreatitis or a bad attack of mumps that damages the pancreas. The shortage of insulin is due to damage to the islets in the pancreas where your insulin is made.
The pancreas is a gland is behind your stomach, and throughout its tissue
are these tiny groups of cells called islets.It is these islets that make your
insulin, and they release the insulin into your blood stream, just as it is
needed. In this type of diabetes the islets become damaged and effectively
This process may be the main cause of your diabetes if you are not overweight, have always had a healthy diet, and have always taken exercise.
Normally the insulin is released by the pancreas into the blood stream. The insulin circulates to muscle cells, where it acts as a 'door opener' and lets the glucose into the cell. The muscle cell uses it for energy.
However, in this type of diabetes the muscles and other tissues are much less responsive to insulin. This means the pancreas has to produce more insulin for the same effect. This poor response to insulin is called 'insulin resistance'. Insulin resistance develops if you are overweight or take too little exercise, and especially if you are overweight and take too exercise.
Losing weight and
exercise (30-60 minutes walking
a day for example) both lower the insulin resistance. With less insulin resistance,
you need less insulin for the same effect, and so the insulin that your beta
cells make (or that you inject) will go further. The amount of 'resistance'
varies according to how much fat there is.
So if you are overweight, your pancreas has to produce considerably more insulin for the same effect, versus someone who is not overweight. If you can lose weight, the responsiveness to insulin will increase, your insulin will have a much greater effect, and your diabetes will be easier to control.
In practice this means that unless you lower your 'insulin resistance' your pancreas is even more likely to 'run out of insulin' and you may need insulin injections sooner, and if you are fatty tissue actually becomes deposited in your pancreas, and this damages the pancreas even more.
At the beginning, the resistance to insulin makes the pancreas compensate by producing more insulin, but eventually it cannot produce enough. Joslin. Type 2 is progressive: the pancreas produces less insulin each year, more treatment and eventually insulin is often needed. However, this process is a lot slower with regular exercise, a healthy diet, and keeping thin.
Genes linked to diabetes work in different ways. Some genes may not cause diabetes directly, but make you overeat and become overweight, and the excess weight causes the diabetes. One gene may make people fidget, and fidgeters are less likely to become overweight. Finally, there are many genes that may cause diabetes. These include MODY genes and haemochromatosis. It is often worth having an iron test for haemochromatosis, as early diagnosis will help your relations (iron binding capacity and serum ferritin tests?).
Stress increases the risk of heart disease, and probably diabetes itself also.
These factors to cause a low grade inflammation/ oxidative stress. BMJ 2011, and this causes more damage.
there is a 50% risk of becoming diabetic if you are overweight and exercise very little. (After Williams & Pickup.)
risks increase with a combination of factors
These risks combine, as opposite:
- At the beginning of type 2 diabetes, a healthy diet may be sufficient to lower the sugar and keep the HbA1c below 7%
- Later, metformin is needed.
- Later still, add exanatide/liraglutide if overweight or other drug if thin.
- Later still insulin may be required
Exercise and losing weight (if overweight) dramatically slow this progression rate down, and even prevent diabetes in some people. Exercise reduces the dose of insulin needed (BMJ 2011). If you are on a diet (without drugs or insulin: diet controlled diabetes), and your HbA1c is 6%, this is an ideal level. But if the HbA1c rises to 8%, you need to eat less (if you are overweight) or may need tablets, so you should see your GP or nurse. See weight below.
Similarly, if you are on one set of tablets, and your HbA1c is 6%, you are controlled. But if it is 8%, you need to eat less (especially if you are overweight) or go on more tablets, or possibly insulin. See 'Exercise in diabetes'. Your doctor and diabetic specialist nurse will need to advise you if your HbA1C is higher than 7%.
|Test your glucose and aim for|
If you want to know whether or not your diabetes is controlled, your doctor can check your HbA1c level. But you should test your own glucose level.
See testing. If you 'embrace' your diabetes, you will gradually learn to control it and achieve an HbA1c of 7% or below. But to do this, you need to check test your glucose:
- now and again if not using insulin and well controlled
- test at different times each time you test
- test much more often if you are trying to improve your control
- 4-6 times a day if using multiple dose insulin
- remember, you still need tablets if you are ill; if you are being sick or cannot swallow the tablets, let your doctor or nurse know.
- If well you need to increase medication until well controlled, as advised by your doctor/nurse
- Accept higher levels if you are very ill
- ketones can be present (although they are more common in type 1 diabetes) BMJ 2013
Once your sugar levels start to rise despite exercise and the best diet you can stick to, you need tablets. Similarly, if you are on tablets and your sugar levels start to rise, you need a higher dose, or an extra tablet, or need insulin. Here is a protocol as to what you may need, from here. All patients should generally start with metformin: all other drugs lower the HbA1c equally, but with different 'side' effects/effects on weight etc (JAMA 2010).
Type 2 diabetes: a treatment plan (separate page)
proceed down until target reached
0-8 weeks, if levels higher than target (<HbA1c 7.5%)
0-8 weeks, if levels higher than target
if low weight
Reduced renal function
These drugs (and only one of this list would normally be added) will only lower the HbA1c 0.5-1.0%.
Therefore if the HbA1c is >8.5%, a 7.5 target will not be reached, so insulin may be best. However, a gradual HbA1c drop may be best in retinopathy patients.
12 weeks, if levels higher than target
12 weeks, if levels higher than target
in diabetes as it allows glucose to enter your body's tissues where it is used
for energy etc. It makes the tissues more responsive to insulin, and this lowers
the sugar levels (this is 'lowering insulin resistance'). Benefits NEJM
As a result, in addition to the lower blood sugar levels, you may lose weight.
|Insulin resistance in type 2 diabetes: insulin has reduced effect on muscles cells, so each muscle cell cannot absorb the glucose. The glucose stays in the blood where it reaches high levels which are harmful.||
Metformin acts on muscles to allow glucose to enter and be utilised. Blood glucose levels drop and you may lose weight.
Metformin starting dose is 500mg twice/day, increasing to 1gm twice/day. There is a slow release form that can be used once daily.
Side effects may include nausea (feeling sick), diarrhoea,
loss of appetite, and the presence of a metallic taste in your mouth.
These usually occur when treatment is first started, when the dose is increased,
or when metformin is taken in high doses (greater than 2,500 mg per day).
To avoid these side effects, take metformin with meals. Also, when treatment is first started, your doctor should prescribe a low dose and slowly increase the dose over a few weeks. If you experience frequent diarrhoea, ask your doctor about lowering the dose of metformin, which may help. With continuous use, these side effects usually subside within one month. For details see www.diabetes.org
There are other rare side effects. Contact your doctor if you become ill. It is still safe if your kidneys are damaged, although there is a small risk of acidosis. It is probably safe in heart failure.
Metformin NEJM 2012 in type 2 younger people.
is one of many 'sulphonylureas' There are many others. (Glipizide is another.)
These drugs act on the pancreas to make it release more insulin. Side-effects are generally mild and include feeling sick, bowel changes, headache, and weight gain.
Dose: initially, 40-80 mg daily, adjusted according to response; up to 160 mg as a single dose, with breakfast; higher doses divided; max. 320 mg daily. Ideally gliclazide is taken 30 minutes before a meal.
Sulphonylureas contribute to hypoglycaemic episodes. Gliptins are more expensive, but have few side effects and far fewer hypos. They probably should be considered second line after metformin.
This group of drugs, given by injection, probably should be consdidred third line if the HbA1c is not too high, as it will only be lowered 1-2%. So an ideal patient for this group of drugs will have an HbA1c of ~9.0%, already be using metformin and a gliptin.
They are GLP-1 analogues. Glucagon-like peptide-1 (GLP-1) is a naturally occurring peptide hormone, released from the gut after eating. GLP-1 stimulates insulin release, reduces glucagon release (this stops the liver making glucose), delays stomach emptying, and stops hunger feelings. (BMJ)
do not cause hypos...so frequent glucose monitoring is not required
lower HbA1c 1%.
if the HbA1c is 10% it will lower it to 9%..but would not achieve a target of ~7% needed to keep your ophthalmologist happy.
it does help weight loss...about 7lb for each of the first 2 years.
the main side common effect is nausea/sickness, but many patients prefer to stay on them
they are second line in type 2 diabetes, if overweight, in addition to metformin.
they are added to metformin.
generally they reduce the rise in glucose with meals, not the basal glucose.
they should not be used in conjunction with a sulphonylurea or glitazone (sulphonylurea or glitazones are no longer ideal for overweight patients as they always increase weight ..Exenatide/Liraglutide are best). Sulphonylurea/glitazones are stopped if Exenatide started.
if patient thin, BMI <25,
previous pancreatitis or alcohol abuse: the main rare side effect is pancreatitis;
avoid if heart failure/risk of fracture
avoid if there is reduced kidney function: GFR <30
Care if GFR 30-50
Here are some example patients..licenced use, in addition to metformin
Patient overweight, HbA1c 8%, using metformin, add Exenatide ...expect HbA1c 7%, some weight loss. In such patients Exenatide is used instead of starting insulin.
Patient overweight, HbA1c 9%, using metformin, add Exenatide...expect HbA1c 8%, some weight loss, control not ideal.
There are new versions of this drug that can be used once a week, and they can reduce heart problems etc. 2011
it is very useful in addition to insulin and metformin.
- Patient HbA1c 9%, using metformin,
very overweight, large insulin dose (e.g. >100units/day). Can halve
the dose of insulin, add Exenatide, will reduce weight, perhaps a few
stone (HbA1c may drop a little, but will not achieve 7%). Generally reduce
the pre-meal boluses i.e. rapid acting. By adding Exenatide and reducing
insulin dose, patients will lose weight.
Hypos are possible if using insulin.
Once the weight is reduced a little, and the insulin dose reduced, consider bariatric surgery to lower the HbA1c further.
a once weely subcutaneous injection..likely to become very popular
if you have type 2 diabetes and are overweight and have an HbA1c 8.0-9.0, this is the drug for you
a DPP-4 inhibitors, 100mg once day.
It can be used in addition to metformin, glitazone, or sulphonylurea, lowering
the HbA1c 0.7-1.0%%. See: "Sitagliptin
reduces blood glucose concentrations by enhancing the effects of ‘incretins’.
Incretins are hormones (chemicals) which are produced by the gut (bowel) in
response to food. These drugs are therefore also known as ‘incretin enhancers’. "
Lowers HbA1c 0.7-1%.
Side effects are uncommon. Nausea, flatulence has been reported. When combined with glitazones swelling of the feet may be seen. As with some other oral blood glucose lowering drugs, hypoglycaemia may occur.
It is not suitable with type 1 diabetes, previous diabetic ketoacidosis, see. Reduce the dose if renal function reduced. (details) GFR 60-30 50mg; GFR <30 25mg. Combination with metformin Janumet usually bd.
Linaglyptin works in a similar way to sitaglptin above, but is is safe in reduced renal function. (It is excreted in the liver not the kidney.) It is also a DPP-4 inhibitors.
If you work hard to control your diabetes using the once daily regime, but it still does not produce good control, and you happy to test your sugar levels 4-6 times a day, basal-bolus insulin would be the next step. See.
Normally your doctor will recommend you carry on taking your metformin but
stop other drugs.
As soon as you go on insulin your weight will tend to go up. Diet and exercise will be even more critical.
If overweight you need to weight yourself and lose weight slowly
As mentioned type 2 diabetes is partly caused by resistance or lack of responsiveness to insulin. This resistance depends on the amount of body fat. The lower your weight, the less insulin resistance there is, and the less insulin you need (whether your natural or injected), and the better the control of the diabetes. If you cannot lose weight, it is important not to put weight on.
Remember, certain foods are very 'fattening' and you do not need them to be healthy: red meat, full fat dairy food like cheese, butter, cream, and cakes. See diet and weight. Find out if you overweight.
Insulin seems to make most people put weight on. Diet and exercise becomes even more important; a Levemir/detemir basal-bolus regime is said to reduce the weight gain considerably. Exenatide as above can reduce weight, and it can now be used in addition to insulin (there will be less wieght gain and often weight reduction, and less insulin is needed).
See Exercise is
very important in diabetes. As well as helping your heart, it helps to lose
weight. Walking, swimming, or dancing help a great deal. If you are disabled,
a physiotherapist, expert gym instructor, your doctor, or your nurse might
be able to suggest gentle exercises you can do.
Start gently, such as a minute every half hour, or 10 minutes 3 times a day.
If you are exercising, or cannot, and are unable to lose weight, you must be eating too much. Most people in this situation eat more meat than they should, or have cakes at weekends, or indulge in some way. We are not saying 'stop' this, but it is your choice, but if you are interested in good health then losing weight is important.
If you are struggling to lose weight
Eating more meat than the size of half a weetabix will prevent you losing weight. Fish too is fattening, so again, try and stick to an amount about the size of half a weetabix.
If you are hungry, you can eat almost as many vegetables and fruits as you wish. Naturally five bananas a day is fattening, but generally you will not put weight on.
A side salad included in lunch and supper will be helpful, although best without much mayonnaise. If you use mayonnaise or oil, use small amounts. Small amounts of fat as vegatable fats as olive or sunflower oil are essential as part of your diet. A strictly no fat diet is very harmful. On the other hand, animal fat is not essential, and more than a small amount is harmful. See the diet page for help.
If you eat to much and cannot reduce what you eat, BMI >40, consider bariatric surgery.
discussed BMJ 2011
simvastatin protects the heart
Lipids are discussed in more detail here; Low lipid levels prevent/slow down retinopathy and all other diabetic complications HPS . Fibrates low triglycerides, statins lower cholesterol. Diet and exercise lower both.
Typical medications for someone with type 2 diabetes in 2007, not severe enough to require insulin
As you will have read above life has not become easier if you have type 2 diabetes. We know a lot more, and there is a lot more patients and professionals can do. On the positive side the health of patients is a lot better.
We will have to wait many years before we can say goodbye to all the tablets though.