Treatment of Diabetes

A landmark study, the 10-year, multi-center Diabetes Control and Complications Trial (DCCT), has now shown that intensifying diabetes management with stricter control of blood sugar levels can reduce long-term complications.

The results of DCCT are extraordinary in that they prove that tight control of glucose levels can in fact dramatically slow the onset and progression of diabetic complications in both Type I and Type II diabetes. Additionally, researchers have found strict attention to diet and exercise also helps in the management of diabetes.

• Management of Type I Diabetes

Virtually everyone with Type I diabetes (and more than one in three people with Type II) must inject insulin to make up for their deficiency. Until recently, insulin came only from the pancreases of cows and pigs (with pork insulin more closely duplicating human insulin). While beef, pork and beef/pork combinations are still widely used, there are now two types of "human" insulin available: semisynthetic (made by converting pork insulin to a form identical to human) and recombinant (made by using genetic engineering). All insulin helps glucose levels remain near normal (about 70 to 120 mg/dl).

Different types of insulin work for different periods of time. The numbers shown below are only averages. The onset (how long it takes to reach the bloodstream to begin lowering the blood sugar), peaking (how long it takes to reach maximum strength) and duration (how long it continues to lower the blood sugar) of insulin activity can vary from person to person and even from day to day in the same person.

Rapid or Regular Activity: Onset is within half an hour and activity peaks during a 2 to 5 hour period. It remains in the bloodstream for about 8 to 16 hours. These fast-acting, short-lasting insulins are useful in special cases: accidents, minor surgery or illnesses, which cause the diabetes to go out of control or whenever insulin requirements change rapidly for any reason. These are also being used more and more in combination with a long-acting insulin or alone (prior to meals and at bedtime).

Semilente: A special type of short-acting insulin that takes 1 to 2 hours for onset, peaks 3 to 8 hours after injection and lasts 10 to 16 hours.

Intermediate-Acting: Reaching the bloodstream 90 minutes after injection, intermediate-acting insulin peaks 4 to 12 hours later and lasts in the blood for about 24 hours. There are two varieties of this type of insulin: Lente (called L) and NPH (called N).

Long-Acting: These insulins, which take 4 to 6 hours for onset, are at maximum strength 14 to 24 hours after injection, lasting 36 hours in the bloodstream. Long-acting insulin is referred to as U (for Ultralente).

Please be aware of the following problems that exist with insulin intake:

• Hypoglycemia (low blood sugar) is sometimes called an insulin reaction or insulin shock. It can occur suddenly in people using insulin if too little food is eaten, if a meal is delayed or in the case of extreme exercise. Symptoms include feeling cold, clammy, nervous, shaky, weak or hungry, and some people become pale, have headaches or act strangely.
• Hyperglycemia (high blood sugar) occurs when too much food is eaten or not enough insulin is taken. The warning signs are large amounts of sugar in the urine and blood, frequent urination, great thirst and nausea.
• Ketoacidosis (in its most severe form - diabetic coma) develops when insulin and blood sugar are so out of balance that ketones accumulate in the blood. Symptoms include high blood sugar or ketones in the urine, dry mouth, great thirst, loss of appetite, excessive urination, dry and flushed skin, labored breathing, fruity-smelling breath and possible vomiting, abdominal pain and unconsciousness.

In addition to daily injections of insulin, regular physical activity and a controlled diet are essential. The American Diabetes Association (ADA) recommends the following daily dietary guidelines:

• Up to 70 percent of all calories should be obtained from carbohydrates and unsaturated fats. These carbohydrates should be mainly complex carbohydrates and naturally occurring sugars (simular to those in milk and fruits). Examples of unsaturated fats are vegetable oils and margarine.
• Between 10 and 20 percent of calories should be obtained from protein.
• Less than 10 percent of all calories should be obtained from fat. Saturated fats are found in animal products and in some vegetable oils (such as coconut, palm, and palm-kernel oils).
• Eat 30 to 35 grams of fiber.
• Eat no more than 300 mg of cholesterol.

For Type I diabetes, the meal plan should be tailored to the person's individual needs and is likely to include three meals and two or three snacks a day. A person with diabetes must eat these meals and snacks at set times each day to properly balance insulin.

• Management of Type II Diabetes

The ADA recommends diet (see ADA guidelines stated above) and regular physical activity as the first line of treatment for Type II diabetes. If normal glycemic levels are not achieved within three (3) months, drug treatment is recommended.

Currently there are four (4) classes of prescription drugs available for the treatment of Type II diabetes:

1. Sulfonylureas (Diabinese, Dymelor, PresTab, Orinase, Tolinase, Micronase, DiaBeta, Glynase, Glucotrol, Glucotrol XL and Amaryl), which stimulate the pancreas to release more insulin.
2. Biguanides (Glucophage and Metformin), which keep the liver from releasing too much glucose.
3. Alpha-glucoside inhibitors (Precose), which slow the digestion of some carbohydrates.
4. Thiazolidinediones, which control glucose levels by making muscles more sensitive to insulin and reduce the amount of glucose that the liver produces.

Clinical trials suggest that oral antidiabetic agents - particularly the new noninsulin secretagogues (including Troglitazone and Metformin, which act on the liver and skeletal muscle) - may be useful in delaying or preventing development of Type II diabetes. Both agents, acting primarily by different mechanisms of action, also have demonstrated potential beneficial effects on serum lipid profiles.

Although these oral medications work in different ways, they can be combined to work more effectively to manage Type II diabetes. When these combinations of oral treatments are no longer effective (for about 60 percent of people with Type II diabetes), the doctor will start a regimen of insulin alone or in combination with an oral medication.