Lee Chung Horn
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  DIABETES MELLITUS

 

ORAL DIABETES MEDICATIONS

People with type 1 diabetes don't make insulin. For them, insulin injections are the only way to keep blood sugar levels down. People with type 2 diabetes tend to have two problems. They don't make quite enough insulin, and the cells of their bodies don't seem to take in glucose as eagerly as they should. Diabetes pills work in different ways to lower blood sugar.

The first class of drugs stimulates the beta cells in your pancreas to release more insulin.

1. Sulfonylurea drugs have been in use since the 1950s. Chlorpropamide and tolbutamide are examples of two first-generation sulfonylurea still in use today. The second generation sulfonylureas are used in smaller doses than the first-generation drugs. There are three second-generation drugs: glipizide, glibenclamide and glicazide. Glimepiride is another new sulphonylurea drug.  These drugs are generally taken one to two times a day, before meals. All sulfonylurea drugs have similar effects on blood sugar levels, but they differ in side effects, how often they are taken, and interactions with other drugs. Their side effects are not dangerous.

2. Repaglinide is presently the only meglitinide. It is taken before each of three meals. It is also called Novonorm. It stimulates the pancreas and causes it to release insulin at the time of your meal. You should take note that alcohol and some diabetes pills may not mix. On rare ocasions, chlorpropamide, and more rarely other sulfonylureas, can interact with alcohol to cause some vomiting and flushing--or even to make you very dizzy. Ask your doctor if you are concerned about this effect. Starlix is another new agent that works in a similar fashion to repaglinide.

The second class of diabetes drugs sensitizes the body to the insulin that is already present. 

1. Metformin is a biguanide. It lowers blood sugar by helping insulin work better, mostly in the liver. It is usually taken two to three times a day. A side effect of metformin may be diarrhea and mild tummy upset, but this is improved when the drug is taken with food.

 2. The glitazones, rosiglitazone and pioglitazone form a group of drugs called thiazolidinediones. They help insulin work better in the muscle and fat. Glitazones are taken once or twice a day with food. Up-to-date research now shown these drugs to be safe, although they must be used with care in patients with pre-existent heart disease. 

The third class of oral drugs slows or blocks the breakdown of starches and certain sugars. Acarbose and miglitol are alpha-glucosidase inhibitors. They help the body to lower blood sugar by blocking the breakdown of starches, such as bread, potatoes, and pasta. They also slow the breakdown of some sugars, such as table sugar. Their action slows the rise in blood sugar levels after a meal. They should be taken with the first bite of a meal. These drugs may have side effects, including gas and diarrhea.

A new group of anti-diabetes called DPP4-inhibitors has recently been introduced. Sitagliptin (Januvia) and vildagliptin (Galvus) increase insulin effect after eating a meal, thereby lowering blood glucose.

Oral Combination Therapy

Because the drugs listed above act in different ways to lower blood sugar, they are often used together. For example, a biguanide and a sulfonylurea may be used together. Many combinations can be used. Switching to another pill is usually less effective than adding another type of diabetes medicine. It is safe to combine different classes of pills, and your doctor will know how to do this. 

Can Diabetes Pills Help Me?

Remember only people with type 2 diabetes can use pills for their diabetes. Pills do not work for type 1 diabetes patients. These pills work best when used with meal planning and exercise. This way you have three therapies working together to lower your blood sugar. 

Diabetes pills don't work for everyone. Although most people find that their blood sugar levels go down when they begin taking pills, their blood sugar may not go near the normal range.

What are the chances that diabetes pills will work for you? Your chances are lower if you have had diabetes for more than 10 years or already take more than 20 units of insulin each day. On the other hand, your chances are good if you developed diabetes recently or have needed little or no insulin to keep your blood sugar near normal.

You should also know that diabetes pills sometimes stop working after a number of years. The cause is often unknown. This doesn't mean your diabetes is worse. Switching to another pill doesn't work as well as adding another type of diabetes medicine.  

Even if diabetes pills do bring your blood sugar near the normal range, you may still need to take insulin if you have a severe infection or need surgery. Pills may not be able to control blood sugar during these stressful times, when blood sugar levels shoot up.

Also, if you plan to become pregnant, you will need to switch to insulin until the baby is born. It is not safe to take oral pills during pregnancy.

There is no "best" pill or treatment for type 2 diabetes. You may need to try more than one type of pill, combination of pills, or pills plus insulin.

What About Insulin?

Although it is a common practice to try pills before insulin, you may start on insulin, based on several factors. These factors include:

               how long you have had diabetes

              how high your blood sugar level is

              what other medicines you take

              your overall health

 Because diabetes pills seem to help the body use insulin better, some people take them along with insulin shots. The idea behind this "combination" therapy is to try to help insulin work better.

Many patients are fearful that taking diabetes pills for a long stretch is dangerous and would harm their liver or kidney. This is a myth and is absolutely not true. Sadly, often times, this wrong notion causes patients to skip or stop pills, and the resultant poor control creates problems or complications.


 

Copyright of Lee Chung Horn Diabetes & Endocrinology 2009