Ronald Chusid, D.O.
Several new medications have been released for diabetics over the few couple
years that have allowed for better control of blood sugars and complications of diabetes.
Some of them have helped make it possible to take Type 2 diabetics off of insulin, and
control their sugar with pills alone.
Before discussing the pills which have enabled many Type 2 diabetics to discontinue insulin, I should clarify a common misconception about the classification of diabetes. Unfortunately I even find these terms misused by many medical professionals. Type 1 diabetics (also labeled Insulin Dependent Diabetes Mellitus, or IDDM) typically develop diabetes in childhood, and need insulin to survive. By survive, it means that Type 1 diabetics will die in a short period of time if they do not receive any insulin. They were previously referred to as Juvenile Diabetics as most develop the disease in childhood.
Type 2 diabetics (also labeled Non Insulin Dependent Diabetes Mellitus, or NIDDM) will survive for many years without insulin. Their sugars may be uncontrolled with insulin, but they will still survive for many years. What makes these terms confusing is that many Type 2 diabetics are treated with insulin because of the inability to achieve satisfactory blood sugar results with diet, exercise, and oral medications. Even though they are on insulin, they are still classified as NIDDM. As there are far more Type 2 than Type 1 diabetics, it is estimated that seventy-five percent of diabetics on insulin are actually non-insulin dependent.
In the past it didn't matter as much whether a Type 2 diabetic who is treated with insulin was inaccurately labeled Type 1. It is now becoming important due to the multiple new medications which are available. While Type 1 diabetics will always need to take insulin, it may be possible to treat Type 2 diabetics without insulin by utilizing these new medications. Even if Type 2 diabetics cannot be taken off of insulin, these new medications can often be combined with insulin to achieve better control with reduced doses of insulin.
Until recently, sulfonylureas were the only type of oral medication which could be used to lower blood sugar. This class of medications includes Glucotrol, Micronase, Diabeta, Amaryl, and the older diabetic pills such as Diabinese, Tolinase, and Orinase. Diabetics have often developed resistance to the effects of these medications after being on them for several years, and then required the use of insulin. New types of diabetic medications have allowed many diabetics to either stop insulin or reduce the amount of insulin needed. Unlike insulin and sulfonylureas, treatment with most of these new medications alone cannot result in hypoglycemic reactions. Reactions remain a risk if combined with sulfonylureas or insulin.
Metformin (Glucophage), the first alternative to sulfonylureas, was approved by the FDA in December 1994. Metformin works by sensitizing cells to the effect of the insulin already made by the body. Metformin will also reduce the amount of sugar released by the liver at night, helping to lower fasting blood sugars. Metformin has additional benefits including weight loss and reduction of cholesterol.
Acarbose (Precose) and Miglitol (Glyset) reduce the absorption of sugar, and can be added to the other medications to further lower blood sugar. They should be taken with the first bite of meals. Their most common side effect is gas.
Repaglinide (Prandin) stimulates beta cells to produce insulin similar to sulfonylureas. It is less likely to cause hypoglycemia because it is taken just before meals, and is short-acting.
Troglitazone (Rezulin) lowers blood sugar by reducing resistance to the body’s own insulin, a common problem in Type II diabetics. There have been rare cases of liver damage from Rezulin, requiring regular laboratory studies to monitor it. Two newer medications, Avandia (Rosiglitazone) and Pioglitazone (Actos) work similar to Rezulin, but are believed to be free of hazardous effects on the liver. Early studies also suggest that Actos might be more beneficial than other medications in its class for lipid abnormalities.
While the medications discussed above will often reduce or eliminate the need for insulin, many diabetics will continue to require insulin. Lispro (Humalog) insulin was released last summer and works more quickly than older forms of Regular insulin. Lispro insulin is the structurally the same as Regular insulin, except for a change in position of two amino acids. To work effectively, Regular insulin must be taken at least thirty minutes prior to meals. (In cases of elevated sugars, Regular insulin should be give forty-five minutes to one hour before eating). Lispro insulin can be taken within fifteen minutes of a meal. Besides being more convenient, its use can also reduce the risk of hypoglycemic reactions by allowing for better control of when insulin is active. When converting from Regular to Lispro insulin, it is often necessary to increase the amount of intermediate acting insulin. While true with any form of insulin, it is especially important to remember when using Lispro insulin to eat a meal after the insulin is taken. There has also been progress in developing an inhaled rather than injected form of insulin.
Other medications which do not directly affect blood sugar are also of interest to diabetics. Midodrine (ProAmatine) was approved by the FDA for use in dizziness caused by diabetic neuropathy.
As weight loss will often bring about considerable improvement in blood sugar, as well as cholesterol and blood pressure, many new medications to assist with weight loss are also under development. Dexfenfluramine (Redux) was on the market from 1996 until mid 1997, when it was withdrawn due to side effects. Meridia is now available and other medications are expected to be released in the future which we hope will help with weight loss without the side effects of medications currently available. Xenical can be used to lose weight (and lower blood sugars) by reducing absorption of fat in the diet.
Dr. Chusid has practiced Internal Medicine in Muskegon since 1985, and has held positions including Chairman of the Department of Medicine and Chairman of the Critical Care Committee at Muskegon General Hospital. He is also an Assistant Clinical Professor of Medicine at Michigan State University, Medical Director of IHS Home Care, and a member of the Council on Complications of the American Diabetes Association. His office is located at 1762 E. Oak Avenue, Muskegon, Michigan. Phone (616) 773-3258.
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