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.

Insulin treatment in type 2 diabetics.

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.