Diabetes 2002: Dr. Grimshaw’s Guide, Part II


Checking Your Sugars:
‚    Who Should? Anyone on a medicine (pills or  insulin) that lowers blood sugar, and anyone who is having trouble controlling their sugar, even if only on diet.
‚    How to do it: we suggest the Freestyle by Therasense. It’s easy to care for, “dry”and much less painful than most others. We suggest checking in the am day 1, 2 hours after breakfast day 2, 2 hrs after lunch day 3, 2 hrs after supper day 4.
‚    What’s Coming?  

The GlucoWatch is due to be approved soon by the FDA; you strap it to your wrist, and it tells your blood sugar with a remark-able degree of accuracy for 12 hours.  The FDA and the manufacturer, Cygnus, say that decisions on insulin shots should still be double checked with a blood meter.  The cost may be $300 for the hardware and $4 for each sensor pad (good for 12 hours); & it tells time!

Treatment:
‚    Diet: Still remains the cornerstone.  We’ve come a long way from the “strict” diet developed by Dr. Eliot Joslin when he attended my father.  You can have a lot of different foods, just “sensibly” -- in modest portions.
‚    Exercise: Again, extremely important. Most type 1 (insulin) and type 2 (non-insulin) patients do much better with regular exercise, especially after meals.

Medication:
Insulin Sensitizers:
‚    Metformin (Glucophage) works by making your insulin work better for you, especially in your liver.  It can’t be used by everyone, particularly if there are significant kidney or liver problems.  Dose is 500- 2000 mg per day. The big advantage is no low blood sugars.
‚    Rosiglitazone (Avandia) makes your insulin work better in your muscles.  It’s not for people with liver problems, and requires regular liver checks. It can be used 1st line or with other medications . It does not cause low blood sugars.
‚    Pioglitazone (Actos) is another in the Avandia class, and also can be combined with other agents or used 1st line.  Again, it does not cause low sugars

Sulfonylureas: force the pancreas to secrete extra insulin and may normalize liver glucose production. They all work with metformin.
‚    Chlorpropamide (Diabinese) is the longest acting and oldest.  We don’t use it much due to the risks of low blood sugar; it lasts 3 days.
‚    Tolazamide (Tolinase), also older, lasts about 18 hours.
‚    Glyburide (Glynase, Diabeta, Micronase) lasts 24 hours.
‚    Glipizide (Glucotrol): 12-18 hours.

•   Glucovance is a combination
of metformin and glipizide and lasts about 12 hours.
‚    Glimepiride (Amaryl): lasts
about 24 hours.

Meglitinides: also stimulate insulin release from the pancreas.
‚    Repaglinide (Prandin)
is taken right before a meal (0-30 minutes); dose is 0.5-4mg 2-4 times daily.  The drug can be combined with metformin.
‚    Neteglinide (Starlix)is similar to Prandin and can also be combined with metformin


Glucosidase Inhibitors: These work by inhibiting sugar absorption.  Side effects are bloating, gas and diarrhea from the non-digested food.

‚    Acarbose (Precose) is taken at 1st bite.  
‚    Miglitol (Glyset) is similar.

Insulins: were originally of animal origin; now most in use are made by recombinant DNA methods.

 
‚    Insulin Glargine (Lantus) provides essentially 24 hour "peakless" insulin levels.
‚    Insulin Aspart (NovoLog) is the fastest “bolus” insulin to date, with a peak at 20 minutes and a duration of 3 hours..
‚    Lispro (Humalog) has an onset of action in 15 minutes, and a peak at 30-90 minutes, lasting 5 hours.
‚    Regular has onset at 1/2-1 hr, peaks at 2-3 hrs, lasts 4-6 hrs.
‚    NPH has onset at 2-4 hrs,  peak at 4-10 hrs, lasts 14-18 hrs.
‚    Lente has onset at 3-4 hrs, peaks at 4-12 hrs, lasts 16-20 hrs.
‚    Ultralente has onset at 6-10 hrs, no peak and lasts 20-30 hrs.

What’s Coming:
‚    Inhaled insulin will mimic Aspart, peak in 60 minutes, with an effect like lispro.


March 2002  Robert S. Grimshaw, Jr
MD FACP.  All Rights Reserved.