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TAKING CHARGE OF DIABETES

WHO HELPS A PERSON WITH DIABETES?

Who are “trained diabetes personnel”?

Trained diabetes personnel are nonmedical people who have received in- depth training about diabetes and diabetes management. They are often hired by school systems to help students with diabetes take care of certain tasks, such as blood glucose monitoring, administering insulin, and helping to recognize possible emergencies, such as hypoglycemia and hyperglycemia. They can also help the school nurse or diabetes-trained health care professional test urine or blood for ketones, if necessary. They are also often referred to as unlicensed assistive personnel, assistive personnel, paraprofessionals, or trained nonmedical personnel.

What is the Diabetes Complications Severity Index?

The Diabetes Complications Severity Index is a tool used to predict deaths and hospitalizations among people with diabetes. It was developed to model the severity of diabetes complications at any one point in time and is used by researchers (used to predict mortality, hospitalizations, and severity of these complications), by hospitals, and even to understand

health care costs. The severity index includes seven categories of complications: cardiovascular disease, nephropathy, retinopathy, peripheral vascular disease, stroke, neuropathy, and metabolic problems.

HEALTH-CARE TESTS AND DIABETES

What is the fasting plasma glucose (or fasting blood glucose) test?

The fasting plasma glucose test is a test that measures blood glucose levels after a person has not eaten for at least eight hours (some suggest 12 to 14, depending on the testing lab). Thus, no foods interfere with the results. According to the American Diabetes Association and Harvard Medical School, for the majority of people, a fasting plasma glucose level of less than 100 mg/dL (milligrams per deciliter) is considered normal.

If the blood glucose level is at or above 126 mg/dL, it is an indication of diabetes. If a person’s reading suggests diabetes, most health care professionals suggest a second test to confirm the results, as various conditions (such as excessive stress) can cause blood glucose levels to fluctuate. A person with a blood glucose level between 100 and 126 mg/dL is thought to be prediabetic (for more about prediabetes, see the chapter “Prediabetes and Type 1 Diabetes”).

What is a random plasma glucose (or random blood glucose) test?

A random plasma glucose (also called random blood glucose) test measures the glucose in a person’s blood. For this test, the person does not have to fast. But overall, the amount of carbohydrates, and the amount of time since the person had a snack or meal, can affect the outcome of the test. Although it is usually not as reliable as other tests (see below), it is most often used for emergencies (for example, in a hospital emergency room) or if a doctor needs a faster result of a person’s glucose level. In this case, if the glucose reading is over 200 mg/dl, the person probably has diabetes, although there may be other circumstances that result in a high measurement. If the number is high, then a fasting glucose test (see above) is usually ordered by the person’s health care professional.

How is an oral glucose-tolerance test used to determine blood glucose levels?

An oral glucose-tolerance test is used to determine blood glucose levels after a person has fasted overnight (the usual length of the fast is around 12 hours). The person then drinks a sugar solution, and another reading is taken two hours later. If the levels rise and fall quickly, then the person usually does not have indications of diabetes; if the levels rise above normal and decrease slowly, then it may indicate that the person has diabetes.

While this test is thought to be accurate, it is mostly used for determining gestational diabetes in pregnant women. This is because the fasting plasma glucose test is less time consuming than the oral glucose- tolerance test (the fasting test is done after fasting for around 12 hours only). If an oral glucose-tolerance test is taken, a blood glucose measurement less than 140 mg/dL when the two-hour blood sample is taken is normal; if the reading is 200 mg/dL or higher, then the person is thought to have diabetes. If the number is between 140 and 200 mg/dL, then the person is thought to have prediabetes.

What is a glycated hemoglobin (HbA1c, or more often seen as A1c) test?

A glycated hemoglobin (also called glycosylated hemoglobin or glycohemoglobin) test, or HbA1c, often abbreviated as A1c, measures a person’s blood glucose levels over the preceding two to three months. Glucose in the blood attaches itself to hemoglobin (an oxygen-carrying protein in red blood cells). Thus, the higher a person’s blood glucose level, the more hemoglobin is bound to glucose. Because red blood cells have a lifespan of about three months, the HbA1c measurement—as a percentage

—reflects the blood glucose control over that period.

The A1c percentages are often used by health care professionals to diagnose diabetes, and no fasting is required. The percentages are as follows: Normal (no diabetes), when the reading is less than 5.7 percent; prediabetes, when the reading is 5.7 to 6.4 percent; and diabetes, when the reading is 6.5 percent or higher. (The test result may be in error if a person has anemia, kidney disease, or certain blood disorders.) If the level is 7 percent and the person has diabetes, then it often indicates that his or her blood glucose levels are not well controlled.

How can a person with diabetes convert HbA1c (A1c) data into average blood glucose level?

There is a general way for a person with diabetes to convert HbA1c data

into average blood glucose level. The following lists this conversion:

HbA1c to Blood Glucose Level Conversion

Blood Glucose

HbA1c Level

6.0 % 135 mg/dl

6.5 % 153 mg/dl

7.0 % 170 mg/dl

7.5 % 188 mg/dl

8.0 % 205 mg/dl

8.5 % 223 mg/dl

9.0 % 240 mg/dl

9.5 % 258 mg/dl

10.0 % 275 mg/dl

10.5 % 293 mg/dl

11.0 % 310 mg/dl

11.5 % 328 mg/dl

12.0 % 345 mg/dl

SELF-MONITORING DIABETES WITH METERS

How does a person with either type 1 or 2 diabetes monitor blood sugar levels?

Most people with diabetes—types 1 and 2 and even some with prediabetes

—monitor their blood glucose levels using a blood glucose meter. In general, the glucose meter measures a person’s blood glucose in milligrams per deciliter (seen as mg/dl or mg/dL).

What are test strips?

Most glucometers require what are called test strips in order to obtain a reading of a person’s blood glucose level. The strip contains special enzymes designed to react with the person’s blood.

What is a glucometer?

A glucometer is a meter that measures blood glucose levels. Today’s meters come in all kinds of forms, from talking and large-display meters to

those that light up (for testing in the middle of the night, if necessary). Some also have built-in food databases and record-keeping systems. Almost all glucometers measure plasma glucose results by taking the value derived from a drop of whole blood and adding 12 percent to the measured value. For most meters, this is equivalent to a reading that a laboratory obtains.

A glucometer (right) and syringe.

Where does one purchase glucometers?

Most glucometers are found at pharmacies and clinics, and many of them are free through special offers from the manufacturer. (It is the test strips used in the glucometers that often are the more costly items, since many people with diabetes have to test their blood glucose levels several times a day.) Some meters also have mail-in rebates after the meter is purchased, and some even offer trade-in rebates if a person has an older machine. For the coverage of diabetes supplies, such as test strips, patients should

contact their insurance company to see what is covered (if anything). At this writing, for people on Medicare, the program will cover the costs of blood testing supplies for people with diabetes.

What is a continuous glucose monitor (CGM)?

A continuous glucose monitor tracks a person’s glucose levels every few minutes. It is also often used in conjunction with a regular blood glucose meter (that does not continuously monitor glucose levels). Once used mainly for young children (especially for nighttime monitoring) and less mobile people, the technology has improved enough for many others to use the device, such as diabetics who travel extensively, who have an active lifestyle, or who can’t stop and monitor their blood glucose levels as much. The monitors have a small filament with a sensor that is inserted just below the skin, usually in an unobtrusive spot, such as just above or below the waist. Using a small radio transmitter, the sensor sends information to a handheld receiver; an iPhone, tablet, or computer can receive the data. The receiver displays the person’s glucose level every few minutes. Depending on the model, special alarms can alert the person to fluctuations in blood glucose levels, especially drops in levels that can lead to hypoglycemia.

What should a person look for when choosing a glucometer?

Choosing a glucose meter is mostly a personal choice (but not always, especially when certain health insurance companies cover only specific types of glucometers). There are some features to think about before picking a meter, including the speed (meters can take anywhere from five to 20 seconds to show results); a beeping or silent monitor for prompts; type of test strips (wrapped or not); or a meter with a memory. Other things to consider include how much the meter has to be cleaned; how portable it is (especially for travel); whether the meter checks for glucose and ketones; the size of blood sample the meter needs; and the types of (and ease of finding) batteries the meter uses. There are more considerations, but these are the most common.

In general, how much fluctuation is there in glucometer readings?

No machine is perfect, and glucometers are no exception. Even if a glucometer is cleaned and calibrated regularly, it may vary in accuracy from other meters, perhaps by as much as 20 percent. If a person with diabetes has any question about the accuracy of a glucometer, it is best to

have the device checked out by a health care professional, pharmacy, or diabetes educator.

Can test strips give erroneous readings?

Yes, test strips can give a person with diabetes erroneous readings for a number of reasons. For example, the test strips may be too old. The enzymes that are embedded in the test strip can lose their activity and cause bare spots on the strips, giving an erroneous reading. A person may use the wrong test strips for the glucometer, giving a false or inaccurate reading, or no result. (This is usually because every machine has its own special test strips.) Abnormal readings may also occur if the temperature is too low. Low temperatures often affect the ability to draw blood for testing (blood does not circulate as close to the skin’s surface in lower temperatures as it does in higher temperatures).

Lancets allow you to make a clean, safe prick on the finger to draw a blood sample for testing.

What is a lancet?

In order for patients to get a clean prick of the finger to obtain a blood sample for a glucometer, many companies provide a lancing device, commonly called a lancet. This tool for pricking a finger is usually ad- justable to varying depths into the skin, depending on the individual’s need. The lancet needle has a release button, pricking the finger quickly. For most people, this way of obtaining a drop of blood is easy, fast, and clean.

What are some general steps when a person with diabetes takes his or her blood glucose level?

There are some very general steps a person with diabetes can take when using a blood glucose meter. Some people may have to take other steps, so it is best to check the procedure with a health care professional).

What events and actions can often throw off blood glucose levels?

Several events and actions can throw off a person’s blood glucose levels, no matter how well the person monitors his or her blood glucose. Ordinary or non-ordinary events such as stress, certain illnesses, unanticipated activity, menstruation, eating, alcohol, or medications can throw the blood glucose levels off balance and cause (sometimes dangerous) fluctuations.

What medical conditions can lead to erroneous readings on a glucometer?

Several medical conditions a person with diabetes can have affect the readings on a glucometer. For example, blood disorders can cause inaccurate readings, such as in people who are anemic whose readings are often falsely high. A person with high levels of hemoglobin in the blood (polycythemia) can experience false low readings. If a person is dehydrated or in shock, he or she may also have false or abnormal glucometer readings.

What other things can interfere with blood glucose readings on a glucometer?

Many things can interfere with blood glucose readings on a glucometer. For example, acetaminophen (commonly referred to as Tylenol) and acetaminophen-containing drugs (some over-the-counter cough and cold medications contain the drug, as do some prescription pain medications such as Zutripro) can interact with certain chemicals used in various medical devices. This interaction can cause the person’s blood glucose levels to rise, interfering with the correct readings. In addition, if a person does not clean his or her hands before collecting a blood sample, incorrect readings can result (the more recent meters only need a small sample, and if it is contaminated with other chemicals or dirt, it can throw off the reading). Other more technical conditions may lead to false blood-sugar readings. For example, glucose meters vary in the way they work and are calibrated. Failure to calibrate the meter regularly can lead to false blood

glucose readings.

Why do many doctors suggest that blood samples for a glucometer be taken from a person’s fingertips?

For some blood glucose meters, there is a reason for taking most of the blood samples from the person’s fingertips—obtaining it in almost any other part of the body (unless it is necessary) can result in a false reading. That being said, many of the more modern glucose monitors require a tiny blood sample, some as small as a third of a microliter. For many of these machines, the small sample can be taken from other sites on the body, such as the forearm or thigh.

How many times a day should a person with diabetes test his or her blood glucose levels?

There is no set number of times a day that blood glucose levels should be tested. This is because everyone’s needs and blood glucose levels are different. Some health care professionals suggest monitoring after a meal; others advocate testing as many times as possible throughout the day. Most believe it is a good idea to check glucose levels before a person drives, exercises, uses heavy equipment, or performs any high-risk task. But overall, the number of times a person monitors glucose levels depends on the individual, the extent of the diabetes, and the recommendations of health care professionals and diabetes-care team.

Taking blood from the tip of one’s finger provides the most accurate readings of glucose levels.

Who should test their blood glucose levels on a regular basis?

Although not all people with diabetes need to diligently self-monitor their blood sugar levels, whether they should or not seems to depend on what type of diabetes a person develops. Most health care professionals suggest that people who take insulin should test their blood sugar regularly. Those who take oral diabetes medication for type 2 diabetes should test their levels frequently, especially if they are taking sulfonylureas or glinides, both of which can occasionally cause low blood sugar.

In addition, Harvard Medical School suggests that certain situations warrant more frequent testing of blood sugar levels, including very high levels at the time diabetes is diagnosed, recent weight gain or loss (not explained by dieting or stress), exercising more than usual (or even less than usual), a change in a person’s diabetic medications (especially sulfonylureas and glinides), and during an illness, such as a gastrointestinal

virus (because even a flu or cold can cause blood sugar levels to fluctuate).

Are there any Internet tools a person can use to manage diabetes?

Yes, thanks to current technology and the Internet, there are many tools that a person with diabetes can use to manage diabetes. For example, there are websites that help keep track of blood glucose readings, which is important for the patient and the health care professionals who are helping their patient to stay healthy. There are also websites that offer diabetes- management assistance, and some clinics and health care providers can send your lab results directly to a patient’s account. The Internet also offers many personal health-management or electronic health record websites, some for free (but such sites may have online advertising) and some for a price. It is up to the individual to decide how much information he or she is willing to provide when signing up for an account. For security purposes, a person with diabetes interested in such a service should do some research on the company before choosing. (For more about the websites, see the “Resources, Websites, and Apps” section of this book.)

DIABETES AND MEDICATION

What types of medicines are used to treat diabetes?

Two main types of medications are used. The first are oral medications, or those that are taken by mouth; these are most often associated with type 2 diabetes. The second type is insulin that is injected or administered using an insulin pump or pen and is most associated with type 1 diabetes. (Insulin cannot be taken as a pill because the acid and digestive enzymes in a person’s stomach destroy the hormone.) According to the Centers for Disease Control and Prevention, the medicines used by adults with diabetes (both type 1 and 2) can be broken down by how they are taken. Among adults, 57 percent take oral medications only, 14 percent take only insulin, 14 percent take a combination of insulin and oral medication, and 15 percent take no medication (mostly people with prediabetes).

How long will it take before someone with diabetes can see an improvement in blood glucose levels—after taking medications and/or making lifestyle changes?

Everyone differs when it comes to how long it takes to see an

improvement (or a worsening) in blood glucose levels. And, of course, everyone is different when it comes to taking medications and making lifestyle changes after being diagnosed with diabetes. But, on the average, most people with diabetes will see an improvement in three to four months. Therefore, a follow-up blood glucose test is usually administered three to four months after a diagnosis. There is one caveat: according to the American Diabetes Association, if a person has had uncontrolled diabetes for a long time and has just been diagnosed, most doctors will test the person’s blood glucose levels after two to three weeks to make sure there is an improvement.

Does a person with diabetes always have to take some type of medication?

Unfortunately, if a person has type 1 or type 2 diabetes, then he or she will probably have to take some medication for the rest of his or her life. Diabetes is a progressive disease, and the longer a person has it, the more likely the person will need pharmaceutical help to manage it. Most people with prediabetes—people who have blood glucose levels above the normal range but not high enough to be called diabetes—will not need to take diabetes medication or will take medication only for a short time (until their blood glucose levels are lower and/or stable). And if a person who has prediabetes can maintain normal blood glucose levels and not develop diabetes, then he or she will never need any diabetic medication.

Insulin is only one medication diabetics can take to control blood sugar. For example, metformin works for those with less pronounced cases.

What diabetes medications have recently been approved by the U.S. Food and Drug Administration?

For the past few decades, the U.S. Food and Drug Administration (FDA) has approved many different types of diabetes medications. These include medicines that are taken orally, injected, or inhaled. The following chart lists the diabetes medications that were approved between 2013 and 2016:

Recently Approved Diabetes Medications Brand Name     Generic Name Approval Date

Basaglar insulin glargine injection December 16, 2015 Tresiba insulin degludec injection   September 25, 2015

Ryzodeg insulin aspart: insulin degludec

September 25, 2015

Toujeo insulin glargine injection February 25, 2015

Lucentis ranibizumab February 6, 2015

Glyxambi empagliflozin and linagliptin

January 2015

Trulicity duglaglutide September 18, 2014

Invokamet canagliflozin and metformin hydrochloride

August 8, 2014

Jardiance empagliflozin August 1, 2014

Afrezza Inhalation Powder

insulin human June 27, 2014

Tanzeum abliglutide May 2014

Farxiga dapaglifozin January 2014

Invokana canagliflozin March 29, 2016

Nesina alogliptin benzoate January 25, 2016

Duetact pioglitazone hydrochloride and glimepiride

January 2013

Source: FDA website. All FDA-approved medicines used in the treatment of diabetes are either taken orally, injected, or inhaled and can be found listed at what is called Drugs@FDA (http://www.accessdata.fda.gov/cder/drug-satfda/). For drug-labeling information, go to the National Library of Medicine database of current drug information called DailyMed (http://dailymed.nim.nih.gov/dailymed/about.cfm).

What is the common procedure if a person is diagnosed with type 2 diabetes?

According to Harvard Medical School, people who have been newly diagnosed with type 2 diabetes should start by concentrating on lowering their blood glucose levels. The two most frequent steps are making lifestyle choices—mainly eating better and exercising more—and to start taking a medication called metformin. Initially, traditional treatment started with lifestyle changes, and if that did not work, then the person was treated with medications. In the meantime, the disease would progress. Now, most doctors recommend that both lifestyle changes and medication be started when a person is first diagnosed. This is because research has shown that many times, in the early stages of the disease, the insulin- secreting cells in the pancreas that are “wearing out” may be saved. This results in either slowing down the disease’s progression or even, for some people, mitigating the disease before it can take over.

Metformin lowers your HbA1c without causing weight gain or hypoglycemia.

What is metformin?

The type of drug most often used to treat a person who has just been diagnosed with diabetes is called by the generic name metformin (one brand name is Glucophage). It is known to lower a person’s HbA1c by about 1.5 percent and, in most cases, does not cause weight gain or hypoglycemia. It acts by reducing glucose secretion by the liver, lowering the organ’s resistance to insulin, and it decreases blood glucose levels without stimulating the secretion of insulin. It is considered a biguanide (see above for other types of medications), a type of oral diabetes medication, and is most often taken twice a day (usually with breakfast and dinner) or one to two times a day if an extended-release formula is taken. There are some side effects, such as nausea and diarrhea, and in rare cases, it may cause lactic acidosis. In addition, there are often some restrictions to metformin that a person should discuss with his or her health care provider, especially if the person has kidney, heart, or liver disease.

Does metformin have a peculiar smell?

Yes, there is one aspect of the diabetes drug metformin that no one expected. According to most people who take metformin, it has a distinctive smell that some describe as a “fishy” odor. Some doctors are concerned that this characteristic may cause a person to stop taking the drug. And since the drug works so well for most people with type 2 diabetes, stopping metformin would be detrimental to the person’s health! There are potential solutions. One study indicated that switching to certain extended-release versions of the drug may help (these drugs are said to have less smell, if any at all). But the best solution if the smell is a concern

—without holding one’s nose as they take the drug—is to contact a health care professional about possible alternative formulations.

Do any non-diabetic medicines affect a person with diabetes?

According to the Centers for Disease Control and Prevention, some non- diabetic medications can affect a person’s blood glucose level. This is a concern if a person already has type 1 or type 2 diabetes. This is also why health care professionals must know the various medications a person with diabetes is taking, including those taken without a prescription (for example, vitamins and herbal supplements). The following are only some types of medications that can cause a problem with blood glucose levels:

Is type 2 diabetes always treated with oral medications?

Most people with type 2 diabetes are commonly treated with oral medications. But if the drugs no longer work, then the person may have to turn to insulin injections. This means either insulin only or oral medications augmented with insulin injections.

What are some possible ways to get off or lower diabetic medication if a person has type 2 diabetes?

Some health care professionals suggest that there are certain specific

conditions in which a person with type 2 diabetes may be able to take less diabetes medication or even stop taking medication. One of the major problems in coping with diabetes is that the person usually has to make conscious lifestyle changes. In fact, certain lifestyle changes may help immensely. These include more healthful eating habits, starting or maintaining better exercise routines, and keeping excellent track of blood glucose levels. The following lists some target glucose levels to reach in order to reduce, possibly, or even stop a person’s type 2 diabetes medication (of course, getting off medication also depends on other health conditions and what the health care provider says):

126 to 140 or 150 mg/dl—This is still above the normal level, but if these readings are consistently low enough, the person may be able to eventually stop taking medication.

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.