In treating Diabetes, we follow the guidelines of the Canadian Diabetes Association. A panel of the foremost experts in Diabetes in Canada have put together a set of recommendations and treatment guidelines based on scientific evidence. These were the first evidence-based guidelines in the world. Since the publication of 2 major studies (The Diabetes Control and Complications Trial on Type 1 Diabetics in 1993 and the United Kingdom Prospective Diabetes Study on Type 2 Diabetics in 1998) we have known that the complications of Diabetes (blindness, kidney failure, high blood pressure, heart disease etc.) depend upon the level of glucose in the blood. We measure long term glucose control using a blood test called HbA1c (or glycosylated hemoglobin) which is done every 3 months. We know that in order to have the lowest possible risk of complications we need a HbA1c within 115% of the upper limit of normal, this corresponds to an average glucose level of 7.0 mmol/L or less.
When we start treating Type 2 Diabetes, in accordance with the Canadian Diabetes Association's recommendations, we start with diet and exercise, if we cannot achieve normal glucose levels by these means, then we must add on medications.
There are several classes of medications we can use:
Sulphonylureas (Glyburide, Amaryl and Diamicron): These drugs stimulate the pancreas to produce more insulin, the increased insulin levels in turn reduce blood glucose. These drugs can be increased to a maximum dose of 4 tablets a day although usually a lesser dose gives most of the effect of the maximum dose. If we give more than 4 tablets a day, we gain nothing and in fact the drug may become less effective while the side effects increase. The downside to this class of drug is that frequently the person with diabetes is insulin resistant, so increasing insulin quantities has only minimal effect. Another problem is that these drugs, particularly in the elderly may cause low blood sugars (although Diamicron is much less likely to do this). If control is not achieved then we may add on a member of another drug class.
Biguanides (Glucophage or Metformin): These drugs act primarily be reducing the amount of Glucose manufactured by the liver overnight. They reduce high morning glucose levels. These drugs will not normally cause low blood sugars but will reduce high sugars. Dosage is up to 4 500 mg tablets a day. If normal glucose levels cannot be achieved then we must ADD ON a drug of another class.
Thiazolidenediones (Avandia and Actos): These drugs treat the insulin resistance that is frequently part of Type 2 Diabetes. Meaning that it takes a greater amount of insulin to cause a reduction in the blood sugar of a diabetic than it does in a normal person. This class of drug helps correct this deficit and allows smaller quantities of insulin to be more effective. It may be added on to the above classes of drugs or may be started on it's own.
Acarbose (Prandase) slows the absorption of carbohydrates allowing the failing pancreas more time to deal with the incoming sugar load. If the load is reduced by slowing absorption then the pancreas even though it is not functioning at full capacity may be able to produce enough insulin over time to deal with the meal load. This drug may be given alone in the early stages of diabetes or may be added on to other drugs if control cannot be achieved.
The principle of Diabetes Treatment is that we start with one thing and if control cannot be achieved, we keep on adding on more drugs with different actions until we do achieve control. We also have goals for blood pressure and lipid (cholesterol) levels. These are also based on scientific evidence and if we can't achieve the goal levels (recommended by the Canadian Diabetes Association) we continue to add on more treatment until we reach goals. It may seem to you that you are taking too many pills but you should be assured that you are taking only those pills needed to reach treatment goals and prevent complications and that the choice and dosage of pills is in accordance with the recommendations of the foremost experts in Canada on Diabetes.
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