Reducing the incidence of complications and possibly saving your own life. How's that for a start?
The benefits of tight glucose level control are astounding - you can lower the incidence of complications by up to 75% by paying close attention to your blood sugar levels. In this program, you'll find out about the importance of monitoring, what's on the horizon in monitoring devices and target levels to aim for. You'll also hear about the array of diabetes medications available - from Avandia to Glucovance - and what they mean for you. Hear the story of Cathi White as she transitions from the now-banned drug, Rezulin, into a brand new medication.
monitoring is important because monitoring enables the person to get lower blood sugars. You can't improve your sugar control unless you know what the sugar level is, and we know that if we can get lower blood sugars and better control, we will have fewer long-term complications of diabetes.
What are the benefits of tight control over glucose levels?
Insulin began being used in the early 1920s, and it wasn't until 1993 that we had proof that using insulin led to fewer complications.
We've had two very big studies, one called the Diabetes Control and Complications Trial; the other called the United Kingdom Prospective Diabetes Study. The first is in type 1 diabetics, the second in type 2 diabetics. Both of those studies show that with better control of the sugar level, we have dramatically decreased incidences of the complications.
And we're talking about a 30 percent or so decrease in the complication rate for every one percent your hemoglobin A1c goes down. So, the hemoglobin A1c, which is a measure of how your blood sugar has been over the preceding three months, if it's nine and you get it down to eight, you've cut your risk for complications between 20 and 40 percent, depending on the complication. In the Diabetes Control and Complications Trial, a two percent decrease in A1c was associated with about a 75 percent decrease in retinopathy progression. That's the eye problem.
Give us an overview of how we monitor. What are the options that we've got?
For the sugars, day to day, we have what we call the glucometers, and there are about at least a dozen of those, and they're always coming out smaller and faster, requiring less and less blood, so that now we have meters that will measure your blood sugar in 15 seconds and require 1.5 microliters of blood, which you can hardly see. In the old days you had to get a big, fat drop. Milk your finger... You don't have to do that anymore. The strips will actually draw the blood right up for you, so that's being done much more easily today than it was several years ago.
They're very tiny. So, the glucometers are wonderful for the day-to-day checking of your sugars. Then there's the longer-term measurement called hemoglobin A1c, which measures the blood sugar, kind of the average blood sugar over the proceeding two to three months. The nice thing about that is when you check your blood sugar with the meter, you're only getting one point in time whereas this averages what your sugar has been like for the preceding two to three months.
And that can be pretty surprising because if you test, as you typically do, before meals, you may be surprised how much it's going up in between if you aren't checking.
NEW GLUCOSE METER PRODUCTS
Yes, there is a watch called the Glucowatch. It goes on your wrist like a watch. That's why it's called that. And it measures your sugar from the fluid which accumulates. It was approved by the FDA over a year ago. We haven't seen it on the market yet. We're waiting for it. This is a device where you would change the pad that reads the sugar about twice a day, and you wouldn't have any finger sticks, but you could look and see what the sugar was.
The beautiful thing about a device like this, is if it has an alarm that goes off when your blood sugar is, say, 60, and then you can drink a little bit of orange juice to avoid those real bad lows. That, to me, is the great promise of that sort of device.
Then we also have a device, which is probably going to go into the patient market early in the next year, and this is a little device that you put under your skin. It's a very tiny little electrode-y kind of thing, which will monitor your sugar continuously and send the results to a little meter that you can also look at. And you would change that every two or three days.
What about frequency? How often and when should a diabetic check glucose levels? And is it different for type 1 and type 2?
it's quite different, and it's different from one type 1 to one type 1 and one type 2 to one type 2. It really depends on what the patient is going to be doing with the information. I have sometype 1patients who have great control. They check their sugar a couple of times a week. Now, I don't endorse that necessarily. But that's their habit, and they've been doing fine. So that's fine.
If I get a hemoglobin A1c back that's nine, well, then it's probably time to check more frequently, and for that person, I would usually say, "Why don't you check before each meal and before bed? So, four times a day. Write the readings down. Bring it in. We'll take a look, and we'll see if there are any patterns that we can adjust your insulin regimen for."
There are sometype 2son insulin who need adjustment who will test frequently. If somebody is diet controlled, they probably should check their sugars once or twice a week. If they're taking oral hypoglycemics, maybe about the same, two or three times a week. Checking that hemoglobin A1c is critical. That really should be done at least two and preferably four times a year. It all depends on where the person is in their control
It's been shown over and over again in studies that it is very difficult to predict what the sugar is by how you feel.
"Don't get too crazy with monitoring."
That’s why I'm not so sure that the new non-invasive methods are going to add that much because people may go crazy. People who don't have great control, bringing them in and having their sugars checked for three days, and we download it onto a computer, get nice graphs and take a look at it. And sometimes, it's just a head-scratcher. It's like, whoa, what happened there?
I want to make a point briefly that it's not just your medication and your food, or even your medication and your food and your exercise. It'sstress, how much sleep you've got, just seems so hard to control.
There are several hormones that are involved in sugar metabolism besides insulin.
We have all sorts of complications that we need to avoid.
Blood pressureis something that is a major risk factor for heart disease. Diabetes is a major risk factor for heart disease. So people need to have their blood pressures checked, and their blood pressures need to be made as good as possible.
n the UKPDS, there was a sub-study looking at blood pressure control. It showed - and this blew everybody away - that people who had their blood pressure better controlled using either what we call a beta blocker or an ACE inhibitor, those folks, compared to people who had less good blood pressure control with two other types of medication, these people with the good control had not only significantly decreased events of heart disease, but they had fewer diabetic complications.
It was even more powerful at decreasing diabetic complications than lowering the hemoglobin A1c from 7.9 to 7, which had been done in the study. So, blood pressure control is critical, particularly, I think, with those medications
You mentioned there was a urine test, I think, for kidney damage. How often should you get that done?
That should be done once a year. That really should be done once a year unless you're on that ACE inhibitor because if you have the test and it shows positive, then we should put you on an ACE inhibitor. So, the kidney test should be once a year. So should the blood pressure test. These are yearly examinations.
Creatinine is a test of kidney function.Usually we don't see problems with the creatinine until there has been evidence of kidney damage through the other test, which is called, by the way, amicro-albumentest. Your albumen is a protein, and "micro" means little, and the kidneys get a little bit leaky when they're first damaged, and they leak out little bits of albumen. And that's what the micro-albumen test is for. That's the first sign of kidney damage. If the kidney function decreases, then you see this creatinine level start to go up. We typically measure that every year or every two years.
Lipid profile,again, just like blood pressure and heart disease, cholesterol - lipids are cholesterol and triglyceride - cholesterol is a horrible risk factor for heart disease. And we need to control that very well. So, that should be tested about every year. If someone has a beautiful lipid profile, you don't need to test that but maybe every two or three years if they have diabetes, but we do want everybody to know what their lipid profile is.
we try to very aggressively decrease the cholesterol in people with diabetes. We know, for instance, that people with diabetes who have had a heart attack, say, who get lipid lowering will have55 percent fewer cardiac eventover the next several years than people who don't have lipid lowering. So it's really a very powerful intervention.
FOOT EXAMS
Take your shoes and socks off, and show your doctor. When you get in the exam room, take them off.
There are some very distinct differences in treatment for type 1 and type 2 diabetes
We have long-acting, intermediate-acting, short-acting, ultra-short-acting insulin, and then various combinations.
one of the biggest changes that I've seen in insulin use was several years ago we started taking the NPH insulin or the Lente insulin, which is intermediate-acting, and instead of giving it before dinner, which we always did, we started to give it before bed. That made an enormous difference for many people because the way the insulin gets absorbed and starts acting when you give it before dinner, you end up with a whole bunch of insulin around 3:00 in the morning. Who needs it? People had a lot of hypoglycemia, low blood sugars, in the middle of the morning. Once you take that NPH or Lente and take it before bed, then you're having a bunch of insulin in your system around breakfast time.
There's also something called a "dawn phenomenon," where the blood sugars start to rise around dawn - again, a good time to have a little bit more insulin in your system.
We have pharmaceutical companies working oninhaled insulin, oral insulin. We also have the promise of thecontinuous sugar sensorthat we talked about before hooking up to&an insulin pumpwith a brain, and then what you have is what we call aclosed-loop insulin systemso that you don't have to think about it anymore. It takes your own brain out of the loop, and then it's like an artificial pancreas.
So we would think within the next three to five years, maybe.
I guess you could call it that- is the islet cell transplants, or pancreas transplants. We have pancreas transplants which are done some, and now islet cell, the islet is the part of the pancreas that makes insulin. They can be isolated from the rest of the pancreas, and just this summer we had the first reports of successful islet cell transplants.
theislet cell transplant is that it doesn't require an operation. It's really an interventional radiological procedure where you just put them into the portal vein, which then brings the islets to the liver, and they live in the liver and make insulin.
type 2 treatment. What's the first line of treatment there?
The first line is diet and exercise.
we havepills called sulfonylureas, which are classically the first line. These were the first drugs we had, the only drugs we had for a long time. They make the pancreas secrete more insulin: glyburide, Glucotrol, Micronase, DiaBeta. Medicines like that.
combination pill which is just on the market called Glucovance, which has a little bit of glyburide, a little bit of Glucophage. And in general we find that when we use combination medicines we can use lower doses so have fewer side effects and have a little bit better effect.
a fairly new class of drugs, the Rezulin-Avandia-Actos class, which also attack the insulin resistance. There are medicines which decrease carbohydrate absorption called Precose or acarbose. There are other medicines - repaglinide - which affect insulin secretion slightly different than the glyburide. There's a whole host of medicines. And then we have insulin also for type 2.
how do you decide what to use?
What we usually do is if somebody is overweight, as most type 2s are, we will use Glucophage first. And the reason for that is that in the UKPDS we found that obese people who were treated with Glucophage did better overall than people who were treated with glyburideÖ well, with a sulfonylurea or with insulin.
So, we'll use Glucophage in that group. That leads to a little bit of weight loss sometimes. It's good for the triglyceride level, one of the lipid levels. So that's what we use in most type 2s. Now there are side effects, so if we have to not use that, then we'll use something else.
You mentioned Rezulin, and it was taken off the market. What is that all about, and what does it say about drug safety?
That was an unfortunate incident. Rezulin, also known as troglitazone, was the first of a class of drugs, a really revolutionary class, called thiazolidinediones.
TZDs, that's a little easier. This class works quite well for some people. But Rezulin was associated with liver problems, liver damage, and there were several patients who either died, unfortunately, or required liver transplantation because of liver failure as a result of Rezulin.
many of those patients probably were not monitored appropriately. The FDA had said if somebody goes on Rezulin, you need to[monitor] their liver level frequently, and probably a lot of those people didn't have it monitored because a big deal was not made of it until much, much later.
It's the same sort of complication rate as many other drugs have. Very rare, one in 50 or 60,000 people is the number that I've seen quoted. But because other drugs came around which didn't appear to have that liver problem, the FDA really had to remove it from the market.
And the two other drugs like Rezulin - Avandia and Actos - so far have not been associated with liver problems. And if the problem with the Rezulin was, if you looked at the what we call pre-clinical data, in the early development, there were little hints that this drug was not the best for the liver. And some people feel like the FDA just kind of pushed that aside a little bit.
Type 1 Diabetes
Test your blood glucose at least before each meal, and at bedtime. Also test periodically at 3 A.M. and two hours after meals. Before and between meal tests reflect the action of background (basal) insulin. After meal tests reveal the match between food and rapid-acting insulin such as lispro and aspart.
The right amount of testing for you depends on your goals and how you will use the results. Blood test results have more power to improve glucose control if you know how to use them right away. For example, you may use the value to help set an insulin dose or make a decision about driving or exercising.
Also test before driving and at other times when your glucose level is critical to safety. Your goal is to achieve a blood glucose level near normal. Keep records of test results.
Type 2 Diabetes
- Test whenever you can use the information.
- Test before each meal and before bedtime to determine the action of background insulin.
- Test after each meal to determine the balance between food and available insulin. This is equally important when you use injected insulin or you body’s own insulin.
- Learn what to do about high or low values. Options include changing food choices, exercising, etc.
- Keep a record of your readings. Review patterns occasionally and share with your health care provider.
- An after-meal elevated glucose level is highly associated with heart disease risk.
Acceptable gluc levels
A normal blood glucose is 70-110 mg/dl before a meal and less than 120 mg/dl 2 hours after a meal.
Target ranges are different for different people. Your health care professionals can help you set realistic target levels. Here are some guidelines:
Intensive treatment: less than 110 mg/dl before meals; less than 140 mg/dl 2 hours after meals; A1C (glycated hemoglobin)* within 1/2% of normal.
Patients with chronic disease, complications, or hypoglycemia: 80-160 mg/dl before meals; less than 200 mg/dl 2 hours after meals; A1C within 1% of normal.
Pregnant women with diabetes: 60-105 mg/dl before meals; less than 120 mg/dl 2 hours after meals; glycated hemoglobin within normal range.
