Short stories, Travel and Health Information
In writing this series of articles about Diabetes, I must admit that the condition we refer to as Diabetes is more complex than just a situation of inadequate insulin production by the body. What I have aimed to do is simply to present a practical and plausible framework for Diabetes management in manner that is easy to understand for the intelligent non-medical reader.
The treatment of Diabetes in years gone by was relatively straightforward because all we had as medications were tablets of the Biguanide group (like Metformin) and the Sulphonylurea group (like Glibenclamide and Gliclazide) plus injections of Insulin.
During the past three decades, however, novel medications have improved blood sugar control for diabetics but they have complicated the picture by increasing the costs of treatment and the range of possible adverse effects. These days it is not so easy to decide which particular drug combination will suit a particular patient at a particular stage in their disease.
Our current guidelines for blood glucose control recommend diet, weight control and physical exercise as the first step, with oral Metformin added when needed – followed as necessary by one of the Sulphonylureas. When these become inadequate to control blood glucose levels, the third line agents recommended are Acarbose, Thiazolidinediones, Incretin-based medications and Insulin.
If these two measures prove inadequate, most doctors would suggest a small dose of Metformin tablets (sold under various trade names like Diabex, Diaformin, Glucophage, etc). Usually one starts with a 500 mg tablet once or twice or even three times a day. This dose can be increased up to a maximum total daily dose of 2000 grams.
Measuring blood glucose levels and the HbA1C level (which indicates what the average blood sugar level was like over the preceding three months) or the Fructosamine level (which indicates what the average blood sugar level was like over the preceding three weeks) allows the doctor to modify the dosage of Metformin in order to achieve optimum blood sugar control. If using the maximum permissible dose proves ineffective, the usual practice today would be to add a tablet from the suplhonylurea group. Several of these are available (Daonil, Diamicron, Amaryl etc) varying in their duration of action and the rapidity with which they take effect.
When Diet, weight loss, exercise and therapy with Metformin and sulphonyl urea tablets fails to achieve sufficient control of blood glucose levels, what other tablets are available?
Pioglitazone (sold as Actos) can be tried, but is associated with weight gain, swelling of the ankles and worsening of cardiac failure. Latterly there has also been a suggestion that long term use is associated with an increased risk of bladder cancer. Acarbose is another tablet worth worth trying, although its possible side effects such as flatulence and diarrhoea can prove to be a social disadvantage.
Among the latest medications available for managing Diabetes are those known as DPP-4 Inhibitors – the tablets currently available being Saxagliptin (Onglyza), Sitagliptin (Januvia) and Vildagliptin (Galvus). Basically, these tablets increase the amount of GLP-1, a hormone belonging to the Incretin group, which enhances the production of insulin in response to sugars taken in as food. They are relatively inactive when there is no glucose entering the blood from the intestine. Consequently, their risk of inducing Hypoglycaemia (blood sugar levels falling too low) is small. The only limitation in the use of these Incretin-based therapies is the lack of long term data as they are relatively new medications.