Drugs Expert

Diabetes is a chronic (lifelong) disease marked by high levels of sugar in the blood.

Causes

Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused by too little insulin, resistance to insulin, or both.

To understand diabetes, it is important to first understand the normal process by which food is broken down and used by the body for energy. Several things happen when food is digested:

• A sugar called glucose enters the bloodstream. Glucose is a source of fuel for the body.
• An organ called the pancreas makes insulin. The role of insulin is to move glucose from the bloodstream into muscle, fat, and liver cells, where it can be used as fuel.

People with diabetes have high blood sugar. This is because:

• Their pancreas does not make enough insulin
• Their muscle, fat, and liver cells do not respond to insulin normally
• Both of the above

There are threemajor types ofdiabetes:

• Type 1 diabetes is usually diagnosed in childhood. Many patients are diagnosed when they are older than age 20. In this disease, the body makes little or no insulin. Daily injections of insulin are needed. The exact cause is unknown. Genetics, viruses, and autoimmune problems may play a role.
• Type 2 diabetes is far more common than type 1. It makes up most of diabetes cases. It usually occurs in adulthood, but young people are increasingly being diagnosed with this disease. The pancreas does not make enough insulin to keep blood glucose levels normal, often because the body does not respond well to insulin. Many people with type 2 diabetes do not know they have it, although it is a serious condition. Type 2 diabetes is becoming more common due to increasing obesity and failure to exercise.
• Gestational diabetes is high blood glucose that develops at any time during pregnancy in a woman who does not have diabetes. Women who have gestational diabetes are at high risk of type 2 diabetes and cardiovascular disease later in life.

Diabetes affects more than 20 million Americans. Over 40 million Americans have prediabetes (early type 2 diabetes).

There are many risk factors for type 2 diabetes, including:

• Age over 45 years
• A parent, brother, or sister with diabetes
• Gestational diabetes or delivering a baby weighing more than 9 pounds
• Heart disease
• High blood cholesterol level
• Obesity
• Not getting enough exercise
• Polycystic ovary disease (in women)
• Previous impaired glucose tolerance
• Some ethnic groups (particularly African Americans, Native Americans, Asians, Pacific Islanders, and Hispanic Americans)

Symptoms

High blood levels of glucose can cause several problems, including:

• Blurry vision
• Excessive thirst
• Fatigue
• Frequent urination
• Hunger
• Weight loss

However, because type 2 diabetes develops slowly, some people with high blood sugar experience no symptoms at all.

Symptoms of type 1 diabetes:

• Fatigue
• Increased thirst
• Increased urination
• Nausea
• Vomiting
• Weight loss in spite of increased appetite

Patients with type 1 diabetes usually develop symptoms over a short period of time. The condition is often diagnosed in an emergency setting.

Symptoms of type 2 diabetes:

• Blurred vision
• Fatigue
• Increased appetite
• Increased thirst
• Increased urination

Exams and Tests

A urine analysis may be used to look for glucose and ketones from the breakdown of fat. However, a urine test alone does not diagnose diabetes.

The following blood tests are used to diagnose diabetes:

• Fasting blood glucoselevel — diabetes is diagnosed if higher than 126 mg/dL on two occasions. Levels between 100 and 126 mg/dL are referred to as impaired fasting glucose or prediabetes. These levels are considered to be risk factors for type 2 diabetes and its complications.
• Oral glucose tolerance test — diabetes is diagnosed if glucose level is higher than 200 mg/dL after 2 hours. (This test is used more for type 2 diabetes.)
• Random (non-fasting) blood glucose level — diabetes is suspected if higher than 200 mg/dL and accompanied by the classic diabetes symptoms of increased thirst, urination, and fatigue. (This test must be confirmed with a fasting blood glucose test.)

Persons with diabetes need to have their hemoglobin A1c (HbA1c) level checked every 3 – 6 months. The HbA1c is a measure of average blood glucose during the previous 2 – 3 months. It is a very helpful way to determine how well treatment is working.

Treatment

Anti-diabetic drugs treat diabetes mellitus by lowering glucose levels in the blood. With the exceptions of insulin, exenatide, and pramlintide, all are administered orally and are thus also called oral hypoglycemic agents or oral antihyperglycemic agents. There are different classes of anti-diabetic drugs, and their selection depends on the nature of the diabetes, age and situation of the person, as well as other factors.

Diabetes mellitus type 1 is a disease caused by the lack of insulin. Insulin must be used in Type I, which must be injected or inhaled.

Diabetes mellitus type 2 is a disease of insulin resistance by cells. Treatments include

• agents which increase the amount of insulin secreted by the pancreas,
• agents which increase the sensitivity of target organs to insulin, and
• agents which decrease the rate at which glucose is absorbed from the gastrointestinal tract.

Several groups of drugs, mostly given by mouth, are effective in Type II, often in combination. The therapeutic combination in Type II may include insulin, not necessarily because oral agents have failed completely, but in search of a desired combination of effects. The great advantage of injected insulin in Type II is that a well-educated patient can adjust the dose, or even take additional doses, when blood glucose levels measured by the patient, usually with a simple meter, as needed by the measured amount of sugar in the blood.

Insulin

Insulin is usually given subcutaneously, either by injections or by an insulin pump. Research is underway of other routes of administration. In acute care settings, insulin may also be given intravenously. There are several types of insulin, characterized by the rate which they are metabolized by the body:

FAST-ACTING INSULIN:

• Insulin Aspart (Novolog)
• Insulin Lispro (Humalog)
• Insulin Glulisine (Apidra)

LONG-ACTING INSULIN:

• Insulin Glargine (Lantus)
• Insulin Detemir (Levemir)
• Insulin Regular (Novolin R, Humulin R)
• Insulin Isophane (Novolin N, Humulin N)

Sulfonylureas

Sulfonylureas were the first widely used oral hyperglycaemic medications. They are insulin secretagogues, triggering insulin release by direct action on theKATP channel of the pancreatic beta cells.Eight typesof these pills have been marketed in North America, but not all remain available. The “second-generation” drugs are now more commonly used. They are more effective than first-generation drugs and have fewer side effects. All may cause weight gain.

Sulfonylureas bind strongly to plasma proteins. Sulfonylureas are only useful in Type II diabetes, as they work by stimulating endogenous release of insulin. They work best with patients over 40 years old, who have had diabetes mellitus for under ten years. They can not be used with type I diabetes, or diabetes of pregnancy. They can be safely used with metformin or -glitazones. The primary side effect is hypoglycemia.

Typical reductions in A1C values for second generation sulfonylureas are 1.0-2.0%.
First-generation agents

• Tolbutamide (Orinase)
• Acetohexamide (Dymelor)
• Tolazamide (Tolinase)
• Chlorpropamide (Diabinese)

Second-generation agents

• Glipizide (Glucotrol XL)
• Glyburide (Diabeta, Micronase, Glynase)
• Glimepiride (Amaryl)
• Gliclazide (Diamicron)

Meglitinides

Meglitinides help the pancreas produce insulin and are often called “short-acting secretagogues.” They act on the same potassium channels as sulfonylureas, but at a different binding site. By closing the potassium channels of the pancreatic beta cells, they open the calcium channels, hence enhancing insulin secretion.

They are taken with or shortly before meals to boost the insulin response to each meal. If a meal is skipped, the medication is also skipped.

Typical reductions in A1C values are 0.5-1.0%.

• Repaglinide (Prandin)
• Nateglinide (Starlix)

Biguanides

Biguanides reduce hepatic glucose output and increase uptake of glucose by the periphery, including skeletal muscle. Although it must be used with caution in patients with impaired liver or kidney function, metformin, a biguanide, has become the most commonly used agent for type 2 diabetes in children and teenagers. Amongst common diabetic drugs, metformin is the only widely used oral drug that does not cause weight gain.

Typical reductions in A1C values for metformin is 1.5-2.0%.

• Metformin (Glucophage). Metformin may be the best choice for patients who also have heart failure. Should be temporarily discontinued before any radiographic procedure involving intravenous iodinated contrast as patients are at an increased risk of lactic acidosis.
• Phenformin (DBI): used from 1960s through 1980s, withdrawn due to lactic acidosis risk.
• Buformin: also withdrawn due to lactic acidosis risk.

Metformin is usually the first-line medication used fortreatment oftype-2 diabetes. It is generally prescribed at initial diagnosis in conjunction with exercise and weight loss as opposed to in the past, where Metformin was prescribed after diet and exercise had failed. Initial dosing is 500 mg once daily, then if need be increased to 500 mg twice daily up to 1000 mg twice daily. It is also available in combination with other oral diabetic medications.

There is an extended release formulation available, but it is typically reserved for patients experiencing GI side effects.

Adverse reactions include weight gain and hypoglycemia.

Thiazolidinediones

Thiazolidinediones (TZDs), also known as “glitazones,” bind to PPARγ, a type of nuclear regulatory protein involved in transcription of genes regulating glucose and fat metabolism. These PPARs act on Peroxysome Proliferator Responsive Elements (PPRE). The PPREs influence insulin sensitive genes, which enhance production of mRNAs of insulin dependent enzymes. The final result is better use of glucose by the cells.

Typical reductions in A1C values are 1.5-2.0%.

• Rosiglitazone (Avandia)
• Pioglitazone (Actos)
• Troglitazone (Rezulin): used in 1990s, withdrawn due to hepatitis and liver damage risk.

As a result of multiple retrospective studies, there is a concern about rosiglitazone’s safety, although it is established that the group, as a whole, has beneficial effects on diabetes. The greatest concern is an increase in the number of severe cardiac events in patients taking it. The ADOPT study showed that initial therapy with drugs of this type may prevent the progression of disease, as did the DREAM trial.

Concerns about the safety of rosiglitazone arose when a retrospective meta-analysis was published in the New England Journal of Medicine. There have been a significant number of publications since then, and a Food and Drug Administration panel voted, with some controversy, 20:3 that available studies “supported a signal of harm,” but voted 22:1 to keep the drug on the market. The meta-analysis was not supported by an interim analysis of the trial designed to evaluate the issue, and several other reports have failed to conclude the controversy. This weak evidence for adverse effects has reduced the use of rosiglitazone, despite its important and sustained effects on glycemic control. Safety studies are continuing.

In contrast, at least one large prospective study, PROactive 05, has shown that pioglitazone may decrease the overall incidence of cardiac events in people with type II diabetes who have already had a heart attack.

Alpha-glucosidase inhibitors

Alpha-glucosidase inhibitors are “diabetes pills” but not technically hypoglycemic agents because they do not have a direct effect on insulin secretion or sensitivity. These agents slow the digestion of starch inthe small intestine, so thatglucose from the starch of a meal enters the bloodstream more slowly, and can be matched more effectively by an impaired insulin response or sensitivity. These agents are effective by themselves only in the earliest stages of impaired glucose tolerance, but can be helpful in combination with other agents in type 2 diabetes.

Typical reductions in A1C values are 0.5-1.0%.

• Miglitol (Glyset)
• Acarbose (Precose/Glucobay)

These medications are rarely used in the United States because of the severity of their side effects (flatulence and bloating). They are more commonly prescribed in Europe. They do have the potential to cause weight loss by lowering the amount of sugar metabolized.

Research has shown the culinary mushroom Maitake (Grifola frondosa) has a hypoglycemic effect, possibly due to the fact the mushroom naturally acts as an alpha-glucosidase inhibitor.

Peptide analogs

Incretin mimetics
Incretins are insulin secretagogues. The two main candidate molecules that fulfill criteria for being an incretin are Glucagon-like peptide-1 (GLP-1) and Gastric inhibitory peptide (aka glucose-dependent Insulinotropic peptide or GIP). Both GLP-1 and GIP are rapidly inactivated by the enzyme dipeptidyl peptidase-4 (DPP-4).

Glucagon-like peptide (GLP) analogs and agonists
GLP agonists bind to a membrane GLP receptor.[2] As a consequence of this, insulin release from the pancreatic beta cells is increased. Endogenous GLP has a half life of only a few minutes; thus an analogue of GLP would not be practical.

• Exenatide (Byetta) (also Exendin-4, marketed as Byetta) is the first GLP-1 agonist approved for the treatment of type 2 diabetes. Exenatide is not an analogue of GLP, but rather a GLP agonist. Exenatide has only 53% homology with GLP, which increases its resistance to degradation by DPP-4 and extends its half-life. Typical reductions in A1C values are 0.5-1.0%.
• Liraglutide (Victoza), a once daily human analogue (97% homology),is being developed by Novo Nordisk underthebrand name Victoza. Theproduct was approved by the European Medicines Agency (EMEA) on July 3, 2009, and by the U.S. Food and Drug Administration (FDA) on January 25, 2010.
• Taspoglutide is presently in Phase III Clinical Trials with Hoffman-La Roche.

These agents may also cause a decrease in gastric motility, responsible for the common side effect of nausea, and is probably the mechanism by which weight loss occurs.

Gastric inhibitory peptide (GIP) analogs
None are FDA approved

DPP-4 inhibitors
Dipeptidyl peptidase-4 (DPP-4) inhibitors increase blood concentration of the incretin GLP-1 (glucagon-like peptide-1) by inhibiting its degradation by dipeptidyl peptidase-4 (DPP-4).

Typical reductions in A1C values are 0.5-1.0%.

Examples are:

• Vildagliptin (Galvus) EU Approved 2008.
• Sitagliptin (Januvia) FDA approved Oct 2006.
• Saxagliptin (Onglyza) FDA Approved July 2009.

Amylin analogues
Amylin agonist analogues slow gastric emptying and suppress glucagon. They have all the incretins actions except stimulation of insulin secretion. As of 2007, pramlintide is the only clinically available amylin analogue. Like insulin, it is administered by subcutaneous injection. The most frequent and severe adverse effect of pramlintide is nausea, which occurs mostly at the beginning of treatment and gradually reduces. Typical reductions in A1C values are 0.5-1.0%.

Experimental agents

Many other potential drugs are currently in investigation by pharmaceutical companies. Some of these are simply newer members of one of the above classes, but some work by novel mechanisms. For example, at least one compound that enhances the sensitivity of glucokinase to rising glucose is in the stage of animal research. Others are undergoing phase I/II studies.

• PPARα/γ ligands (muraglitazar and tesaglitazar – development stopped due to adverse risk profile, aleglitazar – under clinical development)
• SGLT2 (sodium-dependent glucose transporter 2) inhibitors increase urinary glucose.
• FBPase (fructose 1,6-bisphosphatase) inhibitors decrease gluconeogenesis in the liver.

Alternative medicine

A recent review article presents the profiles of plants with hypoglycaemic properties, reported in the literature from 1990 to 2000 and states that “Medical plants play an important role in the management ofdiabetes mellitus especially in developingcountries where resourcesaremeager.”

The first registered use of anti-diabetic drugs was as herbal extracts used by Indians in the Amazon Basin for the treatment of type 2 diabetes, and today promoted as vegetable insulin although not formally an insulin analog. The major recent development was done in Brazil around Myrcia sphaerocarpa and other Myrcia species. The usual treatment is with concentrated (root) Myrcia extracts, commercialized as “Pedra hume de kaá”. Phytochemical analysis of the Myrcia extracts reported kinds of flavanone glucosides (myrciacitrins) and acetophenone glucosides (myrciaphenones), and inhibitory activities on aldose reductase and alpha-glucosidase.

Walnut leaf can significantly reduce fasting blood glucose levels in rats with alloxan-induced diabetes, and rats thus treates show some evidence of regeneration of the beta cells. Garlic also significantly reduces fasting blood glucose levels in rats with alloxan-induced diabetes.

At least two studies have shown that cinnamon can act significantly reducing some effects of diabetes. One study on people used fine ground cassia (Cinnamomum aromaticum) for oral consumption. Another study used an extract (MHCP) on laboratory rats. The study on people published in 2003 conducted in the Department of Human Nutrition, NWFP Agricultural University, Peshawar, Pakistan concluded “that the inclusion of cinnamon in the diet of people with type 2 diabetes will reduce risk factors associated with diabetes and cardiovascular diseases.” The study on laboratory rats at Department of Biochemistry, Biophysics and Molecular Biology, Iowa State University published in 2001 used purified hydroxychalcone (MHCP) from cinnamon. Part of the study’s conclusion stated that “the MHCP is fully capable of mimicking insulin” and recommended further studies. The Food and Drug Administration has not yet evaluated the use of cinnamon for the management of diabetes. It should be noted that the spice sold as cinnamon is often obtained from C. verum (true cinnamon), not C. aromaticum (cassia).

Research has shown the Maitake mushroom (Grifola frondosa) has a hypoglycemic effect, and may be beneficial for the management of diabetes. The reason Maitake lowers blood sugar is due to the fact the mushroom naturally acts as an alpha glucosidase inhibitor. Other mushrooms like Reishi, Agaricus blazei, Agrocybe cylindracea and Cordyceps have been noted to lower blood sugar levels to a certain extent, although the mechanism is currently unknown.

Cinnamon
Though not yet evaluated by the Food and Drug Administration, at least two studies have shown that cinnamon can act significantly reducing some effects of diabetes. One study on people used fine ground cinnamon (Cinnamomum cassia) for oral consumption. Another study used an extract (MHCP) on laboratory rats.

The study on people published in 2003 conducted in the Department of Human Nutrition, NWFP Agricultural University, Peshawar, Pakistan concluded:

The results of this study demonstrate that intake of 1, 3, or 6 g of cinnamon per day reduces serum glucose, triglyceride, LDL cholesterol, and total cholesterol in people with type 2 diabetes and suggest that the inclusion of cinnamon in the diet of people with type 2 diabetes will reduce risk factors associated with diabetes and cardiovascular diseases.

The study on laboratory rats at Department of Biochemistry, Biophysics and Molecular Biology, Iowa State University published in 2001 used purified hydroxychalcone from cinnamon. The extract was named “MHCP”. Part of the study’s conclusion stated that “the MHCP is fully capable of mimicking insulin” and recommended further studies.

Other studies have failed to reproduce these results, and, because large dosesof cinnamon are not innocuous, some experts advise against treatmentofdiabetes with cinnamon.

Chromium and vanadium
Chromium – Cholesterol and triglycerides are risk factors in heart disease and diabetes, and studies show that chromium lowers levels of total cholesterol, LDL cholesterol, and triglycerides. Chromium supplements such as chromium picolinate have been shown to improve glucose tolerance in people with type 2 diabetes, although other studies have not replicated this result. A meta analysis of these trials concluded that chromium supplements had no beneficial effect on healthy people, but that there might be an improvement in glucose metabolism in diabetics, although the authors stated that the evidence for this effect remains weak.

Vanadium – A form of vanadium, vanadyl sulfate, seems to improve glucose control in people with type 2 diabetes.

A pilot study has also found evidence that Tai Chi and Qigong reduce the severity of type 2 diabetes.

Benfotiamine, a pro-vitamin of vitamin B1 which has been in use in Europe as an over-the-counter medicine for alcoholic neuropathy for the past half century with no significant side-effects or toxicity, has recently been found to block the major metabolic pathways by which excess blood glucose in the body is transformed into the advanced glycation endproducts (AGEs) which cause diabetic complications. Studies have shown that taking oral benfotiamine can prevent diabetic retinopathy, diabetic neuropathy, and diabetic nephropathy independently of any affect on the blood sugar levels of the patient. In theory, taking benfotiamine might allow patients to be less scrupulous in trying to normalize blood sugar levels and thus free them from the danger of hypoglycemia and the stress of stringent blood sugar monitoring, while still protecting them against the negative effects of hyperglycemia. Research is ongoing to establish the full significance of benfotiamine in the treatment of diabetes.

Traditional plant treatments for diabetes
A study was made of the effects on glucose homeostasis in normal and streptozotocin (induced) diabetic mice of eleven plants that have been used as traditional treatments for diabetes. The mice were given diets containing dried leaves from the following plants: agrimony (Agrimonia eupatoria), alfalfa (Medicago sativa), blackberry (Rubus fructicosus), celandine (Chelidonium majus), eucalyptus (Eucalyptus globulus), lady’s mantle (Alchemilla vulgaris), and lily of the valley (Convallaria majalis); seeds of coriander (Coriandrum sativum); dried berries of juniper (Juniperus communis); bulbs of garlic (Allium sativum) and roots of liquorice (Glycyrhizza glabra). The study concluded that “The results suggest that certain traditional plant treatments for diabetes, namely agrimony, alfalfa, coriander, eucalyptus and juniper, can retard the development of streptozotocin diabetes in mice”.

Mushrooms
Research has shown the Maitake mushroom (Grifola frondosa) has a hypoglycemic effect, and may be beneficial for the management of diabetes. The reason Maitake lowers blood sugar is due to the fact the mushroom naturally acts as an alpha glucosidase inhibitor. Other mushrooms like Reishi, Agaricus blazei, Agrocybe cylindracea and Cordyceps have been noted to lower blood sugar levels to a certain extent, although the mechanism is currently unknown.

Aloe vera
Oral administration of aloe vera might be a useful adjunct for lowering blood glucose in diabetic patients as well as for reducing blood lipid levels in patients with hyperlipidaemia. Ten controlled clinical trials were found to reach that conclusion infour independent literature searches.However, caveatsreportedineach study led the researchers to conclude that aloe vera’s clinical effectiveness was not yet sufficiently defined in 1999.

Drugs rating:

	Title	Votes	Rating
1	Humalog (Insulin Lispro)	14		(8.8/10)
2	Avandaryl (Glimepiride and Rosiglitazone)	8		(8.5/10)
3	Symlin (Pramlintide)	10		(8.2/10)
4	Prandin (Repaglinide)	20		(8.1/10)
5	Byetta (Exenatide)	278		(8.0/10)
6	Glucovance (Glyburide and Metformin)	10		(8.0/10)
7	Starlix (Nateglinide)	9		(8.0/10)
8	Glucotrol XL (Glipizide)	7		(7.7/10)
9	Victoza (Liraglutide)	26		(7.6/10)
10	Lantus Solostar Pen (Insulin Glargine)	5		(7.6/10)
11	Janumet (Metformin and Sitagliptin)	85		(7.5/10)
12	Glipizide	85		(7.5/10)
13	Actoplus MET (Metformin and Pioglitazone)	47		(7.4/10)
14	Amaryl (Glimepiride)	46		(7.4/10)
15	Lantus (Insulin Glargine)	59		(7.3/10)
16	Levemir Flexpen (Insulin Detemir)	23		(7.1/10)
17	Avandia (Rosiglitazone)	61		(6.7/10)
18	Glucophage (Metformin)	119		(6.6/10)
19	Metformin	513		(6.5/10)
20	Januvia (Sitagliptin)	194		(6.5/10)
21	Fortamet (Metformin)	13		(6.4/10)
22	Actos (Pioglitazone)	293		(6.1/10)
23	Novolog Mix 70-30 FlexPen (Insulin Aspart and Insulin Aspart protamine)	5		(6.0/10)
24	Novolog (Insulin Aspart)	5		(6.0/10)
25	Glumetza (Metformin)	13		(5.8/10)
26	Duetact (Glimepiride and Pioglitazone)	11		(5.8/10)
27	WelChol (Colesevelam)	94		(5.7/10)
28	Levemir (Insulin Detemir)	12		(5.7/10)
29	Onglyza (Saxagliptin)	9		(5.7/10)
30	Avandamet (Metformin and Rosiglitazone)	18		(4.9/10)
31	Humulin R (Insulin Regular)	1		(1.0/10)
32	Humulin N (Insulin Isophane)	0		(0/10)
33	Diabinese (Chlorpropamide)	0		(0/10)
34	Glyset (Miglitol)	0		(0/10)
35	Metaglip (Glipizide and Metformin)	0		(0/10)
36	Humulin 70/30 (Insulin Isophane and Insulin Regular)	0		(0/10)
37	Humalog Mix 50-50 (Insulin Lispro and Insulin Lispro Protamine)	0		(0/10)
38	PrandiMet (Metformin and Repaglinide)	0		(0/10)
39	Apidra SoloStar (Insulin Glulisine)	0		(0/10)
40	Novolog Mix 70-30 (Insulin Aspart and Insulin Aspart Protamine)	0		(0/10)
41	Orinase (Tolbutamide)	0		(0/10)
42	Apidra (Insulin Glulisine)	0		(0/10)
43	Diabeta (Glyburide)	0		(0/10)
44	Humalog Mix 75-25 (Insulin Lispro and Insulin Lispro Protamine)	0		(0/10)
45	SymlinPen 60 (Pramlintide)	0		(0/10)
46	SymlinPen 120 (Pramlintide)	0		(0/10)
47	Glipizide-Metformin	0		(0/10)
48	Novolin R (Insulin Regular)	0		(0/10)
49	Precose (Acarbose)	0		(0/10)
50	Humulin R U-500 “Concentrated” (Insulin Regular, Concentrated)	0		(0/10)
51	Glynase (Glyburide)	0		(0/10)
52	Novolin 70/30 (Insulin Isophane and Insulin Regular)	0		(0/10)
53	Novolin N (Insulin Isophane)	0		(0/10)
54	Micronase (Glyburide)	0		(0/10)
55	Riomet (Metformin)	0		(0/10)

Learn these skills

Basic diabetes management skills will help prevent the need for emergency care. These skills include:

• How to recognize and treat low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia)
• What to eat and when
• How to take insulin or oral medication
• How to test and record blood glucose
• How to test urine for ketones (type 1 diabetes only)
• How to adjust insulin or food intake when changing exercise and eating habits
• How to handle sick days
• Where to buy diabetes supplies and how to store them

After you learn the basics of diabetes care, learn how the disease can cause long-term health problems and the best ways to prevent these problems. Review and update your knowledge, because new research and improved ways to treat diabetes are constantly being developed.

Self-testing

If you have diabetes, your doctor may tell you to regularly check your blood sugar levels at home. There are a number of devices available, and they use only a drop of blood. Self-monitoring tells you how well diet, medication, and exercise are working together to control your diabetes. It can help your doctor prevent complications.

The American Diabetes Association recommends keeping blood sugar levels in the range of:

• 80 – 120 mg/dL before meals
• 100 – 140 mg/dL at bedtime

Your doctor may adjust this depending on your circumstances.

What to eat

You should work closely with your health care provider to learn how much fat, protein, and carbohydrates you need in your diet. A registered dietician can help you plan your dietary needs.

People with type 1 diabetes should eat at about the same times each day and try to be consistent with the types of food they choose. This helps to prevent blood sugar from becoming extremely high or low.

People with type 2 diabetes should follow a well-balanced and low-fat diet.

How to take medication

Medications to treat diabetes include insulin and glucose-lowering pills called oral hypoglycemic drugs.

People with type 1 diabetes cannot make their own insulin. They need daily insulin injections. Insulin does not come in pill form. Injections are generally needed one to four times per day. Some people use an insulin pump. It is worn at all times and delivers a steady flow of insulin throughout the day. Other people may use inhaled insulin.

Unlike type 1 diabetes, type 2 diabetes may respond to treatment with exercise, diet, and medicines taken by mouth. There are several types of medicines used to lower blood glucose in type 2 diabetes.

Medications may be switched to insulin during pregnancy and while breastfeeding.

Gestational diabetes may be treated with exercise and changes in diet.

Exercise

Regular exercise is especially important for people with diabetes. It helps with blood sugar control, weight loss, and high blood pressure. People with diabetes who exercise are less likely to experience a heart attack or strokethan those who do not exercise regularly.

Herearesomeexercise considerations:

• Always check with your doctor before starting a new exercise program.
• Ask your doctor or nurse if you have the right footwear.
• Choose an enjoyable physical activity that is appropriate for your current fitness level.
• Exercise every day, and at the same time of day, if possible.
• Monitor blood glucose levels before and after exercise.
• Carry food that contains a fast-acting carbohydrate in case you become hypoglycemic during or after exercise.
• Carry a diabetes identification card and a cell phone in case of emergency.
• Drink extra fluids that do not contain sugar before, during, and after exercise.

You may need to change your diet or medication dose if you change your exercise intensity or duration to keep blood sugar levels from going too high or low.

Foot care

People with diabetes are more likely to have foot problems. Diabetes can damage blood vessels and nerves and decrease the body’s ability to fight infection. You may not notice a foot injury until an infection develops. Death of skin and other tissue can occur.

If left untreated, the affected foot may need to be amputated. Diabetes is the most common condition leading to amputations.

To prevent injury to the feet, check and care for your feet every day.