Originally published in The Ottawa Citizen June 5, 2002
Original Title: Making the Medicine Go Down

Last week’s column outlined how type 2 diabetes develops and causes harm: the liver produces too much sugar, the muscle, liver and fat cells poorly absorb sugar because they are less responsive to insulin and the insulin producing beta-cells of the pancreas eventually burn out.

Type 2 diabetes can require strict adherence to a treatment plan. For some, it severely compromises their lifestyle. Compliance to a particular regimen can be difficult. Nonetheless, diabetes sufferers should have every opportunity to take control of their condition. Understanding the choice of medical therapy contributes to better compliance.

Treatment is individualized. Risk factors like obesity, smoking, heart disease and high cholesterol levels among others figure prominently in selecting a proper treatment regimen.

The first step to control blood sugar is to eat healthful foods and to exercise. The Ottawa Hospital Diabetic Clinic has the resources to develop specific diabetic diets in line with the patient’s lifestyle. Weight loss especially in overweight individuals will reduce blood sugar levels. Indeed a loss of ten pounds can have significant positive effects. If this step is not helpful then the addition of one or more of the five classes of diabetes medication is in order. Each has a specific mechanism of action but all work to lower blood sugar.

DiaBeta (glyburide) and Diamicron (gliclazide) are one of the mainstays of treatment. They increase insulin production and may provide better sugar absorption into fat and muscle tissue. They can cause weight gain thus may not be the best choice for obese patients. Blood sugar levels can become too low (hypoglycemia) if meals are skipped with use of the medication.

Gluconorm is a newer medication that acts like DiaBeta only faster. It is used immediately before a meal since sugar levels surge upwards after eating. People who may have difficulty maintaining a regular meal schedule use it.

Avandia and Actos are a new class of medication designed to increase insulin’s effect on muscle and fat tissue. The pancreas gets some needed rest. It does not have to produce as much insulin to maintain normal blood sugar levels. Lower insulin levels reduce the growth rate of arterial plaques or clots that can lead to heart attack or stroke. These medications do not cause low blood sugar levels.

Metformin works by reducing the liver’s sugar production and release into the bloodstream. It can increase insulin receptor sensitivity in the liver, muscle and fat cells. It does not cause low blood sugar levels nor weight gain. For this reason, it is usually the first choice of medication for obese or overweight patients.

Prandase prevents the small intestine from absorbing sugar by blocking a digestive sugar enzyme. Blood sugar levels do not increase as much after eating. The main side effects include flatulence, bloating and abdominal discomfort. These wane over time.

Combinations of these medications may be used to provide effective diabetes control. The addition of insulin injections may be required if there is severe disease, lack of efficacy of oral medications or non-compliance.

Type 2 diabetics often have other medical conditions such as high cholesterol, obesity, heart and kidney disease. Smoking must stop and alcohol consumption curtailed. Early diagnoses and intervention is key. It is much easier to prevent the complications of diabetes than to treat the end stages of the disease.

The big stumbling block is compliance. Facing a handful of pills everyday can be demoralizing. It can easily trigger a normal denial defense mechanism. Early stages of diabetes do not have many symptoms. People feel just fine thank you very much. Nevertheless the reaction, albeit understandable, is the wrong path to choose.

Newer once-a-day formulations like Diamicron MR, Actos and Avandia address this issue. They can reduce the daily dose of pills but provide equal if not better control because of better compliance. A once-a-day version of Metformin is available in the United States. Canadian availability usually follows.

Equally important is weight loss and exercise. In some cases, weight loss and exercise over time can reduce the dose of daily medication.

The incidence of diabetes continues to increase. It is no wonder that heart disease is the number one cause of death in Canada and the United States. You cannot feel or see diabetes in its early stages. It is responsible for terrible suffering: kidney failure, stroke, heart disease, loss of limbs, nerve damage and blindness.

If there is a family history or closing in on 40, a simple blood sugar test can aid in early diagnosis. Take the test. Save your life.

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© Dr. Barry Dworkin 2002