GLUCERNA SR

Product Salient Features: Glucerna SR is complete and balanced tailor made nutrition for all types of diabetes. It provides blend of all recommended macronutrients (Fats, Protein, Carbohydrates) and important micronutrients (Vitamins/Minerals) for diabetics.Glucerna SR powder can be used as supplement or as a meal replacement in ambulatory diabetics.Glucerna SR contains a slow release energy mechanism of Complex carbohydrates which helps achieve a better glycemic control.Glucerna SR contains ideally formulated complete & balanced nutrition profile to build sound nutritional status to meet nutritional requirements of diabetics. Glucerna SR provides high MUFA lipid system. It is low in cholesterol to maintain desirable lipid profile Ideal for cardiac patients. Glucerna SR contains myo- inositol, which helps delay long-term diabetic complications such as diabetic neuropathy, nephropathy and retinopathy. Glucerna SR helps to meet nutritional goals in diabetes such as:
Control of blood glucose levels,
Sound nutritional support and helps
Helps prevent/ delay long-term diabetic complications. Glucerna SR Powder Is lactose & Gluten free so there is no risk of lactose intolerance and Gluten sensitivity disease.
Direction for use: To To make a 240ml standard feed, gradually add 4 level scoops (enclosed) or 50.4G of Formance powder in 205ml of water. Once reconstituted, each serving of Formance provides 178 calories. Formance can be recommended once, twice or more depending upon the quality of diet being consumed

Lantus

LANTUS® must NOT be diluted or mixed with any other insulin or solution.

LANTUS® (insulin glargine [rDNA origin] injection) is a sterile solution of insulin glargine for use as an injection. Insulin glargine is a recombinant human insulin analog that is a long-acting (up to 24-hour duration of action), parenteral blood-glucose-lowering agent. (See CLINICAL PHARMACOLOGY). LANTUS is produced by recombinant DNA technology utilizing a non- pathogenic laboratory strain of Escherichia coli (K12) as the production organism. Insulin glargine differs from human insulin in that the amino acid asparagine at position A21 is replaced by glycine and two arginines are added to the C-terminus of the B-chain. Chemically, it is 21A- Gly-30Ba-L-Arg-30Bb-L-Arg-human insulin and has the empirical formula C267H404N72O78S6 and a molecular weight of 6063. It has the following structural formula:
LANTUS consists of insulin glargine dissolved in a clear aqueous fluid. Each milliliter of LANTUS (insulin glargine injection) contains 100 IU (3.6378 mg) insulin glargine.
Inactive ingredients for the 10 mL vial are 30 mcg zinc, 2.7 mg m-cresol, 20 mg glycerol 85%, 20 mcg polysorbate 20, and water for injection.
Inactive ingredients for the 3 mL cartridge are 30 mcg zinc, 2.7 mg m-cresol, 20 mg glycerol 85%, and water for injection.
The pH is adjusted by addition of aqueous solutions of hydrochloric acid and sodium hydroxide. LANTUS has a pH of approximately 4.

Humulin N

(NPH HUMAN INSULIN (rDNA ORIGIN) ISOPHANE SUSPENSION, 10 mL Vial (1000 Units per vial), 100 UNITS PER ML (U-100))

Humulin is synthesized in a special non-disease-producing laboratory strain of Escherichia coli bacteria that has been genetically altered to produce human insulin. Humulin N [Human insulin (rDNA origin) isophane suspension] is a crystalline suspension of human insulin with protamine and zinc providing an intermediate-acting insulin with a slower onset of action and a longer duration of activity (up to 24 hours) than that of Regular human insulin. The time course of action of any insulin may vary considerably in different individuals or at different times in the same individual. As with all insulin preparations, the duration of action of Humulin N is dependent on dose, site of injection, blood supply, temperature, and physical activity. Humulin N is a sterile suspension and is for subcutaneous injection only. It should not be used intravenously or intramuscularly. The concentration of Humulin N is 100 units/mL (U-100).

Humulin R

(regular insulin human injection, USP (rDNA origin)100 Units per mL (U-100))

Humulin is synthesized in a special non-disease-producing laboratory strain of Escherichia coli bacteria that has been genetically altered by the addition of the gene for human insulin production. Humulin R consists of zinc-insulin crystals dissolved in a clear fluid. Humulin R has had nothing added to change the speed or length of its action. It takes effect rapidly and has a relatively short duration of activity (4 to 12 hours) as compared with other insulins. The time course of action of any insulin may vary considerably in different individuals or at different times in the same individual. As with all insulin preparations, the duration of action of Humulin R is dependent on dose, site of injection, blood supply, temperature, and physical activity. Humulin R is a sterile solution and is for subcutaneous injection. It should not be used intramuscularly. The concentration of Humulin R is 100 units/mL (U-100).

Humulin 70-30

(70% HUMAN INSULIN ISOPHANE SUSPENSION AND 30% HUMAN INSULIN INJECTION (rDNA ORIGIN) 10 mL Vial (1000 Units per vial) 100 UNITS PER ML (U-100))

DESCRIPTION

Humulin is synthesized in a special non-disease-producing laboratory strain of Escherichia coli bacteria that has been genetically altered to produce human insulin. Humulin 70/30 is a mixture of 70% Human Insulin Isophane Suspension and 30% Human Insulin Injection (rDNA origin). It is an intermediate-acting insulin combined with the more rapid onset of action of Regular human insulin. The duration of activity may last up to 24 hours following injection. The time course of action of any insulin may vary considerably in different individuals or at different times in the same individual. As with all insulin preparations, the duration of action of Humulin 70/30 is dependent on dose, site of injection, blood supply, temperature, and physical activity. Humulin 70/30 is a sterile suspension and is for subcutaneous injection only. It should not be used intravenously or intramuscularly. The concentration of Humulin 70/30 is 100 units/mL (U-100).

Acarbose

Acarbose is an anti-diabetic drug used to treat type 2 diabetes mellitus and, in some countries, prediabetes. It is sold in Europe under the brand name Glucobay (Bayer AG), in North America as Precose (Bayer Pharmaceuticals), and in Canada as Prandase (Bayer AG). It is an inhibitor of alpha glucosidase, an enteric enzyme that releases glucose from larger carbohydrates.

Since acarbose prevents the digestion of complex carbohydrates, the drug should be taken at the start of main meals. (Taken with first bite of meal.) Moreover, the amount of complex carbohydrates in the meal will determine the effectiveness of acarbose in decreasing postprandial hyperglycemia. Adults are to take doses of 25mg 3 times daily.

Side effects
Since acarbose prevents the degradation of complex carbohydrates into glucose, the carbohydrates will remain in the intestine. In the colon, bacteria will digest the complex carbohydrates, thereby causing gastrointestinal side effects such as flatulence (78% of patients) and diarrhea (14% of patients).
Since these effects are dose-related, it is generally advised to start with a low dose and gradually increase the dose to the desired amount.
If a patient using acarbose suffers from a bout of hypoglycemia, the patient should eat something containing monosaccharides, such as fruit juice or glucose tablets. Since acarbose will prevent the digestion of complex carbohydrates, starchy foods will not effectively reverse a hypoglycemic episode in a patient taking acarbose.

Gliclazide

Gliclazide is an oral hypoglycemic (anti-diabetic drug) and is classified as a sulfonylurea. It is marketed as Diamicron and Dianorm-In India. The modified-release formulation of Diamicron is marketed as Remicron MR, Diabeton MR, Diamicron 30mg, Diamicron LM 30mg, Diamicron MR 30 mg, Diamicron Uno 30mg, Dianormax MR, Diaprel MR and Uni Diamicron.

Control of hyperglycemia in gliclazide responsive diabetes mellitus of stable, mild, non-ketosis prone, maturity onset or adult type which cannot be controlled by proper dietary management and exercise, or when insulin therapy is not appropriate

Adverse effects:
Hypoglycemia, gastrointestinal disturbance (reported), skin reactions (rare), hematological disorders (rare), hepatic enzyme rises (exceptional).

Glibenclamide

Glibenclamide (INN), also known as glyburide (USAN), is an anti-diabetic drug in a class of medications known as sulfonylureas,
It is sold in doses of 1.25 mg, 2.5 mg and 5 mg, under the trade names Diabeta, Glynase and Micronase in the United States and Daonil, Semi-Daonil and Euglucon in the United Kingdom.
It is also sold in combination with metformin under the trade name Glucovance.

Side effects and contraindications
This drug is a major cause of drug induced hypoglycemia. Cholestatic jaundice is noted.
Recently published data suggests that glibenclamide is associated with significantly higher annual mortality when combined with metformin than other insulin-secreting medications, after correcting for other potentially confounding patient characteristics. The safety of this combination has been questioned.[4]

Metformin

Metformin (INN; trade names Glucophage, Riomet, Fortamet, Glumetza, Obimet, Dianben, Diabex, Diaformin, and others) (IPA: /mɛtˈfɔrmɪn/) is an oral anti-diabetic drug from the biguanide class. It is the first-line drug for the treatment of type 2 diabetes, particularly in overweight and obese people and those with normal kidney function,[1][2][3] and evidence suggests it may be the best choice for people with heart failure.[4] It is also used in the treatment of polycystic ovary syndrome.
Metformin is the most popular anti-diabetic drug in the United States and one of the most prescribed drugs in the country overall, with nearly 35 million prescriptions filled in 2006 for generic metformin alone.[5] When prescribed appropriately, metformin causes few adverse effects—the most common is gastrointestinal upset—and, unlike many other anti-diabetic drugs, does not cause hypoglycemia if used alone. It also helps reduce LDL cholesterol and triglyceride levels, and may aid weight loss. As of 2008[update], metformin is one of only two oral anti-diabetics in the World Health Organization Model List of Essential Medicines (the other being glibenclamide).[6]

Combinations with other drugs
Metformin is often prescribed to type 2 diabetes patients in combination with rosiglitazone. This drug actively reduces insulin resistance, complementing the action of the metformin. In 2002, the two drugs were combined into a single product, Avandamet, marketed by GlaxoSmithKline.[50] In 2005, all current stock of Avandamet was seized by the FDA and removed from the market, after inspections showed the factory where it was produced was violating Good Manufacturing Practices.[51] The drug pair continued to be prescribed separately in the absence of Avandamet, which was available again by the end of that year.
In the United States, metformin is also available in combination with pioglitazone (trade name Actoplus Met), the sulfonylureas glipizide (trade name Metaglip) and glibenclamide (known as glyburide in the United States, trade name Glucovance), the dipeptidyl peptidase-4 inhibitor sitagliptin (trade name Janumet), and the meglitinide repaglinide (PrandiMet). Generic formulations of metformin/glipizide and metformin/glibenclamide are available. A generic formulation of metformin/rosiglitazone from Teva has received tentative approval from the FDA, and is expected to reach the market in early 2012.[52]

Pioglitazone

Pioglitazone is a prescription drug of the class thiazolidinedione (TZD) with hypoglycemic (antihyperglycemic, antidiabetic) action. Pioglitazone is marketed as trademarks Actos in the USA, Glustin in Europe and Zactos in Mexico by the pharmaceutical company Takeda.

Pioglitazone is used for the treatment of diabetes mellitus type 2 (previously known as non-insulin-dependent diabetes mellitus, NIDDM) in monotherapy and in combination with sulfonylurea, metformin, or insulin. Pioglitazone has also been used to treat non-alcoholic steatohepatitis (fatty liver), but this use is presently considered experimental.[5]

Pioglitazone as Actos is supplied in oral tablets containing 15, 30 or 45 mg of pioglitazone base. It is also available in combination with metformin as ActoplusMet (tablets containing 15 mg pioglitazone and either 500 or 850 mg of metformin) or in combination with Amaryl as Duetact (tablets containing 30 mg pioglitazone and either 2 or 4 mg of Amaryl).

Glimepiride

Glimepiride is a medium-to-long acting sulfonylurea anti-diabetic drug. It is marketed as Amaryl by Sanofi-Aventis and as DIAPRIDE by Micro Labs Ltd. Glimepiride is the first third-generation sulfonylurea, and is very potent.
It is sometimes classified as third-generation,[1] and sometimes classified as second-generation.[2]

GI disturbance, rarely thrombopenia , leucopenia, haemolytic anaemia, occasionally allergic. In the initial weeks of treatment, the risk of hypoglycemia may be increased.

Blood glucose reagent strips

Reagent strips are saturated with glucose oxidase, an enzyme that interacts with glucose. When a drop of blood is placed on the strip, the glucose oxidase chemically reacts with the blood glucose and the resultant reaction produces a color change on the strip. The higher the glucose level, the greater the reaction and the more dramatic the color change. The blood glucose level can be determined by comparing the color of the strip with a color chart. For accurate results, test strips should be stored at room temperature and away from moisture. To protect the strips from moisture, bottles should be closed after use.
The disadvantage of reagent strips alone is that they do not give an exact glucose measurement. They are accurate enough, however, to alert patients to seriously high or low levels of glucose. Examples of reagent strips that are available over–the–counter (OTC) are Chemstrip bG and Glucostix. For an accurate blood glucose level, the reagent strip must be combined with a blood glucose meter. (See below.)

How is diabetic treatment monitored at home?

The goal of diabetic therapy is to control blood glucose levels and prevent the complications of diabetes. Glucose levels are lowered into a normal range, if possible, but it is important not to reduce the levels to abnormally low levels which can cause symptoms such as sweating, increased heart rate, and even loss of consciousness. Therefore, it is necessary not only to treat the diabetes but to monitor the effects of treatment on blood glucose levels to avoid overtreatment or undertreatment of the diabetes.
There are two types of tests for blood glucose monitoring in the home. The first type uses a reagent strip, and the second type uses a reagent strip and a glucose meter.
Glucose also can be measured in the urine. Ketoacidosis is a complication of the inadequate treatment of diabetes. This condition can be identified by testing the urine for ketones.

How is diabetic treatment monitored at home?

The goal of diabetic therapy is to control blood glucose levels and prevent the complications of diabetes. Glucose levels are lowered into a normal range, if possible, but it is important not to reduce the levels to abnormally low levels which can cause symptoms such as sweating, increased heart rate, and even loss of consciousness. Therefore, it is necessary not only to treat the diabetes but to monitor the effects of treatment on blood glucose levels to avoid overtreatment or undertreatment of the diabetes.
There are two types of tests for blood glucose monitoring in the home. The first type uses a reagent strip, and the second type uses a reagent strip and a glucose meter.
Glucose also can be measured in the urine. Ketoacidosis is a complication of the inadequate treatment of diabetes. This condition can be identified by testing the urine for ketones.

Treatment of diabetes with insulin

Insulin is the mainstay of treatment for patients with type 1 diabetes. Insulin is also important in type 2 diabetes when blood glucose levels cannot be controlled by diet, weight loss, exercise, and oral medications.
Ideally, insulin should be administered in a manner that mimics the natural pattern of insulin secretion by a healthy pancreas; however, the complex pattern of insulin secretion by the pancreas is difficult to duplicate. Still, adequate blood glucose control can be achieved with careful attention to diet, regular exercise, home blood glucose monitoring, and multiple insulin injections throughout the day. For more, please see the Diabetes and Home Care Monitoring article.
In the past, the insulin was being derived from animal sources, particularly cows and pigs. Not only was there a problem with enough supply of insulin to meet the demand, but beef and pork insulin also had specific problems. Originating from animals, these types of insulin caused immune reactions in some people. Patients would become intolerant or resistant to animal insulin. With the acceleration of scientific research in the latter half of the twentieth century, beef and pork insulin were replaced by human insulin. In 1977, the gene for human insulin was cloned, and through modern technology, manufactured human insulin was made available. Human insulin is now widely used.
Insulin now comes in a variety of preparations that differ in the amount of time following injection until they begin to work and the duration of their action. Because of these differences, combinations of insulin are often used to allow for a more tailored regimen of blood sugar control. The table below lists the most common types of insulin currently in use in the U.S. and their specific properties.

Combination medications

Glyburide/metformin (Glucovance), rosiglitazone/metformin (Avandamet), glipizide/metformin (Metaglip), and pioglitazone/metformin (Actoplus met) are four relatively new combination pills that are on the market to treat diabetes.
Glucovance combines glyburide with metformin in varying doses.
Avandamet is a combination of varying doses of Avandia and metformin.
Actoplusmet is a combination of varying doses of pioglitazone and metformin.
Metaglip is a combination pill containing glipizide and metformin in varying strengths.
The benefit to these combination drugs is that there are fewer pills to take, hopefully leading to better compliance. While they work well, I personally like to give patients individual medications until I know what doses are working, and then switch to a combination pill once the patient has been stable on the doses of individual medications for a period of time.

DPP-IV inhibitors

GLP-1 in the body is broken down by an enzyme called DPP IV. Logically, you can either make a synthetic GLP-1 that is not broken down by this enzyme (for example, Byetta) OR you could try to stop the enzyme that breaks down the GLP-1 your body already makes. Hence, the new class of drugs called DPP IV inhibitors. They do just that, that is, they inhibit this enzyme from breaking down GLP-1. This allows GLP-1 already in the blood to circulate longer. There are a number of companies working on this class of drug and the FDA just approved the first drug in this class made by Merck and called Januvia. Januvia can be used in combination with certain other medications and must be dose adjusted in patients with poor kidney function. For more, please read the Januvia pamplet.
These drugs have essentially the same side effect profile as Byetta; however, they are in pill form. While Byetta has a significant weight loss profile, DPP-IV inhibitors so far have had no effect on weight.

Byetta (exenatide)

Byetta (exenatide) is a new medication on the market that has it's origins in an interesting place--the Gila monster's saliva. Scientists studying this small lizard noted it could go a long time without eating. They found a substance in it's saliva that slowed stomach emptying, thus making the lizard feel fuller longer. This substance was similar in nature to a gut hormone found in humans known as GLP-1. GLP-1 is broken down in the body by an enzyme called DPP-IV. So, if you could make a substance like GLP-1 that was not so easy to breakdown, this would have potential benefit; thus, the studies began. Ultimately, after modifying this hormone, exenatide (with the trade name Byetta) was developed. Byetta is the first in a new class of drugs for the treatment of type 2 diabetes called incretin mimetics. Byetta has been shown to have many of the same effects on sugar regulation as GLP-1, so it mimics the body's natural physiology for self-regulating blood sugar. Namely, it slows the release of glucose from the liver, slows stomach emptying thereby regulating delivery of nutrients to the intestine for absorption, and works centrally in the brain to regulate hunger.
Byetta is indicated as additional therapy to improve control of blood sugars in patients with type 2 diabetes who are taking metformin, a sulfonylurea, or a combination of metformin and a sulfonylurea but who have not achieved adequate sugar control. It enhances the way the insulin producing beta cells in the pancreas work. Insulin secretion increases only when blood sugars are high and decreases as blood sugars approach normal. In addition to enhancing the normal physiology of the beta cell, Byetta suppresses glucose release from the liver, slows stomach emptying and the absorption of nutrients including carbohydrate, and reduces intake of food.
Just like Symlin, Byetta is given by injection, but it is given twice a day (usually before breakfast and dinner meals). It comes in a disposable pen form and is available in two doses. The goal is to start with the lower dose for a month or so and then move up to the higher dose if needed and if tolerated. Similar to Symlin, the main side effect is nausea, most likely due to its effects on stomach emptying. This medication is temperature sensitive and it was recommended that the pens be stored at 36-46 degrees F. Recently, this has changed, with a recommendation that unopened pens be refrigerated, and once opened, the pens can be left at room temperature. The risk of hypoglycemia is still a possibility with Byetta, especially when used in combination with sulfonylureas. Your physician may choose to decrease the dose of some of your other medications when initially evaluating how you respond to Byetta.
Similar to Symlin, weight reduction is seen with Byetta in the majority of patients. This makes it particularly suitable for the typical patient with type 2 diabetes who is also overweight. For more, please read the drug information pamphlet on exenatide (Byetta).
A longer acting from of Byetta is currently being considered for approval by the FDA. This would allow for the same benefits (and side effects) without need for such frequent injections.

New medications that affect glycemic control

Symlin (pramlintide)
Symlin is the first in a new class of injectable, anti-hyperglycemic medications for use in patients with type 2 or type 1 diabetes treated with insulin. Pramlintide, the active ingredient in Symlin, is a synthetic analog of human amylin, a naturally occurring neuroendocrine hormone synthesized by pancreatic beta cells that helps control glucose control after meals. Amylin, similar to insulin, is absent or deficient in patients with diabetes. When used with insulin, this compound can improve glycemic control and has additional benefits that cannot be realized with insulin alone.
According to published data, Symlin reduces post meal blood sugar peaks, reduces glucose fluctuations throughout the day, enhances satiety (the sensation of fullness) leading to potential weight loss, and lowers mealtime insulin requirements. Studies have shown it improves A1C beyond the effect of insulin alone.
Symlin is taken just prior to meals, three times a day. It is given in injection form and is used for:
Type 2 diabetes, as an additional treatment in patients who use mealtime insulin therapy and have failed to achieve desired glucose control despite optimal insulin therapy, with or without a concurrent sulfonylurea agent and/or metformin.
Type 1 diabetes, as an additional treatment in patients who use mealtime insulin therapy and who have failed to achieve desired glucose control despite optimal insulin therapy.
Symlin is considered a therapy option in patients with insulin-using type 2 or type 1 diabetes, that are unable to achieve adequate glycemic control despite individualized insulin management. Insulin-using patients with type 2 diabetes may also be taking a concurrent sulfonylurea agent and/or metformin.
The major side effect of Symlin is nausea, and this can be reduced with a slow, steady, increase in dose. The other major side effect is hypoglycemia (dangerously low levels of blood sugar). To avoid this, the dose of mealtime insulin should be cut in half when starting Symlin. Of note is the degree of weight loss seen with Symlin therapy. Studies for up to six months show weight loss of greater than six pounds more than placebo (inactive pills). For more, please read the drug information on pramlintide (Symlin).

Medications that decrease the absorption of carbohydrates from the intestine

Before being absorbed into the bloodstream, carbohydrates must be broken down into smaller sugar particles, such as glucose, by enzymes in the small intestine. One of the enzymes involved in breaking down carbohydrates is called alpha glucosidase. By inhibiting this enzyme, carbohydrates are not broken down as efficiently and glucose absorption is delayed.
Precose
The name of the alpha glucosidase inhibitor available in the U.S. is acarbose (Precose). In clinical trials with over 700 patients, the use of Precose was associated with a reduction in hemoglobin A1c values (a well known measurement of average blood sugars over the preceding three months) that was significantly greater than the use of placebo (no treatment). However, as a single agent, Precose is not as effective as the other medications for diabetes. Since Precose works in the intestine, its effects are additive to diabetic medications that work at other sites, such as sulfonylureas. Clinical studies have shown statistically better control of blood glucose in patients treated with Precose and a sulfonylurea compared to the sulfonylurea alone. Precose is currently used alone or in combination with a sulfonylurea.
Precose is taken three times a day at the beginning of meals. The dosage varies from 25 to 100mg with each meal. The maximum recommended dose is 100mg three times a day. At doses greater than this, reversible abnormalities in liver tests may be seen. Because of its mechanism of action, Precose has significant gastrointestinal side effects. Abdominal pain, diarrhea, and gas are common and are seen in up to 75% of patients taking Precose. For this reason, Precose is administered using a low initial dose that is increased over weeks depending on the patient's tolerance. Most of the gastrointestinal symptoms tend to subside over the course of a few weeks although some patients report persistent problems. For more information, please read the drug information on acarbose (Precose).

Medications that increase the sensitivity of cells to insulin

The class of drugs known as thiazolidinediones lowers blood glucose by improving target cell response to insulin (that is, increasing the sensitivity of the cells to insulin). Troglitazone (Rezulin) was the first of this class in the U.S. Because of severe toxic liver effects, troglitazone has been taken off the market. Sister compounds are now available with a better safety profile. These drugs include pioglitazone (Actos) and rosiglitazone (Avandia).
Pioglitazone (Actos) and rosiglitazone (Avandia) are thiazolidinediones approved for use in the U.S. While they are sister compounds to Rezulin, extensive studies have failed to show that they are associated with any liver problems. Both Avandia and Actos act by increasing the sensitivity (responsiveness) of cells to insulin. They improve the sensitivity of muscle and fat cells to insulin. These drugs have been effective in lowering blood sugars in patients with type 2 diabetes, Actos and Avandia act within one hour of administration and are taken once daily. It is important to note that it takes up to six weeks to see a drop in blood glucose levels with these drugs and up to 12 weeks to see a maximum benefit. Actos and Avandia have been approved as first line therapy in diabetes and for use in combination with other drugs. Both drugs may be used in patients taking other oral drugs as well as those using insulin.
While reported liver problems with these agents are mild (and reversible with discontinuation of the drug), most physicians choose to follow an earlier recommendation to do blood tests to detect liver injury every two months or so during the first year of therapy. Recently this recommendation has been removed. If at any point the liver tests increase to three times the normal upper limit, the drug should be stopped.
The most important contraindications to these medications include any type of liver disease, and heart failure. Fluid retention can be of particular concern in patients with signs or symptoms of heart failure and in those with ejection fractions of less than 40% which indicates poor function of the heart. While the reports are three to eight pounds, clinical experience shows up to 12-15 pounds of weight gain can occur. Usually the majority of this is fluid, but an absolute body weight gain can also occur. This is likely to be dose-dependent and, therefore, the increases in weight may be greater with higher doses of drug. Weight gain is more pronounced in patients who are also taking insulin. In general, the ankle swelling and puffiness due to the accumulation of fluid can be controlled with the addition of a diuretic such as spironolactone (Aldactone) — (furosemide (Lasix) does not work as well) — or by reducing the dose. On occasion, patients may be symptomatic enough from fluid retention to warrant withdrawal of the drug. Some recent studies have suggested an association between pioglitazone and rosiglitazone and untoward cardiac events, for example, heart attacks, though this association is controversial. Regardless of the controversy, it is well established that pioglitazone and rosiglitazone should be avoided in patients with symptomatic heart failure or heart failure.
Another newer concern is an association of treatment with a small increase in the frequency of fractures of the distal long bones of the arms and legs. At present, this does not translate into fractures of the hip and spine, which would be clinically more worrisome. More data is needed to make a definitive statement about cause and effect at this time.
As an aside, Actos and Avandia have an added benefit of changing cholesterol patterns in diabetes. HDL (or good cholesterol) increases with these medications, and triglycerides often decrease. While there is some controversy regarding what happens to bad cholesterol (LDL) levels, there is a suggestion that Actos may be superior in changing lipid profiles than Avandia. In this population of diabetics that is already at an increased risk for heart disease, an improvement in cholesterol profile is beneficial. As more and more data becomes available, there is mounting evidence that this class of drugs may provide direct benefits to the heart and large blood vessels and may actually be valuable in preventing the progression of diabetes in high-risk individuals by reducing inflammation and by decreasing clotting factors. As time goes on, I have no doubt that the uses for this class of medications will expand. For more, please read the drug information on pioglitazone (Actos) and rosiglitazone (Avandia).

Medications that decrease the amount of glucose produced by the liver

A class of drugs called biguanides has been used for many years in Europe and Canada. In 1994, the FDA approved the use of the biguanide metformin (Glucophage) for the treatment of type 2 diabetes in the U.S. Glucophage is unique in its ability to decrease glucose production by the liver. Briefly, because metformin does not increase insulin levels, when used alone, it does not usually cause hypoglycemia. In addition, metformin has an effect whereby it tends to suppress appetite, which may be beneficial in diabetics who tend to be overweight. Metformin may be used by itself or together with other oral drugs or insulin. It should not be used in patients with kidney impairment and should be used with caution in those with liver impairment. The older biguanides that preceded metformin were associated with a serious condition called lactic acidosis, a dangerous acid build up in the blood resulting from accumulation of the drug and its breakdown products. While metformin is safer in this regard, it is recommended that the drug be discontinued for 24 hours before any procedure involving the intravenous injection of dyes (such as for some x-ray studies of the kidney) or surgery is performed. The dyes may impair kidney function and cause a build up of the drug in the blood. Metformin can be restarted after these procedures once the patient is urinating normally.

Meglitinides - repaglinide (Prandin) and nateglinide (Starlix)

The class of drugs known as meglitinides is relatively new. Meglitinides also work on the pancreas to promote insulin secretion. Unlike sulfonylureas that bind to receptors on the insulin producing cells, meglitinides work through a separate potassium based channel on the cell surface. Unlike the sulfonylureas which last longer in the body, repaglinide (Prandin) and nateglinide (Starlix) are very short acting, with peak effects within one hour. For this reason, they are given up to three times a day just before meals. Since these drugs also increase circulating insulin levels, they may cause hypoglycemia, but the literature suggests this is less frequent than the hypoglycemia seen with sulfonylureas.

Sulfonylureas

Historically, increasing insulin output by the pancreas has been the major area targeted by medications used to treat type 2 diabetes. Medications that increase the output of insulin belong to a class of drugs called sulfonylureas. Sulfonylureas primarily lower blood glucose levels by increasing the release of insulin from the pancreas. Older generations of these drugs include chlorpropamide and tolbutamide, while newer drugs include glyburide (DiaBeta), glipizide (Glucotrol), and glimepiride (Amaryl). These drugs are effective in rapidly lowering blood sugar but run the risk of causing hypoglycemia (abnormally low and dangerous levels of blood sugar). In addition, they are sulfa-containing drugs and should be avoided by patients who are allergic to sulfa .

Medications for type 2 diabetes

WARNING: All the information below applies to patients who are not pregnant or breastfeeding. At present the only recommended way of controlling diabetes in women who are pregnant or breastfeeding is by diet, exercise and insulin therapy. You should speak with your doctor if you are taking these medications and are considering becoming pregnant or if you have become pregnant while taking these medications.
Based on what is known, medications for type 2 diabetes are designed to:
Increase the insulin output by the pancreas.
Decrease the amount of glucose released from the liver.
Increase the sensitivity (response) of cells to insulin.
Decrease the absorption of carbohydrates from the intestine.
Slow emptying of the stomach to delay the presentation of carbohydrates for digestion and absorption in the small intestine.
When selecting therapy for type 2 diabetes, consideration should be given to:
The magnitude of change in blood sugar control that each medication will provide.
Other coexisting medical conditions (high blood pressure, high cholesterol, etc.)
Adverse effects of the therapy
Contraindications to therapy
Issues that may affect compliance (timing of medication, frequency of dosing)
Cost to the patient and the healthcare system
It's important to remember that if a drug can provide more than one benefit (lower blood sugar and have a beneficial effect on cholesterol, for example), it should be preferred. It's also important to bear in mind that the cost of drug therapy is relatively small compared to the cost of managing the long-term complications associated with poorly controlled diabetes.
Varying combinations of medications also are used to correct abnormally elevated levels of blood glucose in diabetes. As the list of medications continues to expand, treatment options for type 2 diabetes can be better tailored to meet an individuals needs. Not every patient with type 2 diabetes will benefit from every drug, and not every drug is suitable for each patient. Patients with type 2 diabetes should work closely with their physicians to achieve an approach that provides the greatest benefits while minimizing risks.
Patients with diabetes should never forget the importance of diet and exercise. The control of diabetes starts with a healthy lifestyle regardless of what medications are being used.

How is diabetes treated?

The major goal in treating diabetes is to minimize any elevation of blood sugar (glucose) without causing abnormally low levels of blood sugar. Type 1 diabetes is treated with insulin, exercise, and a diabetic diet. Type 2 diabetes is treated first with weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugars, oral medications are used. If oral medications are still insufficient, treatment with insulin is considered.
Adherence to a diabetic diet is an important aspect of controlling elevated blood sugar in patients with diabetes. The American Diabetes Association (ADA) has provided guidelines for a diabetic diet. The ADA diet is a balanced, nutritious diet that is low in fat, cholesterol, and simple sugars. The total daily calories are evenly divided into three meals. In the past two years, the ADA has lifted the absolute ban on simple sugars. Small amounts of simple sugars are allowed when consumed with a complex meal.
Weight reduction and exercise are important treatments for diabetes. Weight reduction and exercise increase the body's sensitivity to insulin, thus helping to control blood sugar elevations.