www.diabeticretinopathy.org.uk

General

Control of type 2 diabetes

David Kinshuck,
Pat Lamb,
Urmila Griffiths

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Embrace your diabetes

Enlarge  Haemoglobin, in your blood, joins up with glucose to form the chemical called HbA1c

 

We are learning more about diabetes all the time, and it is becoming clear the harder you work to control your diabetes when it is diagnosed the more benefit you will get in the long term. Complications from diabetes will be prevented or delayed (NEJM 08) (UKPDS 08).

Type 2 diabetes is a progressive condition. It is not a 'mild' form of diabetes. The exercise you take and the food you eat need to balance the remaining natural insulin your body makes. This page is designed to give readers an idea how decisions are made concerning their care, but remember every patient is different and advice can vary.

 

Take control....learning how to control type 2 diabetes

Your diabetes nurse can teach you the basics, and reading up is helpful. But there are structured diabetes education programs that your doctor must enable you to attend such a course. The programs teach you how to take control of type 2 diabetes, and patients who have attended the program have better diabetic control and fewer problems.

 

Compliance

Birmingham meeting 2012: Patients only take half their oral medication. Fixed dose combination tablets would help a little. 10% compliance with multiple drugs.

 

What is happening in type 2 diabetes

There are four particular problems.

These factors work together to contribute to type 2 diabetes. The factors may be controlled by genes. So your children or brothers and sisters may be affected, and they should take precautions (exercise, healthy diet, not becoming overweight, and not smoking). Social issues such as conflict/homeless contribute BMJ 18.

 

First, there is a shortage of insulin

You may have inherited this condition from your parents. Alternatively, a few people may have had pancreatitis or a bad attack of mumps that damages the pancreas. The shortage of insulin is due to damage to the islets in the pancreas where your insulin is made.

The pancreas is a gland is behind your stomach, and throughout its tissue are these tiny groups of cells called islets. It is these islets that make your insulin, and they release the insulin into your blood stream, just as it is needed. In this type of diabetes the islets become damaged and effectively 'dry up'. This process may be the main cause of your diabetes if you are not overweight, have always had a healthy diet, and have always taken exercise.

 

Second, there is insulin resistance.

insulin resistance increases with lack of exercise and increase weight

 

 

Normally the insulin is released by the pancreas into the blood stream. The insulin circulates to muscle cells, where it acts as a 'door opener' and lets the glucose into the cell. The muscle cell uses it for energy.

However, in this type of diabetes the muscles and other tissues are much less responsive to insulin. This means the pancreas has to produce more insulin for the same effect. This poor response to insulin is called 'insulin resistance'. Insulin resistance develops if you are overweight or take too little exercise, and especially if you are overweight and take too exercise.

Losing weight  and exercise (30-60 minutes walking a day for example) both lower the insulin resistance. With less insulin resistance, you need less insulin for the same effect, and so the insulin that your beta cells make (or that you inject) will go further. The amount of 'resistance' varies according to how much fat there is.

So if you are overweight, your pancreas has to produce considerably more insulin for the same effect, versus someone who is not overweight. If you can lose weight, the responsiveness to insulin will increase, your insulin will have a much greater effect, and your diabetes will be easier to control.

In practice this means that unless you lower your 'insulin resistance' your pancreas is even more likely to 'run out of insulin' and you may need insulin injections sooner, and if you are fatty tissue actually becomes deposited in your pancreas, and this damages the pancreas even more.

At the beginning, the resistance to insulin makes the pancreas compensate by producing more insulin, but eventually it cannot produce enough. Joslin. Type 2 is progressive: the pancreas produces less insulin each year, more treatment and eventually insulin is often needed. However, this process is a lot slower with regular exercise, a healthy diet, and keeping thin.

 

Third, there are genes

diabetes genes

 

Genes linked to diabetes work in different ways. Some genes may not cause diabetes directly, but make you overeat and become overweight, and the excess weight causes the diabetes. One gene may make people fidget, and fidgeters are less likely to become overweight. Finally, there are many genes that may cause diabetes. These include MODY genes and haemochromatosis. It is often worth having an iron test for haemochromatosis, as early diagnosis will help your relations (iron binding capacity and serum ferritin tests?).

 

Fourth, stress

Stress increases the risk of heart disease, and probably diabetes itself also.

 

Fifth, inflammation

These factors to cause a low grade inflammation/ oxidative stress. BMJ 2011, and this causes more damage.

Sixth, sleep

Sleep difficulties (sleep apnoea) is common, and makes control of the diabetes difficult.

 

These factors combine to cause type 2 diabetes

 

factors contributing to type 2 diabetes there is a 50% risk of becoming diabetic if you are overweight and exercise very little. (After Williams & Pickup.) Sleep apnoea plays a role also.

 

risk factors add up to increase risk of diabetes

 

These risks combine, as opposite:


risks increase with a combination of factors


Excellent article.

 

Pattern of progression

  1. At the beginning of type 2 diabetes, a healthy diet may be sufficient to lower the sugar and keep the HbA1c below 48mmol/mol / 6.5% IFCC-HbA1c
  2. Later, metformin is needed.
  3. Later still, add exanatide/Liraglutide if overweight or other drug if thin.
  4. Later still insulin may be required

 

Slowing down progression

Exercise and losing weight (if overweight) dramatically slow this progression rate down, and even prevent diabetes in some people. Exercise reduces the dose of insulin needed (BMJ 2011). If you are on a diet (without drugs or insulin: diet controlled diabetes), and your HbA1c is 42mmol/l / 6% this is an ideal level. But if the HbA1c rises to 64mmol/l / 8%, you need to eat less (if you are overweight) or may need tablets, so you should see your GP or nurse. See weight below.

Similarly, if you are on one set of tablets, and your HbA1c is 42mmol/l / 6%, you are controlled. But if it is 64mmol/l / 8% , you need to eat less (especially if you are overweight) or go on more tablets, or possibly insulin. See 'Exercise in diabetes'. Your doctor and diabetic specialist nurse will need to advise you if your HbA1C is higher than 53mmol/mol / 7%.

Testing you sugar/glucose level

Test your glucose and aim for

If you want to know whether or not your diabetes is controlled, your doctor can check your HbA1c level. But you should test your own glucose level  testing. If you 'embrace' your diabetes, you will gradually learn to control it and achieve an HbA1c of 48mmol/mol / 6.5%. or below (slightly higher if you have had diabetes a long time). But to do this, you need to check test your glucose:

Test

 

Do you need tablets (or insulin), and if so what? A treatment plan

Once your sugar levels start to rise despite exercise and the best diet you can stick to, you need tablets. Similarly, if you are on tablets and your sugar levels start to rise, you need a higher dose, or an extra tablet, or need insulin. Here is a protocol as to what you may need, from here. All patients should generally start with metformin: all other drugs lower the HbA1c equally, but with different 'side' effects/effects on weight etc (JAMA 2010).

Type 2 diabetes: a treatment plan (separate page)

Proceed down until target reached:
address   diet   exercise   losing weight   learn to test glucose

arrow down 

0-8 weeks, if levels higher than HbA1c 48 mmol/mol / 6.5% at onset of diabetes if well

arrow down

add Metformin  
increase to 2.0 - 2.5gm over 3 months (divided doses)

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0-8 weeks, if levels higher than HbA1c 48 mmol/mol / 6.5% .
this is the target for recently diagnosed patients

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if low weight if overweight
  • Sitagliptin & Linaglyptin (Trajenta) do not cause weight gain, but all the other treatments below increase weight
  • Linaglyptin (Trajenta) if renal function reduced
  • If thin, sulphonylurea and titrate to maximum dose depending on response. Eg gliclazide. start 40-80 mg daily. 160 mg as a single dose, with breakfast; higher doses divided; max. 320 mg daily. Weight will increase. Sulphonylurea do cause hypos.
  • Dapagliflozin (Farxiga) if well
  • or add insulin as below

These drugs (and only one of this list would normally be added) will only lower the HbA1c 0.5-1.0%.

Therefore if the HbA1c is >8.5% 69mmol/l, a 7.5% /58mmol/ltarget will not be reached, so insulin may be best. However, a gradual HbA1c drop may be best in retinopathy patients.

Incretins

Reduced renal function

arrow down 

12 weeks, if levels higher than target (>HbA1c 48 mmol/mol / 6.5% at onset)

Add insulin

  arrow down

12 weeks, if levels higher than target

Metformin

Metformin helps in diabetes as it allows glucose to enter your body's tissues where it is used for energy etc. It makes the tissues more responsive to insulin, and this lowers the sugar levels (this is 'lowering insulin resistance'). Benefits NEJM 2008.
As a result, in addition to the lower blood sugar levels, you may lose weight.

 

metformin lowers insulin resistance

 

Gliclazide

gliclazide stimulates insulin release from pancreas, and increases weight

 

This is one of many 'sulphonylureas' There are many others. (Glipizide is another.)
These drugs act on the pancreas to make it release more insulin. Side-effects are generally mild and include feeling sick, bowel changes, headache, and weight gain.

Dose: initially, 40-80 mg daily, adjusted according to response; up to 160 mg as a single dose, with breakfast; higher doses divided; max. 320 mg daily. Ideally gliclazide is taken 30 minutes before a meal.

Sulphonylureas contribute to hypoglycaemic episodes. Gliptins are more expensive, but have few side effects and far fewer hypos. They probably should be considered second line after metformin.

 

GLP1s (Glucagon-like peptide receptor antagonists)

Exenatide (Byetta) & Liraglutide (Victoza) are new drugs that lower glucose levels and aid weight loss. Details. NICE BMJ.    2012.

This group of drugs, given by injection, probably should be considered third line if the HbA1c is not too high, as it will only be lowered 10-20mmol/l / 1-2%. So an ideal patient for this group of drugs will have an HbA1c of ~75mmol/l / 9.0%, already be using metformin and a gliptin.

 

Exenatide (Byetta) and insulin use

Exenatide weekly (Bydureon)

Gliptins...DPP4 (dipeptyl peptidase-4 inhibitors)

Sitagliptin (Januvia)

 

Linaglyptin (Trajenta)

 

Dapagliflozin (Farxiga)

 

If you need insulin, what type

 

regular weighing..the only way to lose weight

If overweight you need to weigh yourself each week or even more often and lose weight slowly

 

 

Weight and bariatric surgery

As mentioned type 2 diabetes is partly caused by resistance or lack of responsiveness to insulin. This resistance depends on the amount of body fat. The lower your weight, the less insulin resistance there is, and the less insulin you need (whether your natural or injected), and the better the control of the diabetes. If you cannot lose weight, it is important not to put weight on.

Remember, certain foods are very 'fattening' and you do not need them to be healthy: red meat, full fat dairy food like cheese, butter, cream, and cakes. See diet and weight. Find out if you overweight.

Insulin seems to make most people put weight on. Diet and exercise becomes even more important; a Levemir/detemir basal-bolus regime is said to reduce the weight gain considerably. Exenatide as above can reduce weight, and it can now be used in addition to insulin (there will be less weight gain and often weight reduction, and less insulin is needed).

Expert individual advice from a dietician can be very helpful. Bariatric surgery can be better than conventional therapy NEJM 2012 2012 if obese. There are risks, such as 13% need additional surgery, but it can be very effective.

 

Exercise

Exercise is very important in diabetes. As well as helping your heart, it helps to lose weight. Walking, swimming, or dancing help a great deal. If you are disabled, a physiotherapist, expert gym instructor, your doctor, or your nurse might be able to suggest gentle exercises you can do. Start gently, such as a minute every half hour, or 10 minutes 3 times a day.

If you are exercising, or cannot, and are unable to lose weight, you must be eating too much. Most people in this situation eat more meat than they should, or have cakes at weekends, or indulge in some way. We are not saying 'stop' this, but it is your choice, but if you are interested in good health then losing weight is important.

If you are struggling to lose weight

 

simvastatin reuces heart problems (graph)

simvastatin protects the heart

Cholesterol, HDL, triglyceride

Lipids are discussed in more detail here; Low lipid levels prevent/slow down retinopathy and all other diabetic complications HPS . Fibrates low triglycerides, statins lower cholesterol. Diet and exercise lower both.

 

Typical medication

Typical medications for someone with type 2 diabetes in 2014, not severe enough to require insulin

  1. metformin
  2. gliclazide (an alternative as above if overweight)
  3. a statin for cholesterol
  4. an ACE or A2RB inhibitor for high blood pressure
  5. another blood pressure tablet
  6. possible a fibrate & aspirin

As you will have read above life has not become easier if you have type 2 diabetes. We know a lot more, and there is a lot more patients and professionals can do. On the positive side the health of patients is a lot better. We will have to wait many years before we can say goodbye to all the tablets though.