150 to 200 mg/dl , This is above the normal level, but with lifestyle changes, eventually the medication dosage may be lowered. But most people who have levels between these numbers will still need medication, and some may eventually need occasional doses of insulin.
Above 200 mg/dl , At and above this level means that the person with diabetes may need medication or full-time insulin coverage, and maybe even both. If the person with diabetes makes some or all of the above lifestyle changes, it may mean a reduction in medication dose or other adjustments. But it is likely that he or she will need medication for the rest of his or her life.
What are some popular oral medications for people with type 2 diabetes?
A huge range of oral medications has been developed for people with type 2 diabetes, too many to mention in this text. There is a good reason for so many choices as every person who has diabetes has a different body composition and diabetic condition. (For more about listings of the most current medications from government sites, see the chapter “Resources, Websites, and Apps.”) In general, there are several general types of medications. They include the following:
Biguanides , The most commonly prescribed biguanide medication for type 2 diabetes, especially for a person who has just been diagnosed with the disease, is metformin. (For more about metformin, see above.)
Sulfonylurea , The sulfonylureas are the oldest class of oral diabetes medications (often seen as antidiabetic) and often a second choice after metformin.
They work by stimulating the pancreas to make more insulin.
There are some side effects that must be considered.
For example, there is the risk of hypoglycemia, especially for the elderly or those who take a long-acting sulfonylurea (such as glyburide), and even if a person drinks a certain amount of alcohol or skips a meal.
It also should not be taken by a person who is allergic to sulfa drugs.
Alpha-glucosidase inhibitors , These diabetic medications slow down the digestive enzyme that breaks down carbohydrates into smaller sugars, so they are more easily absorbed by the intestines. This action causes sugar levels to rise more slowly, and the insulin the body produces has more time to work efficiently, which helps slow down the surge in blood glucose after a meal. Side effects include flatulence and diarrhea, but if the dosage can be built up slowly, then such effects often slowly diminish over time.
Thiazolidinediones , These diabetes medications, also called glitazones, reduce a person’s insulin resistance and are frequently used in conjunction with other diabetes medicines.
They help a person with diabetes by making the body’s muscles, fat, and liver more sensitive to insulin and thus more able to absorb nutrients from the blood.
There are several side effects, such as weight gain and fluid retention, meaning this drug is not for everyone.
Because of these side effects, thiazolidinediones (especially rosiglitazone and pioglitazone) have been linked to increased risk of heart failure and possible increase in bone fractures and loss.
Thus, it is best to discuss this type of drug with the health care provider to understand these side effects.
Meglitinides , These drugs work by increasing the amount of insulin produced by the pancreas, thereby lowering blood sugar. They act quickly and do not stay in the body long. Therefore, they are usually ingested at or just before each meal. They are often used for people with type 2 diabetes who eat healthfully and exercise but still cannot sufficiently lower their blood glucose levels. There are several side effects in some people, including weight gain and low blood sugar.
What is lactic acidosis and its connection to some diabetes medications?
Lactic acidosis occurs when the body cannot get rid of lactic acid from the blood.
During strenuous exercise, lactic acid (lactate) is created in the muscles and blood as a natural byproduct of the body’s metabolism, primarily because the cells are not getting enough oxygen.
Normally, this acid is cleared from the blood by the liver, kidneys, and muscles.
Although it rarely happens, if lactic acid builds up to very high levels in the body, then it can cause a life-threatening condition called lactic acidosis.
In some people, lactic acidosis can occur, again, rarely, if they take metformin (Glucophage) to control diabetes, especially if they are experiencing heart or kidney failure and if there is a severe infection present. (Because of this, the FDA states that the drug must carry a warning about its possible lactic acidosis side effect.) It is thought that since the liver filters acid from the body when it produces sugar, and metformin decreases the organ’s ability to produce sugar, lactic acid buildup results.
Metformin is not the only drug to have this effect.
Two other diabetes medications, phenformin and buformin, also have lactate side effects and have been banned from use in the United States.
What are some of the more recent oral medications for people with type 2 diabetes?
There are several more recent oral medications prescribed for people with type 2 diabetes. The following lists some of them:
DPP-4 inhibitors , These drugs work by blocking an enzyme called DPP-4. DPP-4 normally deactivates a protein (GLP-1, or glucagon-like peptide) that keeps insulin circulating in the blood, and by blocking the enzyme, it helps reduce sugar production, lowering blood glucose levels. The first DPP-4 that was approved by the Food and Drug Administration was Januvia (sitagliptin phosphate), an oral medication taken once a day, either alone or with diet and exercise or in combination with other oral diabetes medications.
Incretin mimetics , These drugs work by mimicking the action of incretin hormones (which help the body make more insulin). They also slow the rate of digestion so that glucose enters a person’s bloodstream more slowly. This medicine makes the person feel full longer, thus reducing food intake, which can help people lose weight while on the medication.
Byetta (exenatide) , This drug is an injectable medication used in combination with other oral diabetes medications. It is not an insulin, and it does not take the place of insulin. It is used for type 2 diabetes only and cannot be given with insulin. It comes in a pre-filled injector pen, with dosages taken twice a day within an hour before morning and evening meals.
Antihyperglycemic synthetic analogs , These drugs are synthetic versions of human substances. For example, there is a human hormone drug called amylin, which is used by the pancreas to lower blood glucose levels.
Symlin (pramlintide acetate) , Symlin is an injectable medication used with insulin for tighter blood glucose control. It can also increase the risk of severe hypoglycemia; therefore, patients who are put on Symlin are selected carefully and monitored closely by their health care providers.
INSULIN
What are the main types of insulin?
There are several types of insulin you can take. Each type serves a different purpose, and you might need to take a combination of the following (note: some references show different times to take effect; thus, the following is only a general guide):
What two ingredients in some type 2 diabetes medication now have FDA warnings?
N ot all diabetic medications can be used by people with type 2 diabetes, and some even carry warnings on their labels.
For instance, diabetic medications containing saxagliptin (for example, Onglyza) and alogliptin (for example, Nesina) are known to increase the incretin hormones, which increase insulin production after a person eats.
But as with any medication, nothing is perfect.
In 2014, the Food and Drug Administration added warnings and precautions to diabetes medications containing saxagliptin and alogliptin, as clinical trials linked the substances to an increased risk of heart failure, especially in patients who already had heart or kidney disease.
People who are not diabetic may not realize that there are actually several types of insulin. Some take effect more quickly than others.
Rapid-acting insulin , This type of insulin takes effect in 15 minutes or less and is taken before a meal. In someone without diabetes, the body releases the right amount of insulin when the person eats. This insulin helps someone with diabetes process and use the carbohydrates in the food. (The release of insulin at mealtime is called the bolus secretion; thus, rapid-acting insulin imitates the bolus secretion; see below.)
Regular or short-acting insulin , Regular insulin takes effect within 30 minutes of injection. It is also taken before a meal, but its effect lasts longer than rapid-acting insulin. (Regular or short-acting insulin imitates the bolus secretion; see below.)
Intermediate-acting insulin , This type of insulin lasts for 10 to 16 hours, and is generally taken twice a day. (It imitates basal secretion; see below.)
Long-acting insulin , Long-acting insulin is similar to intermediate-acting insulin, as it imitates the basal secretion. Long-acting insulin lasts for 20 to 24 hours, so the person with diabetes needs to take it only once a day (whereas intermediate-acting insulin is injected twice a day).
Pre-mixed insulin , A pre-mixed insulin combines two other types of insulin. For example, it may include rapid-acting and intermediate-acting insulin. This combination ensures that the person with diabetes has enough insulin to cover bolus and basal secretions.
What is basal insulin?
Another name for slow-acting insulin is basal insulin.
It is also called background or long-acting insulin and is used to keep blood glucose levels stable during times when the person with diabetes is not eating, meaning during “fasting” times (the basal secretion is the small amount of insulin that should always be in your blood).
Between meals in someone without diabetes, the body steadily releases glucose into the bloodstream, where it provides the body’s cells with energy.
In a person with diabetes, the injected basal insulin keeps blood glucose levels under control, as long as it is injected once or twice a day (depending on the insulin).
What is the timing of insulin’s action in the body?
In general, the various types of insulin react in different ways in the body.
The following chart shows the type of insulin, how long it takes to begin working, how long it takes to peak, and the estimated duration of the medication.
These various medications can be used alone or in combination (see below).
In addition, there is no guarantee that each insulin type will work the same for everyone and under every condition. ( Note : Some medications, such as the long-acting insulins Lantus and Levemir, differ as to when they start working and their peak and duration.
Thus, there are two listings in the chart below)
Types of Insulin
Type
Starts Working
Peaks
Estimated Duration
Very rapid-acting
15 minutes
1, 2 hours
3, 5 hours
Rapid-acting
30, 60 minutes
1, 2 hours
5, 6 hours
Intermediate-acting
1, 2 hours
4, 8 hours
8, 12 hours
Long-acting
1 hour
none
24 hours
(brand dependent)
3, 4 hours
6, 8 hours
6, 23 hours
What is bolus insulin?
A bolus insulin dose is one that is taken specifically at mealtimes (either before, during, or just after meals) in order to keep a person’s blood glucose level under control following a meal. This type of insulin needs to act quickly to prevent hypoglycemia, and thus, short-acting or rapid-acting insulin is used.