Diet
The
mainstay of treatment in Type 2 diabetes should always be diet. Where
glycaemic control cannot be maintained tablets may be added.
Tablets for Diabetes
The Sulphphonylurea Group of Medicines
Gliclazide, Glipizide, Gliblenclamide, Tolbutamide and Chlorpropramide
are the oral hypoglycaemic agents, which work by making the islet cells
secrete insulin. There appear to be no specific advantages at present
between older versions and newer versions in terms of glycaemic control
of long-term outcomes, although there may be some differences in the
rates of hypoglycaemia with different agents, particularly in the
elderly. A new sulphonylurea receptor agonist agent (glimepiride)
has been recently introduced, but its place in therapy remains yet to
be established. They can all cause lowering of bloodglucose and
therefore hypoglycaemia and also weight gain
Metformin
has
been shown to be increasingly important in the control of diabetes in
overweight subjects. It has no direct effect on the pancreas, but
appears to act on target tissues by increasing insulin sensitivity.
Metformin’s major side effects include abdominal discomfort and
diarrhoea. It also should not be used in patients with heart or renal
failure, and caution should be exercised with the coincident use of
X-ray contrast material. Metformin is currently being formulated to
reduce its gastrointestinal side effects. Metformin does not cause
hypoglycaemia. The UKPDS has shown that metformin has specific
benefits in reducing death rates and reducing diabetic complications in
obese Type 2 diabetes patients. Consequently, metformin will become
increasing important in the treatment of Type 2 diabetes.
Acarbose
Is
a novel gut enzyme inhibitor, may also have a place in the management
of obese patients. It delays the absorption of glucose from the gut,
reduces post meal hyperglycaemia and may also improve insulin
sensitivity. It does not cause hypoglycaemia; its use is limited by
the predicable side effects of diarrhoea and flatulence. A new class of
agent, the thiazolidineiones, is now available (Rosiglitazone and
Pioglitazone). These agents have novel actions, working in the nucleus
of target cells, with the net effect of reduced insulin resistance,
improved insulin sensitivity and reduced fat production. Rosiglitazone
can be prescribed in Type 2 diabetic’s patients with poor glycaemic
control, in combination with sulphonylurea or metformin, but not with
both, or with insulin.
Two Further New Agents
for Type 2 diabetes are Nataglinide and Rapaglinide.
These agents are of the megalitinide class drug, which causes insulin
secretion. They have a very short action, and may reduce post -meal
hyperglycaemia more effectively than sulphonylurea type of drugs and
may cause fewer episodes of hypoglycaemia.
Rosiglitazone and Pioglitazone (TZDs)
are
a new type of medication for diabetes, which work in a very different
way from other diabetic medications. It makes the body more sensitive
to insulin. It is very useful for people with type II diabetes who
are more than average weight. If you are starting TZDs, you will need
to do tests on your liver to ensure that there is no liver problems, at
at intervals afterwards. TZDs cannot be given with insulin treatment
nor can it be given to patients with severe kidney problems or heart
failure. As with all medication there are some side effects such as
nausea, abdominal discomfort and vomiting can occur. However
generally side effects are rare. A theoretical risk of liver disease is
reported; hence the need for blood tests on your liver. Weight gain of
between two and three kilograms per person is commonly reported and can
be controlled by attention to a diabetic diet. There is a beneficial
effect in lowering blood fats.
Even
with all the potential treatments for Type 2 diabetes, because
beta-cell function deteriorates, and insulin production falls, a large
number of people will fail to achieve adequate control with tablets,
and will need to start insulin treatment. Unfortunately, insulin
treatment in Type 2 diabetes is associated with weight gain and
hypoglycaemia, although the rate of hypoglycaemia is probably no
greater than if treated with tablets. In the near future, it is likely
that people with Type 2 diabetes will be treated with
compicated regimes of tablets and insulin to optimise glycaemic control and reduce the rate of weight gain and hypoglycaemia.