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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

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.

 

Take control....learning how to control type 2 diabetes

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.

 

What is happening in type 2 diabetes

There are four particular problems.

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).

 

First, there is a shortage of insulin

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 'dry up'.

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.

 

Second, there is insulin resistance.

insulin resistance increases with lack of exercise and increase weight

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

 

Third, there are genes

diabetes genes

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?).

 

Fourth, stress

Stress increases the risk of heart disease, and probably diabetes itself also.

 

Fifth

These factors to cause a low grade inflammation/ oxidative stress. BMJ 2011, and this causes more damage.

 

 

These factors combine to cause type 2 diabetes

 

factors contributing to type 2 diabetes

there is a 50% risk of becoming diabetic if you are overweight and exercise very little. (After Williams & Pickup.)

 

risk factors add up to increase risk of diabetes
risks increase with a combination of factors

These risks combine, as opposite:

Excellent article.

 

 

 

 

 

Pattern of progression

  1. At the beginning of type 2 diabetes, a healthy diet may be sufficient to lower the sugar and keep the HbA1c below 7%
  2. Later, metformin is needed.
  3. Later still, add exanatide/liraglutide if overweight or other drug if thin.
  4. Later still insulin may be required

 

Slowing down progression

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%.

Testing you sugar/glucose level

Test your glucose and aim for
  • fasting 4 - 7 mmol/l (when wake up)
  • 4 - 7 mmol/l before meals
  • 5-9  2 hours after a meal
  • 4 - 7 mmol/l 4 hours after a meal and other times
  • fasting 5 - 7 mmol/l insulin users

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:

Test

 

Do you need tablets (or insulin), and if so what? A treatment plan

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
diagnosis       
arrow  0-8 weeks, if levels higher than target (<HbA1c 7.5%)

add Metformin  
increase to 2.0 - 2.5gm over 3 months (divided doses)
arrow  0-8 weeks, if levels higher than target
if overweight
if low weight

Reduced renal function

  • Sitagliptin & Linaglyptin (Trajenta) do not cause weight gain, but all the other treatments below increase weight

  • Linaglyptin (Trajenta) if renal function reduced

  • If thin, sulphonylurea and titrate to maximum dose depending on response. Eg gliclazide. start 40-80 mg daily. 160 mg as a single dose, with breakfast; higher doses divided; max. 320 mg daily. Weight will increase.

  • or add insulin as below

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.

arrow  12 weeks, if levels higher than target

Add insulin

  • Add bedtime basal insulin (Lantus/glargine & Levemir/detemir)

  • adjust dose to achieve fasting blood glucose 4-7mmol/l slowly over several weeks

  • Continue treatment with metformin, stop other glucose lowering drugs

  • this is reviewed here (NEJM)

  • Insulin will cause weight gain..consider bariatric surgery if very overweight

arrow  12 weeks, if levels higher than target

  • Add rapid acting insulin prior to meals (basal bolus).

  • Continue metformin

  • infirm/very elderly convert to twice daily insulin mixture +/- metformin

  • twice daily Levemir/detemir is easier to adjust than Lantus/glargine, and would be my reommendation for well motivated patients, especially those taking regular exercise such as a round of golf (less insulin will be needed on golfing days).

  • aim for lower HbA1c is well motivated patients, perhaps 6.5%, if insulin not needed

  • aim for HbA1c <7.5% if using insulin

  • lipids....usually a statin is helpful to lower cholesterol in most patients;

  • a fibrate is preferable if triglycerides high (? fibrate in all type 2 patients)

  • exercise   60 minutes a day, 120 minutes if overweight...any exercise, such as walking, swimming, cycling, gardening

  • losing weight if overweight is critical..overweight patients should be advised about a diet and lose a pound a week..prognosis is significantly improved

  • all patients need to reach low blood pressures as here

  • patients should be taught to monitor their own blood sugar and should attend a diabetes education program

  • for insulin patients taking lots of exercise on some days, or who are well but have lots of hypos, a pump might be helpful.

  • why do insulin users gain weight..Joslin

Metformin

Metformin helps 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 2008.
As a result, in addition to the lower blood sugar levels, you may lose weight.

 

metformin lowers insulin resistance

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.

 

Gliclazide

gliclazide stimulates insulin release from pancreas, and increases weight

This 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.

 

GLP1s (Glucagon-like peptide receptor antagonists)

Exenatide (Byetta) & Liraglutide (Victoza) are new drugs that lower glucose levels and aid weight loss. Details. NICE BMJ.

Exenatide (Byetta) and insulin use

Exenatide weekly (Bydureon)

 

Gliptins...DPP4 (dipeptyl peptidase-4 inhibitors)

Sitagliptin (Januvia)

Sitagliptin is a DPP-4 inhibitors, 100mg once day. It can be used in addition to metformin, glitazone, or sulphonylurea, lowering the HbA1c 0.5%. 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’. "

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, or kidney problems see.

 

Linaglyptin (Trajenta)

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 need insulin, what type

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.

 

regular weighing..the only way to lose weight
If overweight you need to weight yourself and lose weight slowly

Weight

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.

Expert individual advice from a dietician can be very helpful.

 

 

Exercise

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

 

simvastatin reuces heart problems (graph)
simvastatin protects the heart

Cholesterol, HDL, triglyceride

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 medication

Typical medications for someone with type 2 diabetes in 2007, not severe enough to require insulin
  • metformin
    gliclazide (or other drug)
    a statin for cholesterol
  • a fibrate
    aspirin
    an ACE or A2RB inhibitor for high blood pressure
    another blood pressure tablet

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.

 

 

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