Diabetes Basics.

Management and treatment

How is diabetes basics treated?

The treatment of diabetes is usually a complex program involving a specific diet, a specific exercise prescription, and medication(s). These treatments are most effective when carried out with a team of health care providers knowledgeable in the care of people with diabetes. As opposed to high blood pressure, asthma, and even high cholesterol, with diabetes, self-management is the fundamental key to success. Many other conditions can result in good outcomes by taking a medication at the appropriate times. With diabetes, so much more is required since everything from stress, depression, food, exercise, other illness, and a host of other factors effect blood glucose levels. Learning about all of these factors and knowing what to do when blood glucose levels are above or below target can take quite a bit of time. The rewards, however, are great.

Patients who do best are those who measure their blood glucose frequently, pay attention to which factors affect blood sugar, and try to avoid anything that causes a disruption in diabetes control in the future. No one is always successful in keeping blood glucose in the "normal" range, and it must always be remembered that there is no such thing as being "perfect" if you have diabetes. Fluctuations in blood glucose will occur no matter how careful you are.

What can the patient do to treat or manage diabetes basics?

What health care professionals may help treat or manage diabetes basics?

Ideally, it would be best if an entire team of health care professionals were available for everyone with diabetes. This is not always possible but at the very least, all of these people should be available for consultation if needed. These team members include:

1. Physician: Often an endocrinologist but may be a general internist or family practice physician. In the U.S. endocrinologists see a very small number of the adults with diabetes due to the small number of specialists and large number of patients with diabetes.
2. Nurse Specialist: Usually a registered nurse with special expertise in diabetes care. All providers, but especially nurses and nutritionists, may be certified in diabetes education (CDE). A CDE ensures you are receiving up-to-date information about diabetes care and education.
3. Nutritionist: In the opinion of many, the most important person on the team. A nutritionist with a CDE is an expert about the two most important factors of blood glucose control: food and medications. Current nutrition therapy has become quite sophisticated but outstanding nutritionists can simplify the information, especially for those learning how to match food with insulin.
4. Mental Health Professionals: Both psychologists (using mostly counseling techniques) and psychiatrists (doctors who can also prescribe drugs) should be available as any mental health disorder can affect diabetes control.
5. Pharmacist: Due to the complexity of medications with diabetes, the pharmacist has become a critical member of the team.
6. Podiatrist: A doctor with special expertise in disorders of the feet, common for people with diabetes.

How are pain and fatigue caused by diabetes basics managed?

If controlled well, diabetes will not cause pain or fatigue. Poorly controlled diabetes will result in these symptoms and will resolve with proper treatment. For patients with type 2 diabetes fatigue will often improve if insulin is started and blood glucose improves.

For most people, these symptoms mean another problem is present. For those with type 1 diabetes the most common condition is hypothyroidism. It is estimated that 10-20% of people with type 1 diabetes develop some type of thyroid problem.

Can exercise, therapy, rest, posture, or stretching help treat diabetes basics?

Exercise is a key component of a treatment plan for anyone with diabetes. For those with type 2 diabetes, exercise improves insulin's effect on the muscle and will result in blood glucose lowering. For many newly diagnosed individuals, a regular exercise program with proper diet can result in the need for no further therapy. However, if your HbA1c remains above 7%, diet and exercise alone will not be sufficient.

For those on insulin, especially those with type 1 diabetes, exercise needs to be planned to prevent problems with hypoglycemia. Exercise will result in a lowering of blood glucose and either additional carbohydrate or less insulin will be required. More frequent home blood glucose monitoring may be required. This is a large topic beyond the scope of this essay and should be discussed in detail with your healthcare team.

What medications are used to treat or manage diabetes basics?

For type 2 diabetes there are 4 classes of medications:

1. Insulin secretagogues (for example, glyburide, glipizide, repaglinide, glimiperide to name a few)--These agents increase stimulate the pancreas to make more insulin.
2. Biguanides--There is only one available, metformin. This drug makes the liver more sensitive to insulin. It lowers HbA1c levels 1.5-2%, similar to that of insulin secretagugues.
3. Alpha-glucosidase inhibitors (acarbose and miglitol)--These drugs slow down the absorption of carbohydrate.
4. Thiazolidinediones (also called "glitazones") (pioglitazone, rosiglitazone)--These drugs result in insulin becoming more sensitive at the muscle.

Insulin is used for both type 1 and type 2 diabetes. Insulin can be classified as basal (or background) insulin, or mealtime (or prandial) insulin. In general, the basal insulins are the long-acting and intermediate-acting insulins, and the mealtime insulins are the short-acting and rapid-acting insulins.

Long acting:

1. Glargine: no peak, lasts 24 hours
2. Ultralente: broad peak, 10-16 hours, lasts 20-24 hours

Intermediate acting:

1. NPH: peaks 5-8 hours, lasts 12-16 hours
2. Lente: similar to NPH

Short-acting

1. Regular: peaks 2-3 hours, lasts 6-8 hours

Rapid-acting

1. Lispro: peaks 1 hour, lasts 4-5 hours
2. Aspart: peaks 1 hour, lasts 4-5 hours

Can surgery help treat diabetes basics?

People with diabetes have more frequent surgery than those without. However, only rarely do we use surgery to actually TREAT diabetes. This occurs with either a kidney-pancreas transplant, or more rarely, a pancreas transplant by itself. Pancreas transplants are only done for those with type 1 diabetes. For those who do not need a kidney transplant, pancreas transplants may be considered if frequent, life-threatening hypoglycemia is occurring. In the near future we hope that islet cell transplants will become available. Islets are the tiny cells in the pancreas that make insulin.

What are the social impacts of management and treatment programs for diabetes basics?

What kind of ongoing care or monitoring is necessary for diabetes basics?

Ongoing monitoring can be divided into two major categories.

First, monitoring for the diabetes itself needs to be considered. Although this is usually done with two major mechanisms, there other important tests are occasionally needed. Home blood glucose monitoring is the standard for assessing diabetes control at home. Although there is still controversy as to how often someone with type 2 diabetes who does not take insulin should measure their blood glucose, all patients who take insulin should monitor on a regular basis, both to assess any patterns in glucose levels, but also to make changes at the time if the glucose level is too high or too low.

The other way diabetes is monitored is with HbA1c described above. This test allows both patients and their physicians to assess overall blood glucose control during the past 3 months. The goal for the majority of people should be a HbA1c below 7%, which would be an average blood glucose level of 150 mg/dL.

Monitoring also needs to include assessment of complications. Current recommendations include:

1. a yearly dilated eye exam to exam the retina,
2. a yearly test for kidney disease with protein (or microalbumin) from a urine test,
3. a yearly lipid panel with the primary goal to maintain LDL cholesterol below 100 mg/dL
4. at least a yearly comprehensive foot exam to assess risks for foot ulcer, and
5. regular blood pressure measurements with a goal to maintain a blood pressure below 130/80.

What are common misconceptions about remedies and treatments for diabetes basics?

There are numerous misconceptions about treatments for diabetes, but the most common ones involve insulin therapy.

First, some people think that starting insulin therapy will lead to blindness or some other major problem. The thinking here occurs often due to the fact a relative or friend had a similar problem just after starting insulin. In truth, insulin has been shown to PREVENT these problems and there is no cause and effect relationship between the timing of insulin therapy and the start of a complication.

The other problem is that many people feel they can avoid insulin if they "behave" and are careful with the diet. The reality is that over time, insulin secretion normally diminishes so that no matter what is done with pills, diet, and exercise, the only way to maintain the goal of a HbA1c of less than 7% will be with insulin therapy. Insulin is not dangerous if used correctly. Furthermore, the vast majority of patients don't complain about insulin use once they start. A more common complaint regards the finger pokes for home glucose monitoring.

It needs to be emphasized: the goal of therapy is to bring the blood glucose levels down to the target range. Having the primary goal of avoiding insulin will eventually lead to a poor outcome.

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