Topics:
- Diabetics 200% likely to develop cataracts
- Hope for diabetic patients
- Diabetes Drug Alert
- Bone and joint disorders in diabetes
- Diabetes at festive seasons
- Prevention of type 2 diabetes
- Diabetes and Hepatitis B
- Type-1 Diabetes: Quest for a cure
- Diabetes and womanhood
- Economic and social costs of diabetes
- The rise of the glucose meter
- Insulin use and type 2 diabetes
- My diabetes history
- TYPE-1 DIABETES: QUEST FOR A CURE
- Combination therapy in diabetes
- Four steps to manage your diabetes for life
~TheGuardian Nigeria. Wednesday, February 7, 2018.
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| Diabetics |
It is unsure why diabetes leads to cataracts, however, charities consider it a known complication for adults with poorly managed blood sugar levels.
The latest study involved a team of international researchers from Anglia Ruskin University, University Hospitals Bristol, Switzerland and Boston University.
It aimed to assess incidence rates of cataracts in 56,000 patients, all aged over 40, with diabetes. Cataracts are a known complication of diabetes.
The participants were all followed for 15 years to determine the link between the two conditions, which has existed for years.
The research, published in the journal Eye, found that cataracts was diagnosed at an overall rate of 20.4 per 1,000 people with diabetes.
In comparison, just 10.8 per 1,000 of the general population were diagnosed with cataracts – which is also linked to smoking and boozing.
Diabetics aged between 45 and 54 were considerably more likely than non-sufferers to develop cataract, with their risk being 4.6 times higher.
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Hope for diabetic patients
~Xinhua/NAN
New study that was released by some researchers in the University of Otago and Aucklandon on Tuesday said that Women who took a naturally occurring probiotic were less likely to develop diabetes during pregnancy.
Probiotics are live bacteria and yeasts that are good for your health, especially your digestive system.
The joint study by the universities of Otago and Auckland involved the probiotic, Lactobacillus rhamnosus HN001, which was used to make fermented milk products such as yoghurt.
The report said that it was given in capsule form to 194 women from early pregnancy, while 200 women received a placebo.
Gestational diabetes was assessed at 24 to 30 weeks gestation.
“Using the current New Zealand definition for gestational diabetes, 6.5 per cent of the women had diabetes in the placebo group, versus 2.1 per cent in the probiotic group.
“This is a 68 per cent reduction.
“We found that the protective effects were stronger among older women and were stronger among women who had previously had gestational diabetes,” said study leader Professor Julian Crane, of the University of Otago.
Fasting blood glucose was also significantly lower among women taking the probiotic compared to placebo.
“This is an exciting result suggesting that this probiotic may be interacting with the normal gut bacteria in some way to reduce glucose levels in pregnancy,” he said.
The researchers previously showed that the same probiotic had effects on the immune system and reduced eczema by 50 per cent in infancy.
Crane said that the next steps would be to investigate whether the probiotic could reduce the increasingly common risk in the population of developing diabetes.
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Diabetes Drug Alert
TYPE 2 diabetes drugs — canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance) — may lead to ketoacidosis, the Food and Drug Administration (FDA) warned.
The sodium-glucose co-transporter-2 (SGLT2) inhibitors are designed to lower blood sugar in patients with diabetes, but the FDA is investigating a connection between the drugs and dangerously high acid levels in the blood. They are also looking at whether changes will need to be made to the prescribing information.
"Healthcare professionals should evaluate for the presence of acidosis, including ketoacidosis, in patients experiencing these signs or symptoms," the FDA said. "Discontinue SGLT2 inhibitors if acidosis is confirmed, and take appropriate measures to correct the acidosis and monitor sugar levels." The signs and symptoms listed included difficulty breathing, nausea, vomiting, abdominal pain, confusion, and unusual fatigue or sleepiness. The FDA is issuing the warning after they searched their database of adverse event complaints. From March 2013 to June 2014 there were 20 cases of DKA reported, most of them with type 2 diabetes as the indication. Hospitalization was required in all of the cases, and the median time to onset was 2 weeks after starting the drug.
"I would encourage that these cases be studied so we can learn the scenarios behind them so they can be broadcast," said Farhad Zangeneh, MD, medical director of Endocrine, Diabetes and Osteoporosis Clinic, he added that we should look at the background before issuing a general warning against the class. He manages hundreds of patients with the three SGLT2 inhibitors, he said, and has never had any problems. He suggested starting with low doses and making sure that patients are always well hydrated, have no renal problems, and get their lab work done.
Many doctors prescribe SGLT2 inhibitors off-label to type 1 diabetes patients, said Zangeneh, but in that case, the patients should at least be "super-patients" — they should be well controlled, hand-picked, excellent carb-counters."Certainly this report warrants a closer look at these cases to find out the exact details of the individual scenarios," he added. Foiqa Chaudhry, MD, an endocrinology fellow at the University of Florida, described two cases of DKA that developed after the patients were taking SGLT2 inhibitors. An 18-year-old female presented with persistent vomiting and abdominal pain for the last 24 hours. She'd had type 2 diabetes since she was 8, but had never had ketoacidosis. She had started taking metformin and canagliflozin 3 weeks earlier, and her primary care physician increased the dosage from 100 mg to 300 mg one week earlier. She was treated for diabetic ketoacidosis with an insulin drip and was eventually discharged.
In the other case, a 55-year-old man presented with dizziness. It was found that he had recently started taking glipizide and dapagliflozin. He was treated for mild DKA and sent home. It is suggested that more specific counseling be given to patients regarding hydration status when being started on this class of medications."
Potential DKA-triggering factors that were identified in some cases included acute illness or recent significant changes such as infection, urosepsis, trauma, reduced caloric or fluid intake, and reduced insulin dose. Potential factors, other than low insulin levels, contributing to the development of acidosis identified in the cases included low blood volume levels, acute kidney impairment, low blood oxygen levels, reduced oral intake, and a history of alcohol use. But they noted that for half of the cases, there was no triggering factor that was listed.
The FDA asked healthcare professionals to report adverse events and side effects from these products to their MedWatch program.
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Bone and joint disorders in diabetes
INDIVIDUALS with diabetes are leading more productive and longer lives as a result of improvements in diabetes care the world over. As their life spans increase however, disorders of the bones and joints are known to supervene. Though quite debilitating, these disorders are often overlooked and under recognized as being a consequence of diabetes as they are more often attributed to the ageing process.
A very distressing condition referred to as Adhesive capsulitis of the shoulder in medical parlance is a common condition in which there is diffuse pain over the shoulder which is associated with profound restriction of movement in all directions in the affected shoulder. There is spontaneous resolution of this condition in some cases though with a relatively high chance of recurrence. When the disease is severe, it may lead to such a limb becoming disabled. This condition is seen in about ten out of every hundred individuals with diabetes and is commoner in those with Type 2 than Type 1 diabetes. The longer the duration of diabetes and the older the individual is, the greater the risk of the development of this condition.
Treatment aims to increase the range of motion in this tightened joint. Physiotherapy should be started early; splinting should not be done as it would worsen the condition by further leading to restriction of motion. The pain should be addressed with the use of analgesics with the occasional injection of steroids into the joint. Recovery is known to take up to six months.
The diabetic hand syndrome which is also referred to as stiff hand syndrome, or diabetic stiff hand or syndrome of limited joint mobility, though first described in adults with diabetes is also being seen in juveniles with both Type 1 and Type 2 diabetes. It may be seen in up to fifty percent of people with diabetes. It is said to be more common in those with Type 1 disease and that of long duration. When diabetes is poorly controlled on a long term basis, it greatly increases the risk of early onset of this condition. Complaints that will suggest this condition include stiffness in the fingers, loss of dexterity and weakness of the hands. The skin of the hands becomes typically thick, tight and waxy. The fingers become painful with decreased ability to move the fingers at their various joints. The individual may then exhibit what is called the prayer sign in which the individual is unable to bring the palms of the hands together because of the contraction of the tendons of the hands. There is consequent inability to flex the fingers fully leading to inability to grip firmly. Helpful treatments for this condition include an attempt to increase the range of motion through exercise focused on the hands. The use of Aspirin and other analgesics may help in controlling the pain and stiffness.
Another abnormality on the hand also seen in people with diabetes is the deformity of the last three fingers in which they are fully flexed on the palm. This deformity is also common in those without diabetes. It is referred to as Dupuytren disease. It must be treated with aggressive physical therapy, which includes splinting and exercises. Injection of steroids into the joints is known to help reduce pain and improve the range of motion. Surgery is occasionally necessary.
Osteoarthritis, a degenerative joint disease is very common in the general population. It is thought that osteoarthritis is prevalent in young and middle aged people with diabetes and that damage to the joints start at an earlier age and is much more severe than in those without diabetes. Control of pain is essential as is physical therapy guided exercise.
In long standing diabetes, an entity referred to as Charcot joint may develop. There is joint swelling and deformity after the age of fifty. The foot is most commonly involved. It can also involve the ankle and the knee. Painless foot swelling is the commonest symptom. X-ray will show destructive changes of the joints of the foot. There may be development of 'claw toe' with increased tendency for ulcers to form at the tip of the toes due to increased pressure on them. Treatment is difficult though use of appropriate footwear and regular inspection of the feet is helpful.
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Diabetes at festive seasons
The food choices individuals with diabetes make goes a long way in impacting on their blood sugar levels. Despite this, a very wide variety of foods should still be consumed and enjoyed by people living with diabetes regardless of the season of the year we are in. Festive season or not, individuals with diabetes must always strive to keep their blood sugar levels under control.
Controlling blood sugar levels well during festive seasons can pose serious challenges not only due to the preponderance of food at different occasions but also because of socio-cultural issues that in most cases make it culturally unacceptable to refuse foods at parties.
The way out of this quagmire is to make healthy food choices in such instances and to take such foods in moderate quantities. The key questions that thus need to be asked by people with diabetes during festive seasons and at other times are; what am I eating? How much am I eating? And when am I eating this?
The following tips may be helpful in enjoying the festive season while still keeping the blood sugar level under control. Firstly, there is the need for continued close monitoring of the blood sugar levels with personal glucometers, especially with increased frequency of food intake.
Also, the pressure to consume more than your normal quantity of food will need to be resisted steadfastly as also the pressure to eat outside your normal meal times. This will help to prevent unnecessary weight gain that usually follows frequent consumption of food especially around festive seasons.
Individuals with diabetes should also make their input into meal preparation during the season as always; making sure that healthful food is prepared. This may include the use of sugar substitutes to prepare cakes, biscuits and other pastries, increasing the amount of spices and flavourings like nutmeg, thyme, and curry in foods in other to be able to reduce the quantity of salt to be used.
They should also advise that copious amounts of vegetables and moderate portions of fruits be part of the meals.
Focusing on activities rather than on food and the maintenance of one's regular exercise schedule will also go a long in helping to keep a good control. The need for very moderate consumption of alcohol for those that must take alcohol is to be emphasized.
For men whose diabetes has been well controlled, it is advised that they take no more than one bottle of beer per day, or not more than 150ml of wine (equivalent to about a third of the quantity of water in a sachet of pure water) or not more than 50ml of spirits. Women are advised to consume half of what is recommended for men.
Variety and moderation remains the two key words that individuals with diabetes must keep in mind this festive season and always in order to eat right. This is no need for individuals with diabetes to feel deprived-food wise as with careful preparation they can eat healthful meals. Fiber rich meals which help to control the blood glucose levels like the local unpolished rice, whole grain cereals and the likes should be consumed.
There is thus the need to move on from the level of 'un-informed over-consumption' of food commonly associated with festive seasons to that of 'informed consumption' by individuals with and without diabetes.
Thus, festive seasons need not be associated with hazardous overconsumption of foods and drinks that can precipitate diabetes in those that are already in the pre-diabetes state or worsen blood sugar control in those already diabetic. For those travelling out of their bases during the season, the simple act of remembering to take their medications along with them will go a long way in helping to keep their blood sugar and pressure under control. Eat, drink and be healthy!
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Prevention of type 2 diabetes
~ Culled from hsph.harvard.edu
Making a few lifestyle changes can dramatically lower the chances of developing type 2 diabetes. The same changes can also lower the chances of developing heart disease and some cancers. Excess weight is the single most important cause of type 2 diabetes. Being overweight increases the chances of developing type 2 diabetes seven fold. Being obese makes you 20 to 40 times more likely to develop diabetes than someone with a healthy weight. Losing weight can help if your weight is above the healthy-weight range. Losing 7 to 10 percent of your current weight can cut your chances of developing type 2 diabetes in half.
Inactivity promotes type 2 diabetes. Working your muscles more often and making them work harder improves their ability to use insulin and absorb glucose. This puts less stress on your insulin-making cells. Long bouts of hot, sweaty exercise aren't necessary to reap this benefit. Findings from the Nurses' Health Study and Health Professionals Follow-up Study suggest that walking briskly for a half hour every day reduces the risk of developing type 2 diabetes by 30 percent. More recently, The Black Women's Health Study reported similar diabetes-prevention benefits for brisk walking of more than 5 hours per week. This amount of exercise has a variety of other benefits as well. And even greater cardiovascular and other advantages can be attained by more, and more intense, exercise.
Television-watching appears to be an especially-detrimental form of inactivity: Every two hours you spend watching TV instead of pursuing something more active increases the chances of developing diabetes by 20 percent; it also increases the risk of heart disease (15 percent) and early death (13 percent). The more television people watch, the more likely they are to be overweight or obese, and this seems to explain part of the TV viewing-diabetes link. The unhealthy diet patterns associated with TV watching may also explain some of this relationship.
Dietary changes can have a big impact on the risk of type 2 diabetes. Choose whole grains and whole grain products over highly processed carbohydrates.
There is convincing evidence that diets rich in whole grains protect against diabetes, whereas diets rich in refined carbohydrates lead to increased risk. In the Nurses' Health Studies I and II, for example, researchers looked at the whole grain consumption of more than 160,000 women whose health and dietary habits were followed for up to 18 years. Women who averaged two to three servings of whole grains a day were 30 percent less likely to have developed type 2 diabetes than those who rarely ate whole grains. When the researchers combined these results with those of several other large studies, they found that eating an extra 2 servings of whole grains a day decreased the risk of type 2 diabetes by 21 percent.
Whole grains don't contain a magical nutrient that fights diabetes and improves health. It's the entire package-elements intact and working together-that's important. The bran and fiber in whole grains make it more difficult for digestive enzymes to break down the starches into glucose. This leads to lower, slower increases in blood sugar and insulin, and a lower glycaemic index. As a result, they stress the body's insulin-making machinery less, and so may help prevent type 2 diabetes. Whole grains are also rich in essential vitamins, minerals, and phytochemicals that may help reduce the risk of diabetes.
In contrast, white bread, white rice, mashed potatoes, donuts, bagels, and many breakfast cereals have what's called a high glycaemic index and glycaemic load. That means they cause sustained spikes in blood sugar and insulin levels, which in turn may lead to increased diabetes risk.
In China, for example, where white rice is a staple, the Shanghai Women's Health Study found that women whose diets had the highest glycaemic index had a 21 percent higher risk of developing type 2 diabetes, compared to women whose diets had the lowest glycaemic index. Similar findings were reported in the Black Women's Health Study.
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Diabetes and Hepatitis B
~Culled from www.cdc.gov/hepatitis
Hepatitis B is a contagious liver disease that results from infection with the hepatitis B virus. When first infected, a person can develop an "acute" infection, which can range in severity from a very mild illness with few or no symptoms to a serious condition requiring hospitalization. Acute hepatitis B refers to the first 6 months after someone is infected with the hepatitis B virus. Some people are able to fight the virus and clear the infection. For others, the infection remains and leads to a "chronic," or lifelong, illness.
Chronic hepatitis B refers to the illness that occurs when the hepatitis B virus remains in a person's body.
Over time, the infection can cause serious damage to the liver and lead to complications such as liver failure or liver cancer. The hepatitis B virus is usually spread when blood or other body fluids from a person infected with the hepatitis B virus enters the body of someone who is not infected. Hepatitis B can be spread through sharing needles, syringes, or other injection equipment. In addition, the hepatitis B virus can spread through sexual contact and from an infected mother to her baby during childbirth.
Among people living with diabetes, the hepatitis B virus has been spread through contact with infectious blood. People living with diabetes are at increased risk for hepatitis B if they share blood glucose meters, fingerstick devices or other diabetes-care equipment such as syringes or insulin pens.The hepatitis B virus is 50 - 100 times more infectious than HIV which makes it easily transmitted. The hepatitis B virus can survive outside the body at least a week. During that time, the virus can still cause infection if it enters the body of a person who is not infected.
People living with type 1 or type 2 diabetes mellitus have higher rates of hepatitis B than the general population. Some of the cases of hepatitis B have occurred in individuals with diabetes whose equipment came in contact with infected blood, or who had contact with the virus through breaks in the skin. This has happened through improper reuse and sharing of glucose monitoring equipment or other diabetes care equipment. Transmission has occurred among people with diabetes who reside in assisted living facilities when several people received glucose monitoring in close succession.
In 2011, the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices (ACIP) released new guidelines that recommend hepatitis B vaccination for all unvaccinated adults with diabetes who are younger than 60 years of age. Vaccination should occur as soon as possible after diagnosis of diabetes; vaccination should also be given to adults diagnosed with diabetes in the past.
For unvaccinated adults with diabetes who are 60 years and older, the ACIP recommends hepatitis B vaccination at the discretion of their health care provider. As with other vaccines, the effectiveness of the hepatitis B vaccine decreases with age. Decisions to vaccinate should include the patient's likelihood of acquiring hepatitis B, including the need for assisted blood-glucose monitoring, and overall health status. Hepatitis B vaccination may provide partial, if not full protection for many older adults with diabetes.
Diabetes educators should provide their clients or patients with the following information on how to protect themselves from getting the hepatitis B virus:
- Prevent exposure to hepatitis B and other blood borne pathogens by not sharing equipment such as
blood glucose monitors or other diabetes care equipment.
- The best way to prevent hepatitis B is by getting vaccinated. CDC recommends hepatitis B
vaccination for all unvaccinated adults with diabetes younger than 60 years of age.
- If you think you have already been vaccinated, confirm with your doctor.
- The hepatitis B vaccine is given as a series of 3 shots over a period of 6 months (0, 1, 6 month schedule). The entire series is needed for long-term protection.
- If you have not received the hepatitis B vaccine series talk to your doctor about getting vaccinated.
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Type-1 Diabetes: Quest for a cure
- Culled from Diabetes Update for Healthcare Professionals. Summer 2015. Colin Dayan.
Type-1 diabetes is caused by the immune system damaging the insulin producing cells of the body. It is not known why this self destructive process happens, but the evidence points to a combination of being born with slight changes in many immune system genes that make this kind of reaction more likely, with some events in the first year or two of life that trigger this reaction. It then takes many months or years for the damage to the insulin cells to happen – in some people 20 years or more. Laboratory tests can detect that this process is happening and, in many cases, predict who will detect Type 1 diabetes by measuring blood levels of antibodies to the insulin making cells.
A treatment that could slow, or even halt, this self-destructive process could delay the age at which diabetes is diagnosed. Being diagnosed at age 20 or 25, rather than 5 or 10 years old, would certainly have significant advantages, for the person who would not have to live for so many years with diabetes and the possibility of health complications.
Over the last 20 years, a vast array of new drugs that treat the immune system have been developed and been proved effective in diseases such as rheumatoid arthritis, inflammatory bowel disease among others. The question remains, why does similar immune therapies ineffective in Type 1 diabetes? The answer is that drugs that affect the immune system often also carry an increased risk of infections and possible long-term increased risk of cancer.
As it is well known, many people with Type 1 diabetes live very full lives on insulin treatment for 50 or more years, hence any new treatment must prove itself to be better than insulin. This is especially true of any treatment that might be given to patients in the early stages before they actually develop diabetes.
Some progress has already been made in developing immunotherapy for Type 1 diabetes. In the 1980s, it was shown that drugs used for kidney transplants – such as cyclosporine – could slow the loss of insulin production by the body, including in children. However, side effects, such as vulnerability to infection and reduced kidney function, meant that all the children came off the treatment within five years and the benefit was lost.
Since then, over 20 newer treatments have been tried and at least four of these have shown some beneficial effect in preserving insulin production. These include the new antibody treatments: anti-CD3, rituximab among others. Although these drugs are used routinely in other conditions, concerns about safety compared with insulin and a diminution of their therapeutic effect over time have delayed their introduction into routine clinical care. Lower doses have been tried to avoid side effects, with some negative results being reported in the last few years, which has inevitably led to disappointment.
Is effective immunotherapy for Type 1 diabetes really possible? Experience does suggest that where sufficient resources are well targeted, remarkable results can be achieved. For instance, treatment of acute leukaemia and other childhood cancers and HIV/AIDS have been transformed in recent years from universally fatal diseases into long-term manageable, or even curable, conditions. In fact, new cases of acute leukaemia in children are rarer than new cases of Type 1 diabetes. More than 80 per cent of children with this once fatal acute leukaemia can now expect to be cured subsequent to a lot of research carried out on the disease.
A major focus of Type 1 diabetes immunotherapy research is the 'honeymoon period' experienced by those newly diagnosed with the condition. Controlling blood glucose in Type 1 diabetes is not easy. Although there have been major advances in blood testing and insulin delivery technology, it still requires a lot of effort and dedication to achieve tight control of blood glucose levels. How can we make it easier?
In the first few months after diagnosis, many people with Type 1 diagnosis find that blood glucose control is not so difficult and manage to obtain their blood glucose targets then, than later after diagnosis. This is because most still have their own insulin secreting ability intact. This period, soon after diagnosis has been referred to as 'honeymoon period'.
In diabetes immunotherapy research, a major goal is to make the honeymoon last longer, both by understanding it better and targeting patients for treatment when they are still in this state.
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It is known that several aspects of the female reproductive cycle are greatly influenced by insulin. Right from puberty, through the childbearing years unto menopause, women living with diabetes will need to make significant adjustments to their treatment regimens in order to achieve and maintain good blood sugar control for optimal functioning. Menopause with the attendant waning of the level of reproductive hormones and its attendant significant symptoms that may warrant hormone replacement therapy to ameliorate such symptoms also presents a significant challenge due to the risk of softening of the bones (osteoporosis) with increased risk of fractures and the development of endometrial cancer that may follow hormone replacement therapy.
Menstrual periods are often disrupted in poorly controlled diabetes. This is manifested as either absence of the menses (amenorrhoea) or infrequent menstrual flow (oligomenorrhoea). Unusually frequent menstrual flows (polymenorrhoea)has also been reported. The mechanism of this abnormal menses in diabetes has been linked to the lack of stimulation of the endocrine organs that controls the hormonal associated with the female reproductive cycle. Poor blood sugar control and excessive weight loss in the diabetic woman is known to accentuate this dysfunction. The polycystic ovary syndrome associated with excessive hairiness, blood sugar and menstrual abnormalities, and obesity is another condition to exclude in women with abnormal menses. In this group of women, treatment with insulin sensitizing medications like metformin and appropriate weight loss is known to restore the menstrual cycle to normal and enhance fertility.
It is also known that about a week before the menstrual flow, the blood sugar level tends to be higher possibly due to the high level of progesterone in the system at this time. The higher blood sugar level has been associated with increased food consumption in some women at this period.
Sexual dysfunction is another recognized morbidity in the woman with diabetes. Vulvovaginal candidiasis which is highly prevalent in the woman with poorly controlled diabetes is a recognized cause of painful intercourse. Depression, which is common in people with diabetes, is another recognized cause of sexual dysfunction in the woman with diabetes as are some drugs like thiazide diuretics and spirinolactone which are used to treat concomitant hypertension I the woman with diabetes which may significantly reduce vaginal lubrication.
The ability to conceive is not hampered in women with diabetes who have normal menstrual cycles. Those with amenorrhoea and oligomenorrhoea however have reduced opportunities for fertilization. In those with polycystic ovary syndrome and diabetes, this also holds true. While poor blood sugar control may not impair the ability to conceive, it definitely does increase the chances of spontaneous abortions and other untoward sequelae for the pregnancy. In women with diabetes hoping to achieve a pregnancy, it is imperative to optimize the blood sugar control in order to enhance ovulation, reduce the risk of spontaneous abortions and birth defects. The risk of malformation of the developing baby is higher when the blood sugar levels are high during early pregnancy.
Contraception is an important issue in women with diabetes who are in their childbearing years. Pregnancies in them ought to be planned in order to ensure a favourable outcome for mother and child. For those with long-term complicated diabetes, contraception is imperative in other to protect their own health. This is because pregnancy is known to worsen diabetic retinopathy, diabetic kidney disease and increased risk of death of such women especially when there is concomitant heart disease. For such women who have completed their family size, surgical sterilization by ligating the tubes is advised.
Oral contraceptive pills are the most popular form of reversible contraception. The side effect profile of the current 'low dose' formulations is much better than the earlier ones. The risk of stroke, cardiovascular diseases and abnormalities in blood sugar control are reduced with these 'low dose' pills, though they may worsen cholesterol abnormalities. The newly available transdermal forms implanted under the skin is said to have a better risk profile the tablet formulations.
A complication which though rare, but that is unique to the breasts of women with diabetes is diabetic mastopathy. It is a disease that presents as firm, non tender breast lump(s) that may be difficult to distinguish from cancer of the breast. It is seen most commonly in women with Type 1 diabetes prior to menopause. It is commoner in those with other complications of diabetes like damage to the eyes, kidneys and nerves.
Hot flashes and vaginal dryness are the immediate effects of the permanent cessation of menstrual periods referred to as menopause. The age of menopause in women with diabetes is no different from those without diabetes. As women with diabetes attain menopause their risk of developing cardiovascular diseases and osteoporosis increases. Premature ovarian failure, which is the attainment of menopause before the age of forty years may be seen in some individuals with diabetes.
Oestrogen replacement therapy is the prescription of low dose oestrogen in postmenopausal women with the intent of reversing the changes of menopause. In women who have not undergone hysterectomy, the use of progesterone with oestrogen is necessary to prevent endometrial cancer. The combination of oestrogen and progesterone is hormone replacement therapy. This therapy has been used for short term treatment of peri-menopausal symptoms and long-term reduction of cardiovascular risk and as a major treatment for osteoporosis.
The cardiovascular benefits of hormone replacement therapy have been the major reason for its use in women without diabetes. Premenopausal women have a lower risk of heart disease than do men of the same age, but the advantage disappears after menopause. Hormone replacement therapy is known to reduce death from cardiovascular disease by about 30-50%.
The level of the bad LDL cholesterol increases after menopause. This increased level is associated with an increased risk of cardiovascular disease and is reduced by hormone replacement therapy. The diabetic state can exacerbate the postmenopausal high levels of LDL cholesterol, hence, treatment is warranted.
Osteoporosis causes the bones to become weak and brittle. The brittleness can cause fractures during a fall or during mild stresses like bending over or coughing. The extension of the average life expectancy of people with diabetes that has accompanied improvements in medical care has increased the significance of osteoporosis. Bone health is known to be compromised in diabetes. Hip fractures are now recognized as a major cause of morbidity and mortality in both the general population and those with diabetes. Mortality is high in the general population with hip fractures, but the presence of diabetes in an individual with hip fracture increases the risk of mortality. All individuals with diabetes should be evaluated for osteoporosis and counseled about modifiable risk factors (getting appropriate exercise, calcium and vitamin D and avoiding smoking and excessive alcohol.
Endometrial cancer is the fourth most common cancer in women. Diabetes has long been considered a risk factor for the development of endometrial cancer. Women with diabetes have at least double the risk of endometrial cancer in comparison to the non-diabetic population. It has been postulated that additional oestrogen exposure in obese women, from conversion in the excess body fat, induces the cancer.
Vaginal ("http://www. everydayhealth.com/sexual-health/yeast-infections-and-vaginal-itching.aspx") yeast infection, also known as candidiasis, is an irritating condition that causes itching and irritation around the vagina, a thick white discharge, and burning when urinating or during intercourse. Although many women experience yeast infections, it is more common in women with ("http://www.everydayhealth.com/type-2-diabetes/") type 2 diabetes. Thrush due to candida albicans may be the first symptom of diabetes. Some women, especially those with poorly controlled diabetes, have some compromise in their ability to fight off any infection. This means that once a yeast infection has begun, getting rid of it may not be that easy. Improved blood sugar control and the use of anti fungal medications are necessary measures to control the infection.
Women with diabetes should interact closely with their healthcare givers so that appropriate screenings are carried out promptly
Oral contraceptive pills are the most popular form of reversible contraception. The side effect profile of the current 'low dose' formulations is much better than the earlier ones. The risk of stroke, cardiovascular diseases and abnormalities in blood sugar control are reduced with these 'low dose' pills, though they may worsen cholesterol abnormalities. The newly available transdermal forms implanted under the skin is said to have a better risk profile the tablet formulations.
A complication which though rare, but that is unique to the breasts of women with diabetes is diabetic mastopathy. It is a disease that presents as firm, non tender breast lump(s) that may be difficult to distinguish from cancer of the breast. It is seen most commonly in women with Type 1 diabetes prior to menopause. It is commoner in those with other complications of diabetes like damage to the eyes, kidneys and nerves.
Hot flashes and vaginal dryness are the immediate effects of the permanent cessation of menstrual periods referred to as menopause. The age of menopause in women with diabetes is no different from those without diabetes. As women with diabetes attain menopause their risk of developing cardiovascular diseases and osteoporosis increases. Premature ovarian failure, which is the attainment of menopause before the age of forty years may be seen in some individuals with diabetes.
Oestrogen replacement therapy is the prescription of low dose oestrogen in postmenopausal women with the intent of reversing the changes of menopause. In women who have not undergone hysterectomy, the use of progesterone with oestrogen is necessary to prevent endometrial cancer. The combination of oestrogen and progesterone is hormone replacement therapy. This therapy has been used for short term treatment of peri-menopausal symptoms and long-term reduction of cardiovascular risk and as a major treatment for osteoporosis.
The cardiovascular benefits of hormone replacement therapy have been the major reason for its use in women without diabetes. Premenopausal women have a lower risk of heart disease than do men of the same age, but the advantage disappears after menopause. Hormone replacement therapy is known to reduce death from cardiovascular disease by about 30-50%.
The level of the bad LDL cholesterol increases after menopause. This increased level is associated with an increased risk of cardiovascular disease and is reduced by hormone replacement therapy. The diabetic state can exacerbate the postmenopausal high levels of LDL cholesterol, hence, treatment is warranted.
Osteoporosis causes the bones to become weak and brittle. The brittleness can cause fractures during a fall or during mild stresses like bending over or coughing. The extension of the average life expectancy of people with diabetes that has accompanied improvements in medical care has increased the significance of osteoporosis. Bone health is known to be compromised in diabetes. Hip fractures are now recognized as a major cause of morbidity and mortality in both the general population and those with diabetes. Mortality is high in the general population with hip fractures, but the presence of diabetes in an individual with hip fracture increases the risk of mortality. All individuals with diabetes should be evaluated for osteoporosis and counseled about modifiable risk factors (getting appropriate exercise, calcium and vitamin D and avoiding smoking and excessive alcohol.
Endometrial cancer is the fourth most common cancer in women. Diabetes has long been considered a risk factor for the development of endometrial cancer. Women with diabetes have at least double the risk of endometrial cancer in comparison to the non-diabetic population. It has been postulated that additional oestrogen exposure in obese women, from conversion in the excess body fat, induces the cancer.
Vaginal ("http://www. everydayhealth.com/sexual-health/yeast-infections-and-vaginal-itching.aspx") yeast infection, also known as candidiasis, is an irritating condition that causes itching and irritation around the vagina, a thick white discharge, and burning when urinating or during intercourse. Although many women experience yeast infections, it is more common in women with ("http://www.everydayhealth.com/type-2-diabetes/") type 2 diabetes. Thrush due to candida albicans may be the first symptom of diabetes. Some women, especially those with poorly controlled diabetes, have some compromise in their ability to fight off any infection. This means that once a yeast infection has begun, getting rid of it may not be that easy. Improved blood sugar control and the use of anti fungal medications are necessary measures to control the infection.
Women with diabetes should interact closely with their healthcare givers so that appropriate screenings are carried out promptly
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Diabetes is a leading cause of new onset blindness, end-stage kidney disease and amputation of limbs not related to accidents and other trauma. Managing any of these complications does not come cheap. For example, when poorly controlled diabetes leads to kidney disease that will require dialysis, an average of N90,000 would be required on a weekly basis to keep such an individual alive. Diabetes is also associated with a substantially increased risk of death in both men and women with a three-to-fivefold increase in those between ages 45 to 64 and twofold-to-threefold increase in those aged 65 to 74.
Those with diabetes are two-to-four times more likely to experience heart attack or stroke than are people without diabetes. Stroke is a much more common occurrence in Nigerians with diabetes than heart attacks, which is also now being seen commonly. Diseases such as stroke and heart attacks and other diseases that affect the heart and the blood vessels are the commonest cause of death in those with diabetes.
Cataract, the commonest cause of reversible blindness, is twofold higher in those with diabetes than in those without diabetes. A lot of people with diabetes have diabetes related disabilities, which may lead to some degree of social exclusion. These disabilities and impairments that they suffer from are also known to increase with duration of diabetes and age and are more in those that are economically disadvantaged. These disabilities are known to dramatically lower their rates of employment, cause increased rates of absenteeism, lead to increased use of healthcare services, and increased rates of hospital admissions. All the foregoing is known to lead to a higher degree of discrimination in the workplace against them. In those with diabetes but without diabetes-related disabilities however, there is no known increased propensity for absenteeism and they are known to be able to hold their own like others without diabetes.
The economic cost of managing diabetes is high. It is known to be as high as three and half times higher than the cost of managing other diseases. Apart from the direct costs related to hospital admissions and medications, indirect costs like lost productivity and premature mortality are also high. Intangible costs like reduced life expectancy, reduced quality of life can however not have a monetary value attached to them.
Of utmost importance in diabetes care is the education of the person with diabetes about self-management. Once such an individual is so empowered, they are able to competently manage their diabetes and greatly reduce the risk of developing complications of diabetes and diabetes-related disabilities. Good self-management of diabetes will include changes in behaviour and adjustments of some ingrained habits. Making these changes is known to be tough. If done successfully, the effects are salutary. Healthcare providers are also to provide and foster an environment that supports the person with diabetes and reinforces their sense of self-efficacy and responsibility.
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- Culled from Diabetes Update, Summer 2015
Regular monitoring of blood glucose levels is a vital part of diabetes management and appropriate testing 'kit' is part of everyday life for everyone who uses insulin, as well as for some with Type 2 diabetes who use other forms of glucose-lowering medication. This hasn't always been the case however.
For many years, self-testing was regarded as unfeasible, or even dangerous by doctors, and this only changed as the accuracy and user-friendliness of the process improved. In the 1920s, the very first at-home glucose tests involved a laborious 10-minute process that included mixing a sample of urine with a chemical provided by the doctor (Benedict's solution), heating the mixture in boiling water and watching for a colour change. Blue indicated no glucose, green meant there was a trace and red or orange signaled an excess of it.
This approach was slowly, but steadily, improved on over the years – first with the introduction of Clinitest tablets in the 1940s (which didn't require a source of heat) and again, in the 1950s and 1960s with paper test strips that could be used to measure glucose in the urine and, later for more up-to-the-minute readings, the blood. However, these methods were limited because they relied on people's judgement of colour change to give an estimate of glucose levels, which was imprecise and could be misread, especially by those with poor eyesight.
The Ames reflectance meter was the first portable blood glucose meter. It also used test strips, but gave a more precise estimate of blood glucose by accurately measuring their change in colour via the amount of light they reflected. Despite being large, expensive, heavy (at around 1kg), challenging to set up and use, and only available on prescription, the technology behind this meter was a success. Marketed to doctors, but often used by people with diabetes themselves, it was the start of over 45 years of tremendous progress that led to the wide variety of small, user-friendly meters that we know today.
In the late 1970s and 1980s, the work of one scientist was absolutely the key to the creation of a new kind of sensor that is now found in virtually all of the glucose meters that are used in routine diabetes management. Professor Anthony Turner began his career in the early days of biotechnology. His specialty is in linking biochemical reactions with the electronic systems found in most modern gadgets.
In 1982, a five-year fellowship from the Diabetes UK charity helped launch Prof Turner's career in biosensors by giving him the freedom to focus on what was most important. During those five years, Prof Turner and his team at Cranfield University in Bedfordshire took their first steps to becoming one of the top biosensor laboratories in the world.
They developed a new electrochemical biosensor, which was simpler, cheaper and performed better than existing devices. In simple terms, the more glucose present in a sample of blood, the stronger the electrical signal produced by the sensor. The strength of the signal could then be interpreted to give a reading of blood glucose concentration.
This small step forward turned out to be hugely important - thereby enabling Prof Turner and his collaborators to create the first digital hand-held glucose meter, which was more sensitive, faster and required less blood. By 1987, he and his colleagues, in collaboration with the company MediSense, were able to launch a pen-sized glucose meter called ExacTech, the great-grandfather of most meters in the market today.
Despite the progress of glucose meters, tight diabetes management over the long term remains a challenging goal and is an important focus for researchers. Prof Turner said, "We've brought these devices from the size of a microwave down to the size of a pen, and now we are putting them on a piece of paper. We are working on technology that looks like a business card, but which has processors, circuits and a digital display, that can make measurements and send them to a smartphone via Bluetooth. Either you would apply a drop of blood, or wear it like a sticking plaster, it would give you a glucose reading either with numbers or with colours."
Self-monitoring of diabetes empowers people to manage their diabetes, with significant benefits to health and quality of life. It should be regarded as an integral part of treatment for everyone with diabetes.
----------------------------------------------------------------------Insulin use and type 2 diabetes
Type 2 diabetes is progressive disease. It is also a worldwide health crisis with an estimated three hundred million people expected to be living with the disease by year 2025. Most individuals with the disease experience loss of insulin production over time. Most anti-diabetic tablets used to treat Type 2 diabetes which either act by increasing insulin production or enhancing the effectiveness of the insulin in the body fail over time necessitating the addition of insulin injections to the therapy.
The most common reasons for adding insulin to the treatment regimen of an individual with Type 2 diabetes include patient's preference, pregnancy, surgery, intolerable side effects of the oral medications, hospitalization for acute illnesses and increasing blood glucose levels despite use of different oral anti-diabetes medications at maximum doses.
The initial treatment for Type 2 diabetes does not generally include insulin. The initial steps taken to control high blood sugar levels include diet, exercise, weight loss in obese individuals and oral anti-diabetic medications. Insulin can however be used early in the course of diagnosis to achieve control in individuals who are unable to achieve control with a combination of diet, exercise and oral medications.
The goals of insulin therapy include the elimination of symptoms of high blood sugar levels, maintenance of good blood sugar control, restoration of body mass in those who have lost weight, improvement in exercise capacity, reduction in incidence of infections and improvement in the sense of well being.
The appropriate insulin regime for those with diabetes requiring insulin should take into account the patient's lifestyle, age, motivation level, general health, self-management skills and goals of treatment. Prior to the commencement of insulin, the person with diabetes and their family members should be educated appropriately on the use of insulin, the recognition and treatment of hypoglycaemia.
Insulin use becomes imperative when adequate glycaemic control cannot be achieved with diet, exercise and multiple oral agents in those with Type 2 diabetes. Insulin can be used in combination with oral anti-diabetes medications or used alone. Some scientific studies have shown that treatment regimes that contain insulin and an oral medication are equivalent to or better than insulin-only regimens in some circumstances. It is known that adding metformin to individuals with poorly controlled Type 2 diabetes lowers glucose and cholesterol levels more effectively than just increasing the insulin dose alone.
Different combinations of insulin and oral medications are used to treat diabetes. A commonly used regimen is intermediate acting insulin injection given at bedtime in combination with metformin used after breakfast and after dinner. This combination is known to improve blood sugar control, cause less episodes of low blood sugar levels and less weight gain. Insulin Glargine (Lantus) can be used in the place of bedtime intermediate acting insulin and is known to cause less episodes of hypoglycaemia in the night and provides better post dinner glucose control.
Another possible combination is twice daily use of intermediate acting insulin injected in the morning and at bedtime and metformin.
Another group of oral antidiabetic agents referred to as Thiazolidinediones which are known to be insulin sensitizers in that they enhance the effectiveness in the muscles, liver and fat cells by allowing entry of glucose into them thereby lowering the level of glucose in the blood can also be used in combination with insulin. The most commonly used drug in this class in Nigeria is pioglitazone. The addition of these Thiazolidinediones to the treatment in Type 2 diabetes is known to significantly reduce the dose of insulin to be injected on a daily basis.
It is also known however that insulin only can be used in Type 2 diabetes in a similar manner to how it is used in Type 1 diabetes. The type of insulin to be used, the time it is to be used and at what doses will depend on the pattern of the fasting blood glucose levels and the post meal glucose levels.
Insulin deficiency in Type 2 diabetes is progressive and the likelihood that a patient will require insulin continues to increase as the duration of the diabetes becomes longer.
--------------------------------------------------------------------------My diabetes history
- Susanne Francis. Diabetes Forecast. May 2014.
I was born in Senftenberg, Germany in 1931.When my parents got divorced, my mother and I moved to a small town to live with my grandparents. During World War II, all trade with neighbouring food-producing countries ceased. For everybody, being chronically hungry and losing a lot of weight were common. I also had urinary frequency, and my grandmother, one day said to my mother, 'I think this girl has sugar'. Two days before Christmas 1945, my grandma took me to our family physician and her 'diagnosis' was confirmed. A serious problem was the fact that insulin was available only in limited amounts at the local hospital emergency room and intensive care unit.
I was admitted into the hospital, put on a starvation diet, and given scant instructions on how to manage without insulin at home.
There existed no local diabetes society that could have taught me how to properly care for myself and how to handle my food intake. The crops of the farmland surrounding the city consisted mostly of potatoes and sugar beets, and after the harvest we hiked there to collect scattered potato and sugar beet pieces, the latter used by my grandma to make syrup-food I was not allowed to eat.
I was at that time 5 feet and 7 inches tall and weighed just 68 pounds. My father had died in 1943, following stomach ulcer surgery and pneumonia (penicillin was not available at that time).
My mother exchanged my father's clothing on the black market for vegetables, eggs and meat.
I 'sold' my teddy bear and dolls to our milkman for his little daughter.
His payments consisted of cheese and milk. For a while, these manoeuvres helped us to survive, but I kept losing weight and feeling poorly. My uncle, the chief surgeon at the hospital, admitted me to the hospital on several occasions so that I could benefit from temporary insulin injections and a higher calorie intake.
After many attempts, my mother succeeded in locating my godfather who, shortly before the war, had left Germany for Switzerland, where he got his doctor's degree, after which he moved to Cuba.
When he heard about my predicament, he immediately contacted his friends in the United States and made arrangements for them to supply me with parcels of insulin on a regular basis. This insulin kept me alive, and I began to feel better and look like a normal teenager.
My route as a diabetic, however was still not easy. Once a month I had to get up very early before school and walk a mile to the hospital laboratory for fasting blood glucose tests. Glucometers and test strips for glucose testing at home were not yet available, and the glass syringe and giant needle I used had to be boiled after each injection in order to sterilize them.
In June 1948, insulin became available in pharmacies and so did healthy food in stores.
Unfortunately, there was still no local diabetes society to teach proper carbohydrate counting and blood glucose control, nor was there any literature. I will never forget an extended school outing when I experienced my first episode of hypoglycaemia, fainted, and had to be rushed to the hospital.
Somehow, I managed to do fairly well. I decided to visit United States and work there for a year. In May 1961, I arrived in San Francisco, met my husband-to-be in 1962, and the one year visit has become a 53-year stay! I worked until retirement in the newly established Internal Medicine Residency Program at Kaiser Permanente where I learned a great deal. I benefited from the up-to-date medical information always available to me.
In 1997, my kidney values became slightly abnormal, and my physician suggested I switched to insulin pump to improve my blood sugar control.
To facilitate my blood glucose management, I designed a personal daily log sheet for blood glucose results, basal rates, boluses, infusion set changes, exercises and ketones.
I am now 82 years old, have learned a lot about diabetes care, and hope that I will be able to remain in control.
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TYPE-1 DIABETES: QUEST FOR A CURE
- Culled from Diabetes Update for Healthcare Professionals. Summer 2015. Colin Dayan.
Type-1 diabetes is caused by the immune system damaging the insulin producing cells of the body. It is not known why this self destructive process happens, but the evidence points to a combination of being born with slight changes in many immune system genes that make this kind of reaction more likely, with some events in the first year or two of life that trigger this reaction. It then takes many months or years for the damage to the insulin cells to happen – in some people 20 years or more. Laboratory tests can detect that this process is happening and, in many cases, predict who will detect Type 1 diabetes by measuring blood levels of antibodies to the insulin making cells.
A treatment that could slow, or even halt, this self-destructive process could delay the age at which diabetes is diagnosed. Being diagnosed at age 20 or 25, rather than 5 or 10 years old, would certainly have significant advantages, for the person who would not have to live for so many years with diabetes and the possibility of health complications.
Over the last 20 years, a vast array of new drugs that treat the immune system have been developed and been proved effective in diseases such as rheumatoid arthritis, inflammatory bowel disease among others. The question remains, why does similar immune therapies ineffective in Type 1 diabetes? The answer is that drugs that affect the immune system often also carry an increased risk of infections and possible long-term increased risk of cancer.
As it is well known, many people with Type 1 diabetes live very full lives on insulin treatment for 50 or more years, hence any new treatment must prove itself to be better than insulin. This is especially true of any treatment that might be given to patients in the early stages before they actually develop diabetes.
Some progress has already been made in developing immunotherapy for Type 1 diabetes. In the 1980s, it was shown that drugs used for kidney transplants – such as cyclosporine – could slow the loss of insulin production by the body, including in children. However, side effects, such as vulnerability to infection and reduced kidney function, meant that all the children came off the treatment within five years and the benefit was lost.
Since then, over 20 newer treatments have been tried and at least four of these have shown some beneficial effect in preserving insulin production. These include the new antibody treatments: anti-CD3, rituximab among others. Although these drugs are used routinely in other conditions, concerns about safety compared with insulin and a diminution of their therapeutic effect over time have delayed their introduction into routine clinical care. Lower doses have been tried to avoid side effects, with some negative results being reported in the last few years, which has inevitably led to disappointment.
Is effective immunotherapy for Type 1 diabetes really possible? Experience does suggest that where sufficient resources are well targeted, remarkable results can be achieved. For instance, treatment of acute leukaemia and other childhood cancers and HIV/AIDS have been transformed in recent years from universally fatal diseases into long-term manageable, or even curable, conditions. In fact, new cases of acute leukaemia in children are rarer than new cases of Type 1 diabetes. More than 80 per cent of children with this once fatal acute leukaemia can now expect to be cured subsequent to a lot of research carried out on the disease.
A major focus of Type 1 diabetes immunotherapy research is the 'honeymoon period' experienced by those newly diagnosed with the condition. Controlling blood glucose in Type 1 diabetes is not easy. Although there have been major advances in blood testing and insulin delivery technology, it still requires a lot of effort and dedication to achieve tight control of blood glucose levels. How can we make it easier?
In the first few months after diagnosis, many people with Type 1 diagnosis find that blood glucose control is not so difficult and manage to obtain their blood glucose targets then, than later after diagnosis. This is because most still have their own insulin secreting ability intact. This period, soon after diagnosis has been referred to as 'honeymoon period'.
In diabetes immunotherapy research, a major goal is to make the honeymoon last longer, both by understanding it better and targeting patients for treatment when they are still in this state.
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Combination therapy in diabetes
Type 2 diabetes is a long term and mostly lifelong disorder characterized by resistance to insulin action in the liver, the muscles and the fat cells in the body. It is also characterized by progressive reduction in the ability of the body to produce insulin, abnormalities of intestinal functioning, satiety and weight control. These abnormalities lead to elevated blood sugar levels, obesity, cholesterol abnormalities, hypertension, heart and blood vessels abnormalities and damage to the kidneys, the nerves and the retina of the eyes.
As a result of its multi-factorial causation, control is often difficult to achieve and oftentimes requires the use of multiple medications that have different mechanisms of action and will thus produce synergistic effects. Long-term use of a single medication to control blood sugar levels will thus ultimately end in failure. Most professional societies involved in diabetes care have thus emphasized the need for systematic and progressive use of combinations of various types of blood sugar lowering medications.
Metformin is often the preferred first line medication. As the disease progresses however, it will be necessary to combine it with additional medications. It is also known that a time will come when combination of oral medications will also no longer be able to keep the blood sugar levels at bay, at such times one or more injections will be required. The choice of combination therapy to be undertaken will need to take cognizance of factors such as duration of the disease, complications that are present, life expectancy, risk of hypoglycaemia, the patient's personal preferences and capacity for self-care, social support and financial capabilities.
In Type 2 diabetes, there is often concurrent insulin deficiency and insulin resistance. The progressive nature of the disease leads to loss of efficacy of single drugs used in therapy within three years of use. Hence, early use of combination therapy which should include an agent that enhances insulin availability (insulin or sulfonylurea) with one that enhances insulin sensitivity in the target tissues (metformin or pioglitazone) will be advised. Metformin acts primarily by improving the sensitivity of the liver to effects of insulin while pioglitazone acts principally by increasing the responsiveness of the muscles and fat cells to insulin. Hence, combined use of Metformin and Pioglitazone has additive effects.
One of the advantages inherent in the use of combination therapy is that the side effects of each drug become minimized as smaller dosages of each drug are then required. Hence, blood sugar control is improved while side effects are minimized. For example, the maximum daily dose of Metformin is usually 2, 000 mg at which dose significant side effects occur in the intestines. When the dose is lowered to 1, 000mg per day, about 70% of its blood sugar lowering effects will still occur but with significant reduction in the abdominal discomfort, diarrhoea, nausea and vomiting associated with the higher dosage. Hence, use of sub-maximal doses of two drugs can achieve not only a greater reduction in blood sugar levels but also experience of fewer side effects.
Oral agents can also be combined with injections such as insulin.
The continued use of Metformin when insulin is started is quite desirable as lower doses will then be required thus reducing the episodes of hypoglycaemia. Additionally, the concurrent use of insulin and Metformin reduces significantly the weight gain that will have been associated with the use of insulin alone. Beyond improving blood sugar levels, use of combination therapy can assist in other areas. The ability of Metformin to limit weight gain is well recognized.
Combination of Metformin with Glibenclamide (Daonil) or Glimepiride (Amaryl) or with Pioglitazone (Actos) is commonly used. So also is the combination of Metformin with the relatively newer DPP-IV Inhibitors (Vildagliptin, sitagliptin).
To attain the goal of good blood sugar control, the effectiveness of treatment can be optimized by the use of combination therapy.
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Four steps to manage your diabetes for life
Culled from National Diabetes Education Program www.YourDiabetesInfo.org
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Combination therapy in diabetes
Type 2 diabetes is a long term and mostly lifelong disorder characterized by resistance to insulin action in the liver, the muscles and the fat cells in the body. It is also characterized by progressive reduction in the ability of the body to produce insulin, abnormalities of intestinal functioning, satiety and weight control. These abnormalities lead to elevated blood sugar levels, obesity, cholesterol abnormalities, hypertension, heart and blood vessels abnormalities and damage to the kidneys, the nerves and the retina of the eyes.
As a result of its multi-factorial causation, control is often difficult to achieve and oftentimes requires the use of multiple medications that have different mechanisms of action and will thus produce synergistic effects. Long-term use of a single medication to control blood sugar levels will thus ultimately end in failure. Most professional societies involved in diabetes care have thus emphasized the need for systematic and progressive use of combinations of various types of blood sugar lowering medications.
Metformin is often the preferred first line medication. As the disease progresses however, it will be necessary to combine it with additional medications. It is also known that a time will come when combination of oral medications will also no longer be able to keep the blood sugar levels at bay, at such times one or more injections will be required. The choice of combination therapy to be undertaken will need to take cognizance of factors such as duration of the disease, complications that are present, life expectancy, risk of hypoglycaemia, the patient's personal preferences and capacity for self-care, social support and financial capabilities.
In Type 2 diabetes, there is often concurrent insulin deficiency and insulin resistance. The progressive nature of the disease leads to loss of efficacy of single drugs used in therapy within three years of use. Hence, early use of combination therapy which should include an agent that enhances insulin availability (insulin or sulfonylurea) with one that enhances insulin sensitivity in the target tissues (metformin or pioglitazone) will be advised. Metformin acts primarily by improving the sensitivity of the liver to effects of insulin while pioglitazone acts principally by increasing the responsiveness of the muscles and fat cells to insulin. Hence, combined use of Metformin and Pioglitazone has additive effects.
One of the advantages inherent in the use of combination therapy is that the side effects of each drug become minimized as smaller dosages of each drug are then required. Hence, blood sugar control is improved while side effects are minimized. For example, the maximum daily dose of Metformin is usually 2, 000 mg at which dose significant side effects occur in the intestines. When the dose is lowered to 1, 000mg per day, about 70% of its blood sugar lowering effects will still occur but with significant reduction in the abdominal discomfort, diarrhoea, nausea and vomiting associated with the higher dosage. Hence, use of sub-maximal doses of two drugs can achieve not only a greater reduction in blood sugar levels but also experience of fewer side effects.
Oral agents can also be combined with injections such as insulin.
The continued use of Metformin when insulin is started is quite desirable as lower doses will then be required thus reducing the episodes of hypoglycaemia. Additionally, the concurrent use of insulin and Metformin reduces significantly the weight gain that will have been associated with the use of insulin alone. Beyond improving blood sugar levels, use of combination therapy can assist in other areas. The ability of Metformin to limit weight gain is well recognized.
Combination of Metformin with Glibenclamide (Daonil) or Glimepiride (Amaryl) or with Pioglitazone (Actos) is commonly used. So also is the combination of Metformin with the relatively newer DPP-IV Inhibitors (Vildagliptin, sitagliptin).
To attain the goal of good blood sugar control, the effectiveness of treatment can be optimized by the use of combination therapy.
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Four steps to manage your diabetes for life
Culled from National Diabetes Education Program www.YourDiabetesInfo.org
STEP 1: Learn about diabetes. There are three main types of diabetes:
Type 1 diabetes- Your body does not make insulin. This is a problem because you need insulin to take the sugar from the foods you eat and turn it into energy for your body. You need to take insulin every day to live.
Type 2 diabetes- Your body does not make or use insulin well. You may need to take pills or insulin to help control your diabetes. Type 2 is the most common type of diabetes.
Gestational diabetes- Some women get this kind of diabetes when they are pregnant. Most of the time, it goes away after the baby is born. But even if it goes away, these women and their children have a greater chance of getting diabetes later in life.
You are the most important member of your health care team. You are the one who manages your diabetes day by day. Take diabetes seriously. You may have heard people say they have "a touch of diabetes" or that their "sugar is a little high." These words suggest that diabetes is not a serious disease. That is not correct. Diabetes is serious, but you can learn to manage it.
STEP 2: Know your diabetes ABCs. Talk to your health care team about how to manage your A1C, Blood pressure, and Cholesterol. This can help lower your chances of having a heart attack, stroke, or other diabetes problems. The A1C is a blood test that measures your average blood sugar level over the past three months. It is different from the blood sugar checks you do each day. The A1C goal for many people with diabetes is below 7. It may be different for you. Ask what your goal should be.
If your blood pressure gets too high, it makes your heart work too hard. It can cause a heart attack, stroke, and damage your kidneys and eyes. The blood pressure goal for most people with diabetes is below 140/90. It may be different for you. Ask what your goal should be.
There are two kinds of cholesterol in your blood: LDL and HDL. LDL or "bad" cholesterol can build up and clog your blood vessels. It can cause a heart attack or stroke. HDL or "good" cholesterol helps remove the "bad" cholesterol from your blood vessels. Ask what your cholesterol numbers should be. Your goals may be different from other people.
STEP 3: Learn how to live with diabetes. It is common to feel overwhelmed, sad, or angry when you are
living with diabetes. You may know the steps you should take to stay healthy, but have trouble sticking with your plan over time. Stress can raise your blood sugar. Learn ways to lower your stress. Ask for help if you feel down. A mental health counselor, support group, member of the clergy, friend, or family member who will listen to your concerns may help you feel better.
Eat well. Make a diabetes meal plan with help from your health care team. Choose foods that are lower in calories, saturated fat, trans fat, sugar, and salt. Eat foods with more fiber, such as whole grain cereals, breads, crackers, rice, or pasta. Choose foods such as fruits, vegetables, whole grains, bread and cereals, and low-fat or skim milk and cheese. Drink water instead of juice and regular soda.
STEP 4: Get routine care to stay healthy. See your health care team at least twice a year to find and
treat any problems early .At each visit, be sure you have a: blood pressure check, foot check, weight check, review of your self-care plan. Two times each year, have an: A1C test. It may be checked more often if it is over 7. Once each year, be sure you have a:cholesterol test, complete foot exam, dental exam to check teeth and gums, dilated eye exam to check for eye problems, flu shot, urine and a blood test to check for kidney problems At least once in your lifetime, get a: pneumonia hepatitis immunization.
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