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9
DOSING DIABETES
Medicines and Other Treatments
I don’t remember how most of the old song goes, but just a few words come to my mind: “…and forever is a long, long time.”
And that’s how it is with diabetes—once you have it, it’s going to be with you for a long, long time. For the rest of your life, in fact. There are some sicknesses—like a cold, or measles, or chickenpox—that most people recover from automatically after a certain number of days. There are others, like some types of cancer, for which medical science has discovered ways to give you at least some hope of cure. But not so with diabetes. Not yet, at least.
Doctors have been researching and experimenting with various kinds of treatments, including the very expensive (US$35,000-40,000 or more) pancreas transplant. The transplant is usually performed on a patient with kidney failure who must also have a kidney transplant. So far, there is still a high risk of the body’s rejecting the new pancreas, and a patient who has received transplanted organs must take antirejection medicines for the rest of his life.
Researchers in several countries have been experimenting with pancreas cell transplants. In this type of operation, they would transplant only the insulin-producing islet cells, or beta cells, of the pancreas. They hope that these cells would then produce some insulin in the diabetic’s own body. Experiments on human patients have only recently begun, and it may be several years before we know whether or not this will be a successful form of treatment for insulin-dependent diabetes.
For now, the best treatment that medical science can offer is a combination of medicines and good lifestyle. Well, actually that isn’t quite 100 percent true. It is the best that some doctors offer. But more and more doctors today are helping a good percentage of their patients to get away from diabetes medicines.
It is not possible for all diabetics to leave off taking insulin or other diabetes medications, but many can. Maybe as many as half, or even more.
In the next few chapters, we’ll be looking at lifestyle habits such as food and exercise. Most doctors picture living with diabetes as a delicate balance of three major factors, as shown in the triangle in the picture above:
More and more diabetics are learning how to balance exercise and proper diet in such a way that the medicines can become a smaller and smaller part of the picture. Or fade out of the picture entirely in many cases.
Already about 40 percent of the people with type II diabetes control the disease simply by controlling their diet. But the number could be much higher. How? We will go into more details on diet and exercise in later chapters, but for now, just a simple explanation:
*Regular exercise helps the body to use its insulin more efficiently. If your body still does make some insulin but not quite enough, as in type II diabetes, good regular exercise can help that limited amount of insulin to s-t-r-e-t-c-h much farther. Remember, however, the diet must be consistent every day.
*A high-fat diet and overweight or obesity are major causes of type II diabetes, making the body’s insulin less effective. So, reducing the amount of fat in the diet and on the body can greatly help to reduce the problem of diabetes.
*A high-fiber diet is one of the latest discoveries of effective diabetes treatments. Foods with plenty of natural fiber help to regulate the amount of fats and sugars going into the bloodstream.
More about these and other aspects of lifestyle later. But for now, let’s take a look at diabetes medicines and monitoring of diabetes control.
Medicines for Diabetes
As just mentioned, a large number of diabetics can get along without any medicines if they are careful with their diet and exercise. These are type II diabetics whose beta cells are still producing a limited amount of insulin. If they are careful with their lifestyle, they can get by with the insulin they have.
Other type II diabetics also have some insulin still being made by their beta cells, but it just isn’t enough. So they have to take pills regularly in order to maintain control of the diabetes. These pills, called oval hypoglycemic agents, are not insulin, and so they are not useful in type I (insulin-dependent) diabetes.
Also, these medicines are not a substitute for good lifestyle habits—for good diet and exercise. The medicines should be used in addition to diet and exercise, making up for what lifestyle is unable to accomplish.
Oral Medicines
There are several types of oral hypoglycemic medicines available today. Each one has its advantages and its disadvantages, so the doctor will need to prescribe the kind most appropriate for the individual patient’s lifestyle, physical condition and personal needs.
There are two different “families” of medicines, each having a different type of action on the body. Several of the common medicines belong to the sulfonylurea group. They act by stimulating the pancreas to produce more insulin and by helping the body use the available insulin better. The other type of oral hypoglycemic medicines are the biguanides. They work by reducing the absorption of glucose from the bowel and increasing the passage of glucose from the blood into the cells. Because the sulfonylureas and the biguanides work in different ways, doctors sometimes prescribe a combination of the two.
Let’s look briefly at some of the more common medicines and their effects. They are listed first by their generic (“family”) name and then by some of their common brand names (see previous page).
Oral Hypoglycemic Medicines
SULFONYLUREAS
*May cause weigh gain in some people
Tolbutamide (orinase)
*May be the safest for an elderly diabetic living alone because of its low risk of hypoglycemia
Tolazamide (Tolinase)
Glyburide (DiaBeta, Micronase)
Glipizide (Glucotrol)
*Causes less stress to the kidneys, so it may be good for diabetics with kidney problems
Chlorpropamide (Diabinase)
*May have a longer-lasting effect, so not recommended for the elderly because of the possibility of hypoglycemia
Glibenclamide
*May have a longer-lasting effect, so not recommended for the elderly because of the possibility of hypoglycema
BIGUANIDES
*Should not be used in patients with kidney or liver problems
*May cause loss of appetite, nausea, diarrhea or other intestinal problems
*May be useful for overweight type II diabetics because it controls blood sugar without increasing weight
Metformin
If a person is using oral medicines for diabetes control, he should know:
*Some diabetes medicines may actually cause a hypoglycemic reaction if used with alcohol, anabolic steroids, or certain other medicines. Medicines which may interfere or react with the diabetes medications include some steroids, blood pressure medicines, epilepsy-control medicines (Dilantin), thyroid medicines, hormones such as estrogen, et cetera.
*Some oral diabetes medicines will cause a headache and red face if the diabetic drinks alcohol.
*Many oral diabetes medicines can cause nausea.
*A pregnant woman should not use oral diabetes medicines because they cross the placenta and may affect her unborn baby. Insulin, on the other hand, does not cross the placenta or reach the baby. When a diabetic woman plans to become pregnant, she should inform her doctor so that he can change her to an appropriate dose of insulin several months before she becomes pregnant.
*Other patients who normally use oral medications may also need to change to insulin temporarily during a stressful situation such as infection, surgery, or heart attack.
Insulin
The very thought of insulin injections every day strikes fear and dread into the hearts of many. Yet diabetics like Robert and Larry don’t feel that way at all.
When Robert was diagnosed as diabetic at the age of three, doctors told his parents that he probably wouldn’t live past the age of 17. Later on, doctors extended his life expectancy—but he would “probably die by 29 years old”. Now, at age 53, Robert enjoys life to the full—and doesn’t even have any of the usual complications of diabetes yet.
“Without insulin, I would have been dead well within five years, I am sure,” says Larry. “So these 21 years later, I praise God for insulin which has made it possible for me to live a normal life.” To Larry “insulin means life, and how thankful I am for this.”
According to the World Health Organization, about 25-30 percent of all known diabetics need to use insulin regularly. In Southeast Asian countries, the percentage is somewhat lower.
Although insulin usually based for the type I, insulin-dependent diabetic, some type II diabetics also get along better with insulin treatment. Those type II diabetics who have difficulty controlling their diabetes with oral medicines and diet, and those who have pain from nerve damage may use insulin instead of oral diabetes medicines. Some diabetics are able to maintain better control of their blood sugar by using a combination of both oral medications and insulin.
In addition, as mentioned earlier, pregnant women and diabetics who are very sick or who are having surgery are also likely to be given insulin instead of oral medicines.
Insulin cannot be taken by mouth because it is a protein which would be destroyed by the digestive juices in the stomach. Therefore, it has to be given by injection.
The insulin is injected into the fatty tissue just under the skin. From there, it is absorbed into the muscles and the bloodstream, where it begins to do its work.
In the past, most insulin came from either beef or pork pancreas. These are still in common use, although today there is also a chemically-made insulin which is identical to human insulin.
There are many types of insulin available on the market. All are classified, however, according to how long they act in the body. The synthetic, or “human”-type, insulin begins and finishes working more quickly than the beef or pork insulins.
Doctors prescribe a particular type or combination of insulins depending on the individual patient’s needs. Some patients get along well on one injection of insulin per day. Others do better with two or three injections per day—possibly different types of insulin at different times of the day.
Some of the most common types of insulin are listed in the preceeding table. There are actually many variations and numerous band names on the market. Their availability tends to vary from country to country.
Types of Insulin
Begin Peak of Total
Acting Action Action
Time
Short-acting
Regular 30 min. 2-4 hrs. 6-8 hrs.
Semilente 1-2 hrs. 5-10 hrs. 10-16 hrs.
Intermediate-acting
Lente 1-3 hrs. 6-12 hrs. 18-26 hrs.
NPH 1-2 hrs. 4-12 hrs. 18-24 hrs.
Long-acting
Ultralente 4-6 hrs. 10-30 hrs. 28-36 hrs.
PZI (Protamine zinc) 4-6 hrs. 10-30 hrs. 28-36 hrs.
Mixtures
(Combination of 30 min. 2-12 hrs. 24 hrs.
short- and
intermediate-acting,
the peak action time
depending on the
particular
combination used.)
In deciding what type of insulin a patient should use, the doctor’s main goal is to help the patient maintain good control of his blood glucose level. Experts believe—and the recently completed Diabetes Control and Complications Trial (DCCT) study shows—that keeping the blood sugar level as close as possible to that of a “normal” nondiabetic will prevent or at least delay many of the complications of diabetes.
If one type of insulin or a particular injection schedule does not work well, the patient should see his doctor. The doctor may make some changes in the prescription. However, a patient should never change insulins without the doctor’s advice.
Once the patient has gained reasonable control over his diabetes and has learned how his body reacts to insulin and to exercise, he may be able to make some adjustments in his insulin does himself. Even these changes should be made with the doctor’s approval, and only when the patient fully understands what is happing in his body.
The amount of insulin needed varies from person to person, and from one period of life to another. However, just because one person needs twice as much insulin as another, it does not mean that his diabetes is twice as serious. It simply means that their two bodies react differently to insulin.
A person’s insulin dose is based on is height and weight, his metabolism rate, his amount of exercise, and his daily diet. A young diabetic is likely to need more insulin during adolescence because of extra growth and hormone changes in his body. During pregnancy, illness or any other major stress to the body, the need for insulin will probably be different.
Seasonal changes may also bring changes in the insulin need, depending on the amount of exercise a person is getting. Where there are cold winters, people may stay inside the house more and get less exercise. When the weather is too hot, people often have no desire to exercise.
Not long after children are first diagnosed with type I diabetes, many experience what is called a “honeymoon phase”. The pancreas may still be producing a small amount of insulin at that point, so the person may get along with little or no insulin for a few days, weeks, months, or even up to a year. Some are tempted to believe that they are well—cured of their diabetes. They aren’t. In time, the honeymoon will be over, their beta cells will have totally stopped working, and they will have to go onto regular insulin injections.
Giving the Insulin
When a person is first told that he needs to have insulin regularly, the doctor or nurse will teach him how to give the injections. If the diabetic is a small child, both parents should learn how to give the injections, and they should take turns so that the child does not begin to associate one parent with the unpleasantness of his disease.
Actually, with a sharp needle, the diabetic should feel very little pain from the injection. I know. Even as a nurse, I have always hated getting injections, but my diabetes course instructors insisted that all of us in the class inject ourselves so that we would know how to do it and know how it feels! Parents and children can find various ways to make the injections more tolerable.
If the patient is to use more than one kind of insulin, he will also have to learn how to draw the medicines into the syringe correctly. If they are mixed incorrectly, the insulins may not work as they should, and the diabetic may have trouble with high or low blood sugar levels.
Insulin can be irritating to the skin and the tissue where it is injected, causing lumps, pits, and sometimes redness or irritation. To avoid this, the diabetic must “rotate” the sites of injection, using a different place each time.
Doctors or nurses, diabetes associations, and pharmaceutical companies often provide patients with site rotation “maps” on which the diabetic can keep a record of the time and place of each injection. In this way, he can effectively avoid injecting in the same location too often.
For the diabetic who is giving his own injections, it is usually easiest to use the abdomen (the belly) and the things. The buttocks and the upper arms can also be used, but these are less convenient for the person doing it himself. The diagram on page 147 shows the injection map. Injections should be about three to four cm. (one to one and a half inches) apart.
Rotation Sites for Insulin Injection
There are a few important things for a diabetic or his family to remember about taking insulin. He should:
*Know what his insulin is supposed to look like, and not use it if it looks different. Some kinds of insulin should always be clear; others are cloudy or milky looking. If a clear type of insulin looks cloudy, or if any kind of insulin looks like it has separated or gone lumpy, it should not be used.
*Always keep an extra bottle of insulin available. Running out could be disastrous!
*Store the insulin currently being used in a dark cupboard. In very hot climates, keep it in the refrigerator. Insulin loses some of its strength when it is exposed to heat. Never put insulin the freezer or in direct sunlight.
*Buy the type and strength of insulin which the doctor has prescribed, and never change brands without asking the doctor.
*Use the correct type of syringe to go with the insulin prescribed. There are different kinds of insulin syringes, and using the wrong one may result in giving the wrong dose of insulin.
*Check the expiration date on the insulin bottle. Don’t use outdated insulin because its action may be very different from what it should be.
*Take the correct amount of insulin every day. Even if you are eating very little because of sickness, never stop taking your insulin. You still need some insulin, so you should contact your doctor to adjust the dose.
*Check with the doctor if the insulin is causing nausea, vomiting, diarrhea, skin redness, or any other problems.
Although the needle and syringe are the traditional way of giving insulin injections, some patients are now using a pen-like injector. For the person with poor eyesight, the pen may improve the accuracy in giving the correct dose of insulin. For children—and for adults like me!—who dislike the sight of the needle, the insulin pen may be less frightening because the needle is more or less out of sight. If a patient takes relatively small doses of insulin, the pen may also be able to hold two or more does at one time, making it more convenient. Some pharmaceutical companies provide the pen free of charge when the diabetic buys his insulin from them.
A few patients use high-pressure jet injectors rather than the usual needle and syringe. These are convenient, though they are no less painful than a needle. They are quite expensive, and if not used correctly, they may also cause some damage to the skin. Generally they are only recommended for patients unable to use syringes, not for the average diabetic.
For those who wish to avoid the daily injections of insulin, researchers have also been experimenting with giving insulin by nasal spray. So far, they are still studying this method to see whether or not it is effective and safe.
In recent years, scientists have developed the insulin pump, which consists of a tiny microcomputer, a battery, a small pump, and storage area for insulin. The pump, which is worn outside the body like a pager or a walkman, is connected by a small plastic tube to a needle which constantly remains just under the skin. The pump is preset to give a constant amount of insulin throughout the day and night. At mealtimes, the user presses a button and the pump releases an extra amount of insulin to deal with the glucose in the meals.
The pump allows the diabetic much more freedom to live a normal life with much more flexibility in his eating, working and exercise schedules. It frees him of the need to inject insulin once, twice, or even three times a day. It gives the diabetic a feeling of being in control of his diabetes rather than always feeling like his diabetes is controlling him.
The insulin pump is not without some disadvantages, however. First of all, it is too expensive for many people. The diabetic must monitor his blood glucose level frequently to avoid hypoglycemic reactions from the constant insulin supply. Some activities—such as bathing, dressing, sleeping and having sex—are somewhat more awkward with the pump. There may also be more irritation, or even skin infections, where the needle stays in the skin.
Some people dislike the pump because it announces to the world that they have diabetes. More men than women wear the pump, probably because the women fear it will make them look less attractive.
The pump is still new, and all of the problems have not yet been eliminated. There are occasionally mechanical failures, and if the diabetic is not alert to this possibility, he could be in serious trouble. Because of the need for servicing and repairs, the only people who can conveniently use insulin pumps are those who live near a service center.
Whether the diabetic takes his medicine by pills, needle and syringe, pen, or pump, he must take it regularly and without fail.
In order to maintain good diabetes control, he must have some way of knowing what is happening inside his blood stream. To know what is going on, the diabetic will need to do frequent testing, called “monitoring”, which we will look at in the next chapter.