Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
 3 May 2006

            DIABETES MELLITUS – II:  THERAPEUTIC OPTIONS

            Last week’s column was devoted to a discussion of the cause and consequences of diabetes mellitus.  This week’s column will be devoted to treatment options.

            First, to address type I diabetes in which the young individual lacks insulin secretory capability, we have only one effective treatment and that is insulin replacement.  There are now a number of different insulin programs available.  A new type of insulin that can be inhaled as a nasal spray is available.  Experience with this product is new but it does avoid the need for insulin injections and certainly has an aesthetic appeal for that reason.

            As mentioned previously, 90% of the diabetes in our country that have the so-called type II diabetes mellitus, they have much more insulin than a normal individual.  While type II diabetics have much more insulin than normal, their insulin just doesn’t seem to work because of “insulin resistance”.

            Since diabetes is defined as the blood sugar being too high, one can conceptualize two strategies on how to treat the problem.  One could either decrease the rate at which glucose is presented to the blood,or increase the rate at which glucose is taken out of the blood.  That seems simple enough.

            There are two basic ways to decrease glucose into the blood.  The first of these is to eat less and have fewer calories presented to our blood streams as sugar.  Increasing protein and fat in our diet slows the rate at which sugar is released into the blood and increasing carbohydrates and sweets increases the rate at which sugar is released into the blood.  Getting on a low carbohydrate diet is one way to lower blood sugars.  There are also medications called Precose and Glyset, which slow the rate at which sugar is absorbed from the gut.  These pills require a person to take them with meals.  They are relatively expensive and they have little impact on diabetic control.  They may work for some individuals but, as a rule, are not very effective.

            The second way to slow sugar release into the blood is to use a medication called metformin.  This is now a generic product on the market with a cost of about 50 cents per day.  Metformin also seems to make the person a little more sensitive to the insulin that they already have.  Lastly, and perhaps most importantly, metformin does seem to inhibit appetite and contribute to weight loss.  This medication is the backbone for the treatment of a condition called polycystic ovary syndrome of which diabetes is an intrinsic part.

            The second broad strategy to treat diabetes is to increase the rate at which glucose is taken out of the blood stream, therefore lowering the blood sugar.  Exercise is the most effective activity we know for lowering blood sugar.  A diabetic that has checked their blood sugar before and after a long walk will see a drop in sugars of between 30 and 40 mg% or even more.  Using your muscles burns sugar and makes the person more sensitive to the insulin that they already have.

            A second strategy for treating insulin resistance is a medication directed to that purpose alone.  Several years ago, a family of drugs called TZD’s came on the market.  These were called Avandia (rosiglitazone) and Actos (pioglitazone).  Because of the research that went into developing these two drugs, they are terribly expensive costing about $5.00 a day to take.  They have been shown to be very effective in lowering the rate of heart attack and improving the person’s sensitivity to the insulin that they already have.

            The last strategy to make sugar get out of the blood faster is to increase insulin in the blood.  The first and most obvious treatment in this class would be insulin injections.  As a group, diabetics are very resistant to starting insulin injection treatment although they seem to adapt to it very quickly once they make the decision.

            The second strategy to increase insulin in the blood, thereby decreasing blood sugars, is to use a pill which makes the pancreas secrete more insulin.  This type of strategy is effective in lowering blood sugars but has an intrinsic flaw in my estimation.  Specifically, these pills make a pancreas that is already working very hard work even harder, and to me, it just makes sense that you are going to wear it out quicker.  Not all doctors agree with this analysis but I am not a champion of using products such as glipizide (Glucotrol), glyburide (DiaBeta, Micronase), or glimepiride (Amaryl).  This family of drugs has also become dangerous when the person develops kidney failure because very low blood sugars can become a major problem.

            Next week, I will describe a new medication, which while very expensive and injectable, seems to have great promise in preserving the insulin-secretory capacity, contributing to weight loss, and better controlling blood sugars.