Diabetes is a condition in which your body is unable to use and store glucose (a People with diabetes who undertake regular physical activity have been shown to …
Diabetes Mellitus/ High Blood Sugar
1 What is Diabetes Mellitus DM?
Diabetes is a condition in which your body is unable to use and store
glucose a form of sugar properly Glucose builds up and causes your blood
glucose or sugar to rise too high
There are 2 types of diabetes: Type 1 and Type 2
Types 1 DM usually develops in children and young adults usually 20 years
old and comprise 10-20 of the diabetic cases In contrast, type 2 DM
usually occurs in older people and make up 80-90 of the diabetic cases
2 What are the causes of DM?
In Type 1 DM, your body completely stops producing a hormone called
insulin Insulin is responsible for helping your blood glucose to get into
your body cells where the glucose is converted into energy to be used or
stored until it is needed The loss of insulin in Type 1 DM is often due to
an immune-mediated destruction of your insulin-producing pancreatic ?-
cells This results in Type 1 diabetics having to take daily insulin
injections to survive
In Type 2 DM, your body is able to produce insulin but the insulin is
either 1 insufficient or
2 inefficient in converting glucose into energy
This results in high
blood glucose
3 What are the signs/symptoms of DM?
The common signs and symptoms of DM are frequent urination, excessive
thirst, unusual weight loss, increased fatigue and blurred vision As these
symptoms may look similar those of other medical conditions, it is
important for you to see your doctor for a proper checkup if you experience
these signs and symptoms
4 What is the treatment goal for DM?
The primary goals of DM management are to control your blood glucose and
minimize the diabetic complications to the eyes, kidneys, heart, nerve and
some major blood vessels
To monitor your blood glucose control, you are encouraged to do home blood
glucose monitoring regularly and show the results to your doctor at each
clinic visit Your doctor will also conduct an HbA1c test every 3 to 6
monthly This HbA1c results gives the picture of your average blood glucose
over the last 3 to 6 months
To monitor the complications due to diabetes, your doctor will regularly
check your blood pressure, carry out blood tests to check your cholesterol,
kidney function called urine albumin-to- creatinine ratio, and arrange
for
you to have your eyes and feet regularly checked
Table 1 below shows the targets for the various parameters monitored
Table 1: Targets of DM control
|Parameters |Target |
|Fasting pre-meal blood Glucose |44-6mmol/L |
|HbA1c | 7 |
|BP |130/80mmHg |
|Total Cholesterol |below 45mmol/L 200mg/dl |
|LDL-Cholesterol |below 26mmol/l 100mg/dl |
|HDL-Cholesterol |above 1mmol/l 40mg/dl |
|Triglycerides |below 15mmol133mg/dl |
|Urinary Albumin:creatinine ratio |below Men - 25mg/mmol 22mg/g |
| |below Women- 35mg/mmol31mg/g |
5 What are the treatments options for DM?
51 Lifestyle modification
In general, most diabetics will benefit from increased physical activity
The common health goal should be to achieve at least 150 minutes of
moderate-intensity physical activity per week People with diabetes who
undertake regular physical activity have been
shown to have substantially
lower mortality rates over 12-14 years
For underweight individuals with type 1 DM, a high carbohydrate with
modest simple sugar intake, low fat especially low in saturated fat, and
low cholesterol diet is appropriate in most situations Most patients with
type 2 DM will need caloric restriction For more details, please consult
your dietitian
52 Pharmacological therapy
521 Insulin injection
There are many types of insulins available and are differentiated by their
duration of action as shown in Table 2 Your doctor will select the type
and dose of insulin according to your needs based on your diabetes control
and lifestyle
Your insulin is to be injected subcutaneously into the fatty tissue, such
as the abdomen area It is important to rotate the site of injection, as
repeated injection into the same place will result in tough or lumpy tissue
and your insulin will not be absorbed properly The timing of injection
depends on the type of insulin you are on Please consult your doctor or
pharmacist to verify the timing of the insulin injection and whether some
of your insulins can be mixed
It is important to store
your insulin in the fridge do not freeze Once
it is opened, your insulin is stable for up to 4 weeks after opening Make
sure you indicate the date of opening on each opened insulin bottle Do not
use expired insulins Always inspect your insulin and if lumps are present,
change to a new bottle as the lumps indicate the insulin may be damaged
Table 2
|Insulin Preparation |Brand |
| | |
|Ultrashort acting | |
| | |
|Insulin Lispro |Humalog |
|Insulin Aspart |Novorapid |
|Insulin Glulisine |Adipra |
| | |
|Short Acting | |
|Recombinant DNA Origin | |
|Regular human insulin |Humulin R |
| |Actrapid |
| | |
|Intermediate Acting Insulin | |
|Recombinant DNA Origin | |
|NPH Isophane suspension |Humulin N |
| | |
|Long Acting
Insulin | |
|Human Insulin Analogues | |
|Insulin Glargine |Lantus |
| | |
|Insulin Detemir |Levemir |
| | |
|Combination Preparations | |
| | |
|30 Reg Insulin 70 NPH |Humulin 30/70|
| | |
| |Mixtard 30 |
|50 Reg Insulin 50 NPH | |
| |Mixtard 50 |
|Insulin Lispro 25 Lispro | |
|Protamine 75 |Humalog Mix |
| |25 |
|Insulin Aspart 30 Aspart | |
|Protamine 70 |Novomix 30 |
The most common side effect of insulin is low blood glucose level also
known as hypoglycemia The signs and symptoms of hypoglycemia include
dizziness, rapid heart beat, hand tremors, pale skin color, sweating,
hunger, sudden moodiness or behavior changes, clumsy or jerky movement,
difficulty in paying attention, confusion
and seizure Therefore it is very
important for all patients who are on insulin to carry some glucose so that
they can immediately take one when they experience hypoglycemia The other
side effects of insulin are hypersensitivity reaction such as rashes and
lipohypertrophy injection site becoming tough or lumpy due to overuse of
the same site
522 Sulphonylureas tablets
Examples : Tolbutamide, glipizide, gliclazide, glimepiride, glibenclamide
Sulphonylureas stimulate the release of insulin from the pancreas Thus it
only used in type 2 DM whereby the pancreas is still able to secrete
insulin This medication is to be taken before meals The most common side
effects are hypoglycemia and weight gain People allergic to sulphur may
develop an allergic reaction to sulphonylureas and hence, need to use other
kinds of oral antidiabetic drugs instead
523 Metformin
Metformin reduces glucose production from the liver and increase the
utilization of blood glucose by the muscle The most common side effects of
metformin are nausea, vomiting and diarrhea Loss of appetite or a metallic
taste is also frequently reported This side effect can be reduced
if
metformin is to be taken with or after meal Metformin should not be used
in patients with severe kidney disease and heart failure
524 Short acting secretogogues Repaglinide, nateglinide
These secretogogues lowers blood glucose by stimulating pancreatic insulin
secretion in a manner dependent on the glucose level Both repaglinide and
nateglinide should be administered before each meal If you skip a meal,
you should also skip your dose for that meal The main side effect of the
secretogogues is hypoglycemia
525 Thiazolidinediones Rosiglitazone, pioglitazone
The thiazolidinediones increase your body cells sensitivity to insulin
Rosiglitazone has been associated with the side effect of fluid retention
leading to weight gain There are reported cases of liver toxicity in
patients taking this group of drugs, thus routine tests to monitor your
liver are needed
526 Alpha-Glucosidase Inhibitors Acarbose
The alpha-glucosidase inhibitors delay the breakdown of carbohydrates and
hence delay the rise in blood glucose after a meal Acarbose is to be taken
with meal The common side effects are wind, bloating and diarrhoea If you
experience hypoglycemia
and are on acarbose, you must use simple sugar and
not complex sugar, as acarbose will delay the breakdown of complex sugar to
simple sugar that is necessary to correct the hypoglycemia
6 Other new anti-diabetic drugs coming up in the market
61 Exubera inhaled insulin
Exubera is a new inhaled human insulin developed by Pfizer, approved by
USA FDA in Jan 2006 to be used in type 1 DM or type 2 DM It is currently
awaiting approval in Singapore
Exubera should not be used in patient with lung disease such as asthma, as
there is insufficient data to support its safe use in this group of
patients Patients must not smoke during the therapy with Exubera and must
have stopped smoking at least 6 months before starting Exubera therapy
Therapy should be discontinued immediately if a patient starts or resumes
smoking due to the increased risk of hypoglycemia and patient should seek
for alternative treatment
62 Incretin mimetic Exenatide injection
Exenatide Byetta is an incretin-mimetic that was first approved by FDA
in April 2005 It is manufactured by Amylin Pharmaceutical Exenatide is
injected within 1hr before your breakfast and dinner It
stimulates insulin
release according to the glucose level and slows stomach emptying you feel
full easily and reduces glucose produced by the liver Exenatide is
indicated as an add-on therapy for patients with type 2 DM who are taking
metformin, a sulphonylurea, a thiazolidinedione and a combination of
metformin and a sulphonylureas, or a combination of metformin and a
thiazolidinedione, but have not achieved adequate glycemic control
63 Sitagliptin Phosphate Javunia tablet
Sitagliptin phosphate is an orally -active inhibitor of the dipeptidyl
peptidase-4 DPP-4 enzyme It is manufactured by Merk Co and approved for
use in USA by FDA on October 2006 as an adjunct to diet and exercise to
improve glycemic control in patients with type 2 DM Sitagliptin blocks the
DPP-4 enzyme from breaking down the incretin hormone that stimulates the
release of insulin Because of its long duration of action, it is taken
only once-a-day The most common side effects reported are upper
respiratory tract infection, sore throat and headache
These 3 new drugs are not available in Singapore yet For more information
regarding these new drugs,
please approach your doctor or pharmacist
7 What are the possible complications of DM?
Diabetes affects many areas of the body such as the eyes, kidneys, legs and
feet
a Diabetic retinopathy is a most common diabetic eye disease that can
lead to blindness It is caused by changes in the blood vessels of the
retina If you have diabetic retinopathy, you may not notice changes
to your vision initially, but over time diabetic retinopathy can get
worse and cause vision loss It usually affects both eyes
b Diabetic nephropathy is the leading cause of chronic kidney failure in
many countries such as the United States Diabetic nephropathy is a
syndrome occurring in diabetic patient and characterized by presence
of protein in their urine
c Neuropathy Over time, long-term diabetes can cause damage to the
nerves throughout the body It may occur in every organ system,
including digestive tract, heart and sex organ
d Peripheral vascular disease and foot ulcers Peripheral vascular
disease occurs when a fatty material called plaque builds up in the
walls of the arteries that
carry blood from heart to the head,
internal organs and limbs Diabetic foot problems develop from the
combination of causes such as poor circulation and neuropathy
Diabetics may develop minor cuts, pressure sore that they may not be
aware of due to insensitivity caused by poor blood circulation If
these minor injuries left untreated, complication may result and lead
to ulceration and possible even amputation of the affected foot or
limb
e Coronary heart disease Coronary heart disease occurs when the blood
vessels that supply blood to the heart muscle coronary arteries
become hardened and narrowed Therefore, the blood flow to the heart
muscle is reduced and the heart muscle is not able to receive the
amount of oxygen it needs This can result in heart attacks
Statistics shows the risk of coronary heart disease is two to four
times greater in diabetic patients than in non-diabetic individuals
f Hypertension Type 2 DM is closely related to hypertension, and the
presence of both conditions result in a high risk for developing heart
disease, kidney failure and diabetic retinopathy
Contributed by Ms Foo Lic Yong and Ms Lee Yee Ming from Pharmaceutical
Society of Singapore
