To properly control type 2 diabetes you must attack from many different angles. It all begins with proper education, ideally from an American Diabetes Association (ADA) recognized education center with at least two certified diabetes educators, a nurse and a dietitian. Lifestyle modifications is essential — meaning proper diet, with weight loss and exercise. Studies have shown that a mere 10 pound weight loss can be beneficial to blood pressure, cholesterol, and glucose. I recommend a 10% weight loss over the next year for my overweight and obese patients. Then the key is weight loss maintenance which is best accomplished through exercise. The ADA, American Heart Association, and the Surgeon General all provide exercise guidelines and my analysis of all three is that 150 minutes per week of moderate aerobic activity is best. However, the more the merrier! The national weight control registry showed that people best maintained their weight loss when exercising on average about one hour per day while maintaining a low fat, low calorie diet. Your dietitian can help you to set reasonable, reachable, short-term weight loss goals and guide behavior modification, such as eating breakfast everyday.
After proper education and therapeutic lifestyle changes comes medications. I certainly do not want to provide individual treatment recommendations. These you need to discuss with your provider but this is my general treatment algorithm.
- Metformin first-line in nearly all people with diabetes (not to be used with people with kidney failure or heart failure) I prefer the extended-release version for less gastrointestinal side effects.
- Second-line agent depend upon other factors. For example, with obesity I prefer Exenatide while in patient with less of a weight issue I prefer Pioglitizone (not for use in uncontrolled heart failure), and if the patient needs less of a glucose reduction I may use Januvia.
- Third-line I will add Exenatide to Metformin and Pioglitizone or add Pioglitizone to Exenatide and Metformin. I prefer this triple drug combination for a number of reasons.
- Low risk of hypoglycemia
- The possibility of preservation of the beta-cell’s function (insulin-producing cells in the pancreas)
- Good glucose control
- Insulin is a great product when used in experienced hands by a well educated patient. There are numerous insulins on the market (and that may be another factoid in the future) but suffice it to say that long-acting basal (baseline) insulin is typically the first insulin started and is used to control morning glucoses. Insulin therapy is most often initiated when oral medications and/or Exenatide are no longer able to control glucoses but some providers opt for using insulin earlier in the treatment of diabetes. The ADA’s new treatment algorithm (published in Diabetes Care in December 2008) lists insulin as a possible second-line agent after Metformin. I prefer not to start insulin at this stage unless necessary due to the risk of hypoglycemia not often seen with the other medications listed above.
- I try to avoid the use of the older sulfonylureas such as Glyburide, Glipizide, and Glimepiride due to their risk of hypoglycemia. That being said, yes I do use them due to their cost effectiveness ($4.00/month at many pharmacies).
The other incredibly important aspect of diabetes treatment is the management and control of blood pressure and cholesterol as these are major risk factors for heart disease. The leading cause of death in people with diabetes.
I often say that the more I treat people with diabetes the more I realized that medicine is truly an art more than a science. Every patient is different and what works well for one will certainly not always work well for another. Individualized treatment goals and individualized treatment are essential to good care. As is the need to be treated by a team of providers to be sure you are receiving all the care and education you need and deserve.
Sources:
http://www.nwcr.ws/Research/default.htm
http://www.byetta.com/index.jsp
http://www.actos.com/actos/home.aspx
