How Do You Treat Diabetes
Insulins
Oral Medications
Injectable Medications
Insulins
Insulin is a hormone necessary for survival. It regulates our metabolism (of carbohydrate, protein and fat) in countless ways. Patients with type 1 diabetes make none and, to survive, need to give themselves insulin every day (usually 3-4 times a day or through a continuous insulin infusion pump). Those with type 2 diabetes make too little insulin for their needs and secrete it usually too late to successfully cover their meal-related insulin demands. Thus, many persons with type 2 diabetes find it necessary to administer insulin, too (often alongside anti-diabetic pills or injections of other medications). Insulin cannot be ingested by mouth since the stomach juices would destroy it. In order to bypass the stomach, insulin is injected through the skin with a tiny (31 or 32-gauge, 3 to 5/16 inch long) needle. Theoretically, it could also be given in any number of other ways (by inhalation into lungs, by applying on oral or nasal mucosa, by a skin patch or by a rectal suppository).
Rapid-Acting Insulins
These insulins are injected at mealtimes usually in proportion to the carbohydrate content of the meal. They act quickly (within 15 minutes), reach their maximum effect in 1.5 to two hours and last for a total of about four hours. These insulins are represented on the U.S. market by LisPro (Humalog®), aspart (Novolog®), and glulisine (Apidra®).
Short-Acting Insulins
The only one used in the U.S. is Regular human insulin. It is injected 30 - 45 minutes before meals. It takes more than an hour to start working, and its effect lasts about four to six hours.
Intermediate-Acting Insulins
These insulins take four to six hours to start working and maintain their blood-sugar lowering effect for up to 12 to 16 hours. They are typically injected twice daily - in the morning and at bedtime. Because of their prolonged effect, their use is not tied to meals. NPH (N, cloudy) is a representative of this class.
Long-Acting Insulins
Glargine (Lantus®) and detemir (Levemir®) insulins are up to 24-hour lasting, relatively "peakless" insulins. They are usually injected once a day. They reach their effects within one to two hours and maintain a reasonably steady effect throughout the entire day. Some patients need to inject twice daily to avoid low sugar reactions.
Ultralente (UL) insulin is used uncommonly nowadays. Its effect and duration are highly variable, typically lasting 24 - 36 hours.
Pre-mixed insulins
In some cases, physicians and their patients find it more convenient to use one of several pre-mixed insulin combinations. These are mixtures of either rapid-and intermediate-acting insulins (such as 25% Humalog & 75% NP-Humalog, 50% Humalog & 50% NP-Humalog or 30% Novolog & 70% NP-Novolog) or short- and intermediate-acting mixtures (such as 30% Regular & 70% NPH). These insulin mixes are injected at or before meals.
Insulin Injection Devices
Insulin can be injected either by a special syringe which the patient fills with appropriate amount of the specific type of insulin or, preferably, by an insulin pen. The pen devices are either disposable (prefilled with 300 units of insulin) or permanent into which prefilled insulin cartridges are fitted. Needle-less devices also exist. These inject insulin through the skin under pressure.
Insulin Pumps
Insulin can also be delivered under the skin by continuous infusion from an external pump (about the size of a pager). The reservoir inside the pump holds up to 300 units of insulin. Insulin is pumped through thin, plastic tubing, ending in a needle under the skin (OmniPod is a disposable pump which is attached in its entirety to the skin and does not need the tubing). These external pumps (in the U.S. most are marketed by Medtronic MiniMed, Disetronic/Roche, Animas or OmniPod/Insulet) cannot read blood glucose levels. Thus, the patient still has to monitor his or her own sugars with fingersticks to be able to adjust insulin infusion rates ("basal" rates and mealtime "boluses"). The MiniMed's Paradigm was the first insulin pump wirelessly integrated with a continuous glucose sensor. There are two additional continuous glucose monitoring systems on the market: Dexcom and Navigator.
Implantable Insulin Pumps
These pacemaker-like devices infuse insulin into the peritoneal space (not under the skin). A remote-control device adjusts infusion rates. These pumps have been used in Europe for about two decades but remain 'experimental" in the USA.
Oral Medications used in Type 2 Diabetes
Drugs delaying glucose absorption from small intestine
acarbose (Precose®) and miglitol (Glyset®). These are used with meals to lower after-meal hyperglycemia (high sugar).
Drugs increasing insulin secretion
Short-acting: repaglinide (Prandin®) and nateglinide (Starlix®). These are used with meals to reduce after-meal sugar levels.
Long-acting: sulfonylureas, such as glipizide (Glucotrol®), glyburide (Micronase®, Diaßeta®) and glimepiride (Amaryl®). These medications are used once or twice daily to lower overall, but especially overnight, sugar levels.
Drugs improving insulin action
Biguanides: metformin (Glucophage®) has major effect on the way insulin works on the liver to decrease the amount of sugar the liver makes. Metformin should not be used if the patient's kidneys fail.
Thiazolidinediones - (also called glitazones or TZDs) - rosiglitazone (Avandia®) and pioglitazone (Actos®) - help insulin to work especially on muscles and fat. They are long-acting, usually used once a day. They cannot be used when the patient has severe congestive heart failure. On September 23, 2010 FDA placed stringent restrictions on use of Avandia only for patients for whom other medications don't work.
Drugs preserving the "incretin" effect
These pills inhibit the action of an enzyme (DPP-4) which breaks down "incretins" (see below). This allows your own incretins work longer and enables the pancreatic islet cells to make more insulin and less glucagon when you eat. As a consequence, glucose levels are lowered. Sitagliptin (Januvia®), saxagliptin (Onglyza®) and linagliptin (Tradjenta®) are currently representing this class on the U.S. market.
Drugs with dual effects
Colesevelam (Welchol®) lowers both blood sugar and "bad" (LDL) cholesterol.
Drugs with central nervous system effects
Cycloset® (bromocriptine CR) works at the level of the brain, improves insulin action, does not cause hypoglycemia and might have beneficial cardiovascular effects
Drugs combining effects
These medications combine the insulin-action improving and insulin-secreting effects of the above-mentioned drugs.
Avandamet® (combination of Avandia and metformin)
Avandaryl® (combination of Avandia and Amaryl/glimepiride)
Glucovance® (combination of glyburide and metformin)
Metaglip® (combination of glipizide and metformin)
ACTOplus Met® (combination of Actos and metformin)
Duetact® (combination of Actos and Amaryl/glimepiride)
PrandiMet® (combination of Prandin and metformin)
JanuMet® (combination of Januvia and metformin)
Kombiglyze XR® (combination of Onglyza and metformin)
Jentadueto® (combination of Tradjenta® and metformin)
Symlin® (pramlintide)
When a healthy person eats, pancreatic beta cells make two hormones to handle the dietary load: insulin and amylin. We have provided patients with mealtime insulin since 1922. It has been only since 2005 that we have been able to provide the other necessary hormone: amylin. Amylin normally complements insulin's effects: it works through brain and decreases the amount of your own sugar made by the liver (you don't need it since you are eating), it slows stomach emptying thus decreasing the sugar spikes after meals, and it increases the sense of satiety and decreases appetite - patients wind up eating less before they feel full. Symlin® is a synthetic version of human amylin. Since amylin is made by the same cells as insulin, it stands to reason that patients with type 1 diabetes make none and those with type 2 diabetes make too little of it. Symlin® is, therefore, given by patients with either type 1 or type 2 diabetes (by a disposable pen device with the usual tiny needle) at mealtime alongside their rapid-acting insulin. The possible advantages of using Symlin ® are better, smoother glucose control (while using less mealtime insulin), and weight loss.
"Incretin mimetics": Byetta®, Bydureon® (exenatide) and Victoza® (liraglutide)
Several hormones are also normally released from the small intestine when we eat. They are called "incretins". Byetta® was the first analog of an important human incretin (glucagon-like peptide 1 or GLP-1) approved by the FDA in 2005 to be used in the U.S. by patients with type 2 diabetes to improve glucose control. This hormone, injected by a pen device twice daily (before breakfast and before dinner), acts at four different places: it tells the pancreatic islet beta cells to make more insulin at mealtimes; it tells the pancreatic islet alpha cells to make less glucagon (which in turn means your liver will make less sugar at mealtime); it tells the stomach to slow down its emptying (so there is less sugar spike after meals) and finally, it tells the brain that you are full, decreasing appetite and food intake (through a different mechanism from Symlin®). Bydureon® is a once-wekly injectable form of exenatide, approved in 2012. Victoza®, approved by the FDA in 2010, works in a similar way but is injected just once a day regardless of the time of the day. As a result of these drug effects, patients can achieve better diabetes control, sometimes can decrease the amount of pills they take for sugar control, and most experience weight loss.
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