What are the different types of oral glucose medications. How do these medications work to lower blood sugar levels. What are the potential side effects of oral glucose medications. Which oral glucose medications are most commonly prescribed. How do doctors choose the appropriate oral glucose medication for a patient.

Understanding Oral Glucose Medications: A Comprehensive Overview

Oral glucose medications play a crucial role in managing diabetes by helping to control blood sugar levels. These medications come in various types, each with its unique mechanism of action and potential side effects. This comprehensive guide will explore the different classes of oral glucose medications, their uses, and important considerations for patients and healthcare providers.

Alpha-Glucosidase Inhibitors: Slowing Carbohydrate Absorption

Alpha-glucosidase inhibitors, such as acarbose (Precose) and miglitol (Glyset), work by slowing down the breakdown of carbohydrates in the intestine. This mechanism helps to delay the rise in blood sugar levels after meals.

How do alpha-glucosidase inhibitors work?

These medications block the enzymes responsible for breaking down complex carbohydrates into simple sugars. By doing so, they slow the digestion and absorption of carbohydrates, which helps to prevent rapid spikes in blood glucose levels.

Potential side effects of alpha-glucosidase inhibitors

• Gastrointestinal discomfort
• Flatulence
• Diarrhea

To minimize these side effects, it’s recommended to take alpha-glucosidase inhibitors with the first bite of a meal. This allows the medication to work effectively as you consume carbohydrates.

Biguanides: Enhancing Insulin Sensitivity and Reducing Glucose Production

Metformin (Glucophage) is the most widely prescribed biguanide and is often considered the first-line treatment for type 2 diabetes. This medication works through multiple mechanisms to help control blood sugar levels.

How does metformin lower blood sugar?

1. Decreases glucose production in the liver
2. Improves insulin sensitivity in muscle tissue
3. Enhances glucose absorption

Metformin is typically taken twice daily, and its effectiveness has made it a cornerstone of diabetes management. While it can cause gastrointestinal side effects, particularly diarrhea, these symptoms often improve when the medication is taken with food.

Bile Acid Sequestrants: Dual Action on Cholesterol and Blood Sugar

Bile Acid Sequestrants (BASs), such as colesevelam (Welchol), offer a unique approach to managing both cholesterol levels and blood sugar in patients with diabetes.

How do BASs work?

These medications primarily work by binding to bile acids in the digestive system, which forces the body to use cholesterol to produce more bile acids. This process helps to lower LDL cholesterol levels. Additionally, BASs have been found to have a positive effect on blood glucose levels, although the exact mechanism is not fully understood.

Advantages of BASs for diabetes management

• Safe for patients with liver problems
• Not absorbed into the bloodstream
• Dual action on cholesterol and blood sugar

However, patients should be aware of potential side effects such as flatulence and constipation due to the medication’s action in the digestive system.

DPP-4 Inhibitors: Preserving Natural Blood Sugar Control

DPP-4 inhibitors, also known as gliptins, represent a newer class of diabetes medications that work by enhancing the body’s natural ability to control blood sugar levels.

How do DPP-4 inhibitors lower blood glucose?

These medications prevent the breakdown of GLP-1, a naturally occurring compound in the body that helps regulate blood sugar levels. By preserving GLP-1, DPP-4 inhibitors allow it to remain active longer, which helps lower blood sugar levels when they are elevated.

Benefits of DPP-4 inhibitors

• Low risk of hypoglycemia
• Weight-neutral or may promote slight weight loss
• Potential positive effects on cholesterol levels

Currently available DPP-4 inhibitors in the US market include alogliptin (Nesina), linagliptin (Tradjenta), saxagliptin (Onglyza), and sitagliptin (Januvia). These medications offer an alternative for patients who may not tolerate other diabetes medications well.

Meglitinides: Rapid-Acting Insulin Secretagogues

Meglitinides, such as nateglinide (Starlix) and repaglinide (Prandin), are a class of medications that stimulate the pancreas to release insulin quickly. They are particularly useful for managing post-meal blood sugar spikes.

How do meglitinides work?

These medications bind to specific receptors on pancreatic beta cells, triggering the release of insulin. Unlike some other diabetes medications, meglitinides have a rapid onset and short duration of action, making them ideal for mealtime dosing.

Considerations when using meglitinides

• Taken before each meal (usually three times daily)
• May cause hypoglycemia if meals are skipped or delayed
• Should be used cautiously in patients with kidney or liver problems

Patients taking meglitinides should be aware of the potential for hypoglycemia and know how to recognize and treat low blood sugar episodes.

SGLT2 Inhibitors: Promoting Glucose Excretion

Sodium-glucose cotransporter 2 (SGLT2) inhibitors represent an innovative approach to diabetes management by targeting the kidneys’ role in glucose reabsorption.

How do SGLT2 inhibitors lower blood sugar?

These medications work by blocking the action of SGLT2 in the kidneys, which is responsible for reabsorbing glucose from the urine. By inhibiting this process, SGLT2 inhibitors cause excess glucose to be excreted in the urine, effectively lowering blood sugar levels.

Available SGLT2 inhibitors and their benefits

• Canagliflozin (Invokana)
• Dapagliflozin (Farxiga)
• Empagliflozin (Jardiance)

In addition to their glucose-lowering effects, SGLT2 inhibitors have shown potential cardiovascular benefits in some studies. However, patients should be aware of increased risks of urinary tract and yeast infections due to the increased glucose levels in the urine.

Sulfonylureas: Stimulating Insulin Production

Sulfonylureas have been a mainstay of diabetes treatment since the 1950s. These medications work by stimulating the pancreas to produce more insulin, helping to lower blood sugar levels.

How do sulfonylureas lower blood glucose?

Sulfonylureas bind to specific receptors on pancreatic beta cells, triggering the release of insulin. This increase in insulin production helps to lower blood sugar levels, particularly after meals.

Types of sulfonylureas

1. First-generation: Chlorpropamide (Diabinese)
2. Second-generation:
   • Glimepiride (Amaryl)
   • Glipizide (Glucotrol and Glucotrol XL)
   • Glyburide (Micronase, Glynase, and Diabeta)

Second-generation sulfonylureas are generally preferred due to their improved potency and reduced side effect profile. However, all sulfonylureas carry a risk of hypoglycemia, and patients should be educated on recognizing and managing low blood sugar episodes.

Precautions when using sulfonylureas

• Increased risk of hypoglycemia, especially in elderly patients or those with kidney problems
• Potential for weight gain
• Interactions with alcohol, potentially causing flushing or nausea

Patients taking sulfonylureas should work closely with their healthcare providers to monitor blood sugar levels and adjust dosages as needed.

Choosing the Right Oral Glucose Medication: Factors to Consider

Selecting the most appropriate oral glucose medication for a patient with diabetes involves careful consideration of various factors. Healthcare providers must weigh the benefits and potential risks of each medication class against the individual patient’s needs and medical history.

What factors influence the choice of oral glucose medication?

• Patient’s overall health and existing medical conditions
• Severity of diabetes and current blood sugar control
• Risk of hypoglycemia
• Potential side effects and drug interactions
• Patient’s lifestyle and ability to adhere to medication regimens
• Cost and insurance coverage

In many cases, a combination of different medication classes may be necessary to achieve optimal blood sugar control. This approach, known as oral combination therapy, allows for targeting multiple aspects of glucose regulation simultaneously.

Personalized approach to diabetes management

The field of diabetes management is continually evolving, with new medications and treatment strategies emerging regularly. Healthcare providers must stay informed about the latest developments and tailor treatment plans to each patient’s unique needs and preferences.

Patients should be encouraged to actively participate in their diabetes management by:

• Monitoring blood sugar levels regularly
• Reporting any side effects or concerns to their healthcare provider
• Adhering to prescribed medication regimens
• Making lifestyle modifications, including diet and exercise
• Attending regular follow-up appointments

By working collaboratively with their healthcare team and staying informed about their treatment options, patients with diabetes can achieve better blood sugar control and reduce the risk of long-term complications associated with the disease.

Monitoring and Adjusting Oral Glucose Medication Regimens

Effective diabetes management requires ongoing monitoring and adjustment of medication regimens. As a patient’s condition changes over time, their response to medications may also change, necessitating modifications to their treatment plan.

How often should oral glucose medications be reviewed?

The frequency of medication reviews depends on several factors, including:

• The patient’s overall blood sugar control
• The presence of any side effects or complications
• Changes in the patient’s health status or lifestyle
• Introduction of new medications that may interact with diabetes drugs

Generally, patients should have their medication regimens reviewed at least every 3-6 months, or more frequently if there are concerns about efficacy or side effects.

Tools for monitoring medication effectiveness

Healthcare providers use various tools to assess the effectiveness of oral glucose medications:

1. HbA1c tests: Measure average blood sugar levels over the past 2-3 months
2. Fasting and postprandial glucose readings: Provide day-to-day blood sugar information
3. Continuous glucose monitoring (CGM): Offers real-time glucose data throughout the day and night
4. Patient-reported symptoms and side effects
5. Regular physical examinations and laboratory tests to monitor for potential complications

By regularly assessing these parameters, healthcare providers can make informed decisions about whether to continue, adjust, or change a patient’s oral glucose medication regimen.

Emerging Trends in Oral Glucose Medications

The field of diabetes management is dynamic, with ongoing research leading to the development of new medications and treatment strategies. Several exciting trends are shaping the future of oral glucose medications:

What are some promising developments in oral glucose medications?

• Dual and triple-action medications: Combining multiple drug classes in a single pill to simplify treatment regimens and improve adherence
• Smart insulin pills: Research into oral insulin formulations that could potentially replace injections for some patients
• Gut microbiome modulators: Medications that target the gut microbiome to improve glucose metabolism and insulin sensitivity
• Personalized medicine approaches: Using genetic and biomarker data to tailor medication choices to individual patients
• Digital health integration: Combining oral medications with digital health technologies for improved monitoring and management

These emerging trends hold promise for more effective, personalized, and user-friendly diabetes management strategies in the future. However, it’s important to note that many of these developments are still in the research phase and may take years to become widely available.

The importance of ongoing research and clinical trials

Continued research and clinical trials are essential for advancing our understanding of diabetes and developing new treatment options. Patients and healthcare providers should stay informed about ongoing studies and consider participation in clinical trials when appropriate. This engagement not only contributes to scientific knowledge but also provides patients with access to cutting-edge treatments and close medical monitoring.

As the landscape of oral glucose medications continues to evolve, the goal remains to provide patients with effective, safe, and convenient options for managing their diabetes and improving their overall quality of life.

What Are My Options? | ADA

There are different types, or classes, of drugs that work in different ways to lower blood sugar (also known as blood sugar) levels:

• Alpha-glucosidase inhibitors
• Biguanides
• Bile Acid Sequestrants
• Dopamine-2 Agonists
• DPP-4 inhibitors
• Meglitinides
• SGLT2 Inhibitors
• Sulfonylureas
• TZDs 
• Oral combination therapy

Alpha-glucosidase inhibitors

Acarbose (Precose) and miglitol (Glyset) are alpha-glucosidase inhibitors. These drugs help the body to lower blood sugar levels by blocking the breakdown of starches, such as bread, potatoes, and pasta in the intestine. They also slow the breakdown of some sugars, such as table sugar. Their action slows the rise in blood sugar levels after a meal. They should be taken with the first bite of a meal. These drugs may have side effects, including gas and diarrhea.

Biguanides

Metformin (Glucophage) is a biguanide. Biguanides lower blood sugar levels primarily by decreasing the amount of glucose produced by the liver. Metformin also helps to lower blood sugar levels by making muscle tissue more sensitive to insulin so glucose can be absorbed. It is usually taken two times a day. A side effect of metformin may be diarrhea, but this is improved when the drug is taken with food.

Bile Acid Sequestrants (BASs)

The BAS colesevelam (Welchol) is a cholesterol-lowering medication that also reduces blood sugar levels in patients with diabetes.  BASs help remove cholesterol from the body, particularly LDL cholesterol, which is often elevated in people with diabetes.  The medications reduce LDL cholesterol by binding with bile acids in the digestive system; the body in turn uses cholesterol to replace the bile acids, which lowers cholesterol levels. The mechanism by which colesevelam lowers glucose levels is not well understood. Because BASs are not absorbed into the bloodstream, they are usually safe for use by patients who may not be able to use other medications because of liver problems. Because of the way they work, side effects of BASs can include flatulence and constipation.

Dopamine-2 Agonists

Bromocriptine (Cycloset and Parlodel) helps lower blood sugar levels after a meal. 

DPP-4 Inhibitors

A new class of medications called DPP-4 inhibitors help improve A1C without causing hypoglycemia. They work by by preventing the breakdown of a naturally occurring compound in the body, GLP-1. GLP-1 reduces blood sugar levels in the body, but is broken down very quickly so it does not work well when injected as a drug itself. By interfering in the process that breaks down GLP-1, DPP-4 inhibitors allow it to remain active in the body longer, lowering blood sugar levels only when they are elevated. DPP-4 inhibitors do not tend to cause weight gain and tend to have a neutral or positive effect on cholesterol levels. Alogliptin (Nesina), linagliptin (Tradjenta), saxagliptin (Onglyza), and sitagliptin (Januvia) are the DPP-4 inhibitors currently on the market in the US.

Meglitinides

Meglitinides are drugs that also stimulate the beta cells to release insulin. Nateglinide (Starlix) and repaglinide(Prandin) are meglitinides. They are taken before each of three meals.

Because sulfonylureas and meglitinides stimulate the release of insulin, it is possible to have hypoglycemia (low blood sugar levels).

You should know that alcohol and some diabetes pills may not mix. Occasionally, chlorpropamide and other sulfonylureas, can interact with alcohol to cause vomiting, flushing or sickness. Ask your doctor if you are concerned about any of these side effects.

SGLT2 Inhibitors

Glucose in the bloodstream passes through the kidneys, where it can either be excreted or reabsorbed.   Sodium-glucose transporter 2 (SGLT2) works in the kidney to reabsorb glucose, and a new class of medication, SGLT2 inhibitors, block this action, causing excess glucose to be eliminated in the urine. Canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance) are SGLT2 inhibitors that have been approved by the FDA to treat type 2 diabetes.  Because they increase glucose levels in the urine, side effects can include urinary tract and yeast infections.

Sulfonylureas

Sulfonylureas stimulate the beta cells of the pancreas to release more insulin. Sulfonylurea drugs have been in use since the 1950s. Chlorpropamide (Diabinese) is the only first-generation sulfonylurea still in use today. The second generation sulfonylureas are used in smaller doses than the first-generation drugs. There are three second-generation drugs: glimepiride (Amaryl), glipizide (Glucotrol and Glucotrol XL), and glyburide (Micronase, Glynase, and Diabeta). These drugs are generally taken one to two times a day, before meals. All sulfonylurea drugs have similar effects on blood sugar levels, but they differ in side effects, how often they are taken, and interactions with other drugs.

TZDs (Thiazolidinediones)

Rosiglitazone (Avandia) and pioglitazone (ACTOS) are in a group of drugs called thiazolidinediones. These drugs help insulin work better in the muscle and fat and also reduce glucose production in the liver. The first drug in this group, troglitazone (Rezulin), was removed from the market because it caused serious liver problems in a small number of people. So far rosiglitazone and pioglitazone have not shown the same problems, but users are still monitored closely for liver problems as a precaution. Both drugs appear to increase the risk for heart failure in some individuals, and there is debate about whether rosiglitazone may contribute to an increased risk for heart attacks. Both drugs are effective at reducing A1C and generally have few side effects. 

Oral combination therapy

Because the drugs listed above act in different ways to lower blood sugar levels, they may be used together. For example, a biguanide and a sulfonylurea may be used together. Many combinations can be used. Though taking more than one drug can be more costly and can increase the risk of side effects, combining oral medications can improve blood sugar control when taking only a single pill does not have the desired effects. Switching from one single pill to another is not as effective as adding another type of diabetes medicine.

Oral Hypoglycemic Drugs – Boulder Medical Center

Internal Medicine Department
Boulder Medical Center

Oral hypoglycemic drugs are used only in the treatment of type 2 diabetes which is a disorder involving resistance to secreted insulin. Type 1 diabetes involves a lack of insulin and requires insulin for treatment. There are now four classes of hypoglycemic drugs:

• Sulfonylureas
• Metformin
• Thiazolidinediones
• Alpha-glucosidase inhibitors.

These drugs are approved for use only in patients with type 2 diabetes and are used in patients who have not responded to diet, weight reduction, and exercise. They are not approved for the treatment of women who are pregnant with diabetes.

SULFONYLUREAS – Sulfonylureas are the most widely used drugs for the treatment of type 2 diabetes and appear to function by stimulating insulin secretion. The net effect is increased responsiveness of ß-cells (insulin secreting cells located in the pancreas) to both glucose and non-glucose secretagogues, resulting in more insulin being released at all blood glucose concentrations. Sulfonylureas may also have extra-pancreatic effects, one of which is to increase tissue sensitivity to insulin, but the clinical importance of these effects is minimal.

Pharmacokinetics – Sulfonylureas differ mainly in their potency & their duration of action. Glipizide, glyburide (glibenclamide), and glimepiride are so-called second-generation sulfonylureas. They have a potency that allows them to be given in much lower doses.

Those drugs with longer half-lives (particularly chlorpropamide, glyburide, and glimepiride) can be given once daily. This benefit may be counterbalanced by a substantially increased risk of hypoglycemia.

Side effects – Sulfonylureas are usually well tolerated. Hypoglycemia is the most common side effect and is more common with long-acting sulfonylureas. Patients recently discharged from hospital are at the highest risk for hypoglycemia.

Patients should be cautioned about those settings in which hypoglycemia is most likely to occur. They are:

• After exercise or a missed meal.
• When the drug dose is too high.
• With the use of longer-acting drugs (glyburide, chlorpropamide).
• In patients who are undernourished or abuse alcohol.
• In patients with impaired renal or cardiac function or inter-current gastrointestinal disease.
• With concurrent therapy with salicylates, sulfonamides, fibric acid derivatives (such as gemfibrozil), and warfarin.
• After being in the hospital.

Other, infrequent side effects that can occur with all sulfonylureas include nausea, skin reactions, and abnormal liver function tests. Weight gain can also occur unless the diabetic diet and exercise program are followed. Chlorpropamide has two unique effects: it can cause an unpleasant flushing reaction after alcohol ingestion and it can cause hyponatremia (low blood sodium), primarily by increasing the action of antidiuretic hormone.

Clinical use – Sulfonylureas usually lower blood glucose concentrations by about 20 percent. They are most likely to be effective in patients whose weight is normal or slightly increased. In contrast, insulin should be used in patients who are underweight, are losing weight, or are ketotic despite adequate caloric intake.

The choice of sulfonylurea is primarily dependent upon cost and availability, because their efficacy is similar. However, given the relatively high incidence of hypoglycemia in patients taking glyburide or chlorpropamide, shorter acting drugs should probably be used in elderly patients

Repaglinide – Repaglinide is a short-acting glucose-lowering drug recently approved by the Food and Drug Administration for therapy of type 2 diabetes alone or in combination with metformin. It is structurally different than sulfonylureas, but acts similarly by increasing insulin secretion.

The clinical efficacy of repaglinide is similar to that of the sulfonylureas. The recommended starting dose is 0.5 mg before each meal for patients who have not previously taken oral hypoglycemic drugs. The maximum dose is 4 mg before each meal; the dose should be skipped if the meal is missed. Hypoglycemia is the most common adverse effect.

Natiglinide – Natiglinide (Starlix) is a very short-acting glucose lowering drug whose mode of action is similar to the sulfonylureas and is nearing approval by the FDA. A potential advantage of this drug is that it seems to have it’s effect on the first phase of insulin release rather than the late phase of insulin release. The first phase of insulin release is brisk, of short duration and occurs within minutes of ingesting food. It is this first phase of insulin release that is abnormal in early diabetes & can often be found in patients with impaired glucose tolerance prior to the onset of diabetes. The usual dose is 120 mg before meals.

METFORMIN – Metformin has been used in Europe for over thirty years, and has been available in the United States since March 1995. It is effective only in the presence of insulin but, in contrast to sulfonylureas, it does not directly stimulate insulin secretion. Its major effect is to increase insulin action.

How metformin increases insulin action is not known but it is known to affect many tissues. One important effect appears to be suppression of glucose output from the liver.

Clinical use – Metformin is most often used in patients with type 2 diabetes who are obese, because it promotes modest weight reduction or at least weight stabilization. This is in contrast to the increased appetite and weight gain often induced by insulin and sulfonylureas.

Metformin typically lowers fasting blood glucose concentrations by approximately 20 percent, a response similar to that achieved with a sulfonylurea.

Metformin given in combination with a sulfonylurea lowers blood glucose concentrations more than either drug alone.

In addition to causing modest weight loss, metformin has two other advantages as compared with sulfonylureas. They are:

• It is less likely to cause hypoglycemia.
• It has prominent lipid-lowering activity, producing a significant reduction in serum triglyceride and free fatty acid concentrations, a small reduction in serum low-density lipoprotein (LDL) cholesterol concentration, and an elevation in serum high-density lipoprotein (HDL) cholesterol concentration.

There are, however, two disadvantages to metformin: the risk for lactic acidosis described below and its prominent gastrointestinal side effects.

Pharmacokinetics – Metformin should be taken with meals and should be started at a low dose to avoid intestinal side effects. The dose can be increased slowly as necessary to a maximum of 2550 mg/day (850 mg TID).

Side effects – The most common side effects of metformin are gastrointestinal, including a metallic taste in the mouth, mild anorexia, nausea, abdominal discomfort, and diarrhea. These symptoms are usually mild, transient, and reversible after dose reduction or discontinuation of the drug.

A rare problem is lactic acidosis, which may be fatal in as many as one-half of cases. The risk is much less than with another biguanide, phenformin, which was withdrawn from use in the United States in the 1970s because of this complication. Serious lactic acid accumulation usually occurs only in the presence of a predisposing conditions including:

• Renal insufficiency.
• Current liver disease or alcohol abuse.
• Heart failure.
• Past history of lactic acidosis.
• Severe infection with decreased tissue perfusion.
• Hypoxic states
• Serious acute illness
• Hemodynamic instability
• Age 80 years or more

Drug interactions – A potential drug interaction exists between metformin and cimetidine (Tagamet) resulting in an increase in metformin blood levels. This interaction could increase the risk of hypoglycemia in patients taking metformin plus a sulfonylurea or insulin, and could increase the risk of lactic acidosis in those with impaired renal function. These risks could increase now that cimetidine is available over-the-counter. Other h3-blockers are less likely to cause this problem.

The manufacturer also recommends discontinuing metformin for 48 hours after any radiologic procedure involving the administration of iodinated contrast material into the blood. The rationale for this recommendation is to avoid the potential for high plasma metformin concentrations if the patient develops contrast-induced acute renal failure

THIAZOLIDINEDIONES – The thiazolidinediones such as Avandia (Rosiglitazone) and Actos (Pioglitazone) reverse insulin resistance by acting on muscle, fat and to a lesser extent liver to increase glucose utilization and diminish glucose production.

The mechanism by which the thiazolidinediones increase insulin action is not well understood but they may be acting by redistributing fat from the visceral compartment to the subcutaneous compartment. We know that visceral fat is associated with insulin resistance.

Efficacy – In one large study of 284 patients with type 2 diabetes treated with Rezulin, the fall in mean fasting blood glucose concentration was significant but not dramatic over 12 weeks; patients treated with placebo had a fall in blood glucose concentration of only 4 mg/dL. The HbA1c value in the troglitazone group fell from 8.6 to 8.1 percent.

Thiazolidinediones are also effective when given in combination with metformin, although they are not currently approved for this purpose.

Safety – There have been reports of severe liver injury in small numbers of patients receiving Rezulin and this product has now been removed from the market. Most cases of liver damage occured early in treatment with the drug and were reversible when it was stopped but there have been some deaths. The newer agents such as Actos and Avandia have a much lower incidence of this side effect.

ALPHA-GLUCOSIDASE INHIBITORS – The alpha-glucosidase inhibitors include acarbose (Precose) & Miglitol (Glycet) and are available in the United States. They inhibit the upper gastrointestinal enzymes that converts dietary starch and other complex carbohydrates into simple sugars which can be absorbed. The result is to slow the absorption of glucose after meals.

As in patients with type 2 diabetes, patients with type 1 diabetes have a reduction in the amplitude of glucose excursion and HbA1c and a possible reduction in nocturnal hypoglycemia with alpha-glucosidase inhibitors.

The main side effects of alpha-glucosidase inhibitors are flatulence and diarrhea. These symptoms are usually mild and do not necessitate cessation of therapy.

(PDF) Adverse effects during the oral glucose tolerance test in post-bariatric surgery patients

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6

OGTT after bariatric surgery

Arch Endocrinol Metab.

were in use of some anti-hypertensive drug, not patients

who showed elevated BP on the day of the OGTT. It

is not possible to be sure of the operative technique

employed either, since the “Roux-en-Y” gastric bypass

information was also reported by the patients, and this

could be due to the fact that the Roux-en-Y technique is

currently the most commonly used (24,25) (nearly 80%

of the surgical procedures for the treatment of obesity)

(13). Even if the surgery was in fact Roux-en-Y gastric

bypass, there are variations in the technique, e.g., the

placement of the ring of containment around the pou-

ch, size of the gastric pouch, among others, that could

determine variations in the presence and intensity of

the symptoms of dumping.

The ndings of the present study demonstrate that

the OGTT, when performed with patients who pre-

viously underwent bariatric surgery, entails risks for ad-

verse effects, at least limiting, if not severe. The authors

believe that this fact was not properly valued in other

studies. The indication of OGTT should be reviewed

for patients who underwent bariatric surgery, conside-

ring that it is not the only diagnostic choice for the

assessment of glycemic states. Moreover, OGTT values

of reference have not been established for this specic

group of patients, which makes the use of this test even

more questionable for the diagnosis of type 2 diabetes,

gestational diabetes and evaluation of the states sugges-

tive of hypoglycemia in post-bariatric surgery patients.

It is imperative that clinical pathology laboratories pro-

vide adequate facilities and permanent medical supervi-

sion to manage potential clinical instability during the

OGTT in post-bariatric surgery patients. Special atten-

tion should be given to hypertensive patients as well as

to those who start the test with blood glucose levels of

less than 75 mg/dL.

This study was approved by the Research Ethics Committee of

Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

(0385.0.203.000-11).

Acknowledgements: not applicable.

Funding: there was no funding source for this project.

Disclosure: no potential conict of interest relevant to this article

was reported.

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active intestinal peptide, and Roux-en-Y gastrojejunostomy. Their

role in the dumping syndrome. Arch Surg. 1985;120(5):605-9.

19. Bantle JP, Ikramuddin S, Kellogg TA, Buchwald H. Hyperinsulin-

emic hypoglycemia developing late after gastric bypass. Obes

Surg. 2007;17(5):592-4.

20. Goldne AB, Mun EC, Devine E, Bernier R, Baz-Hecht M,

Jones DB, et al. Patients with neuroglycopenia after gastric

bypass surgery have exaggerated incretin and insulin secre-

tory responses to a mixed meal. J Clin Endocrinol Metab.

2007;92(12):4678-85.

What to Know About Glucose Tablets for Hypoglycemia (Low Blood Sugar)

Glucose tablets are a rapidly acting oral treatment for hypoglycemia—or low blood sugar. People with diabetes are at risk of low blood sugar when they use insulin and certain other medicines, such as sulfonylureas. Using glucose tablets can help manage a potentially dangerous situation.

Glucose is a simple sugar your body uses for energy. You get glucose from foods containing it. Your body will also break down more complex sugars and carbohydrates from food into glucose. When your body absorbs glucose, your blood sugar levels rise. In healthy people, the hormone insulin works to help your cells use the glucose for energy. Any extra glucose goes to your liver for storage with the help of insulin. Your liver can release the glucose later when you need it.

People with diabetes do not have enough—or any—insulin to make all this happen. They either use a commercial insulin product or a medicine to help release or enhance insulin to manage high blood sugar levels. Sometimes, these medicines take blood sugar levels too low and cause hypoglycemia.

When is blood sugar too low?

Blood sugar is too low when it is 70 mg/dL or less. Blood sugar is severely low if it goes below 54 mg/dL. The only way to know for sure is to measure your blood sugar using a finger-stick glucometer. But low blood sugar symptoms can be an important clue that you are having a problem. Unfortunately, not everyone gets symptoms and some people get so used to the symptoms that they don’t notice them anymore. So, it’s always best to know your level.

Common hypoglycemia symptoms include:

When are glucose tablets used?

If you feel like you have low blood sugar or a check shows it’s low, you need a quick source of glucose. Most foods and even candy can take too long to get glucose into your blood. In a pinch, things like sugar, honey or juice will do. However, glucose tablets and other glucose products are designed for your body to absorb glucose rapidly.

Another advantage of glucose tablets is that they come in a precise dose. The standard recommended amount of glucose to treat low blood sugar episodes is 15 grams. If you use foods, candy or beverages, you need to know how much you need to consume in order to get 15 grams of glucose. For example, you need about 1 tablespoon of honey or 4 ounces of juice. Using a glucose product gives you confidence you are getting the right amount. Typically, you need to chew four glucose tablets to get enough glucose.

Once you take glucose tablets, recheck your blood sugar in 15 minutes. A simple rule—15 and 15—makes this easy to remember. You need 15 grams of glucose then wait 15 minutes. If your level is still low, repeat the glucose dose.

Be sure to ask your doctor for recommendations specific for you. Verify the amount of glucose you should use and your target levels. Ask how to manage very low blood sugar levels below 54 mg/dL or even 40 mg/dL. Your doctor may want you to use 30 grams of glucose or a glucagon shot. A family member, friend or coworker should know how to assist you—including giving you the glucagon shot—in case you are not coherent.

Seek immediate medical care (call 911) if someone with diabetes has serious symptoms that aren’t responding to treatment or if they have fainted or lost consciousness.

Do you need a doctor’s prescription for glucose tablets?

No, you don’t need a provider’s prescription for glucose tablets. Many tablets and other glucose products are available over the counter at grocery stores, pharmacies, and other retail markets.

What kinds of glucose tablets and products are available?

Glucose tablets and other glucose products are fast-acting sources of glucose. The tablets are chewable for quick absorption. Four of them usually gives you 16 grams of glucose, but be sure to check the label for instructions. There are also gel pouches you squeeze into your mouth and liquids you drink. Gels and liquids typically provide 15 grams of glucose. A powder form of glucose is available as well. It provides 15 grams of glucose you can eat from the pouch or mix with water. For a gel, liquid or powder, finish the entire container to get the full dose.

All glucose products come in a variety of flavors. You can save some money by buying store brands. They have the same amount of glucose and will work just as well. Carry one of these options on your person at all times. Don’t rely on having it stashed in your car or desk.

FDA reinforces safety information about serious low blood sugar levels and mental health side effects with fluoroquinolone antibiotics; requires label changes

[07-10-2018 ] The Food and Drug Administration (FDA) is strengthening the current warnings in the prescribing information that fluoroquinolone antibiotics may cause significant decreases in blood sugar and certain mental health side effects. The low blood sugar levels can result in serious problems, including coma, particularly in older people and patients with diabetes who are taking medicines to reduce blood sugar. We are making these changes because our recent review found reports of life-threatening low blood sugar side effects and reports of additional mental health side effects.

We are requiring these updates in the drug labels and to the patient Medication Guides for the entire class of fluoroquinolones (see List of FDA-Approved Fluoroquinolones for Systemic Use). This affects only the fluoroquinolone formulations taken by mouth or given by injection. Blood sugar disturbances, including high blood sugar and low blood sugar, are already included as a warning in most fluoroquinolone drug labels; however, we are adding that low blood sugar levels, also called hypoglycemia, can lead to coma.

Across the fluoroquinolone antibiotic class, a range of mental health side effects are already described under Central Nervous System Effects in the Warnings and Precautions section of the drug label, which differed by individual drug. The new label changes will make the mental health side effects more prominent and more consistent across the systemic fluoroquinolone drug class. The mental health side effects to be added to or updated across all the fluoroquinolones are disturbances in attention, disorientation, agitation, nervousness, memory impairment, and serious disturbances in mental abilities called delirium.

Fluoroquinolone antibiotics are approved to treat certain serious bacterial infections, and have been used for more than 30 years. They work by killing or stopping the growth of bacteria that can cause illness. Without treatment, some infections can spread and lead to serious health problems (see List of Currently Available FDA-Approved Fluoroquinolones for Systemic Use).

Patients should tell your health care professionals if you are taking a diabetes medicine when your health care professional is considering prescribing an antibiotic, and also if you have low blood sugar or symptoms of it while taking a fluoroquinolone. For patients with diabetes, your health care professional may ask you to check your blood sugar more often while taking a fluoroquinolone. Early signs and symptoms of low blood sugar include:

• Confusion
• Dizziness
• Feeling shaky
• Unusual hunger
• Headaches
• Irritability

• Pounding heart or very fast pulse
• Pale skin
• Sweating
• Trembling
• Weakness
• Unusual anxiety
   

Discuss with your health care professional how to treat yourself if you suspect low blood sugar. Symptoms of low blood sugar can progress and become life-threatening, so seek help immediately by calling 911 or going to an emergency room if you experience more serious symptoms, including confusion, inability to complete routine tasks, blurred vision, seizures, or loss of consciousness. Patients should also tell your health care professional immediately if you notice any changes in your mood, behavior, or thinking. Read the patient Medication Guide you receive with your fluoroquinolone antibiotic prescription, which explains the benefits and risks of the medicine.

Health care professionals should be aware of the potential risk of hypoglycemia sometimes resulting in coma, occurring more frequently in the elderly and those with diabetes taking an oral hypoglycemic medicine or insulin. Alert patients of the symptoms of hypoglycemia and carefully monitor blood glucose levels in these patients, and discuss with them how to treat themselves if they have symptoms of hypoglycemia. Inform patients about the risk of psychiatric adverse reactions that can occur after just one dose. Stop fluoroquinolone treatment immediately if a patient reports any central nervous system side effects, including psychiatric adverse reactions, or blood glucose disturbances and switch to a non-fluoroquinolone antibiotic if possible. Stop fluoroquinolone treatment immediately if a patient reports serious side effects involving the tendons, muscles, joints, or nerves, and switch to a non-fluoroquinolone antibiotic to complete the patient’s treatment course. Health care professionals should not prescribe fluoroquinolones to patients who have other treatment options for acute bacterial sinusitis (ABS), acute bacterial exacerbation of chronic bronchitis (ABECB), and uncomplicated urinary tract infections (uUTI) because the risks outweigh the benefits in these patients.

FDA continues to monitor and evaluate the safety and effectiveness of medicines after we approve them and they go on the market. In the case of fluoroquinolones, we reviewed reports of cases submitted to FDA* and the published medical literature of apparently healthy patients who experienced serious changes in mood, behavior, and blood sugar levels while being treated with systemic fluoroquinolones (see Data Summary for information on the names of fluoroquinolones and numbers of reports). Some of the mental health side effects are already listed in some of the labels and some events are listed using similar terms, but not all fluoroquinolone labels provided this information. As a result, we are requiring several changes to the Warnings and Precautions section in the fluoroquinolones drug labels. Details will be added describing hypoglycemic coma, and the new subheading “Psychiatric Adverse Reactions” found under “Central Nervous System Effects” will help clarify and identify the mental health side effects.

We previously communicated about other safety issues associated with fluoroquinolones in May 2016 (restricting use for certain uncomplicated infections), July 2016 (disabling side effects), August 2013 (peripheral neuropathy), and July 2008 (tendinitis and tendon rupture).

We urge patients and health care professionals to report side effects involving fluoroquinolones or other drugs to the FDA MedWatch program, using the information in the “Contact FDA” box at the bottom of the page.

*The cases were reported to the FDA Adverse Event Reporting System (FAERS).

Glucose tolerance test – non-pregnant

Definition

The glucose tolerance test is a lab test to check how your body moves sugar from the blood into tissues like muscle and fat. The test is often used to diagnose diabetes.

Tests to screen for diabetes during pregnancy are similar, but are done differently.

Alternative Names

Oral glucose tolerance test – non-pregnant; OGTT – non-pregnant; Diabetes – glucose tolerance test; Diabetic – glucose tolerance test

How the Test is Performed

The most common glucose tolerance test is the oral glucose tolerance test (OGTT).

Before the test begins, a sample of blood will be taken.

You will then be asked to drink a liquid containing a certain amount of glucose (usually 75 grams). Your blood will be taken again every 30 to 60 minutes after you drink the solution.

The test may take up to 3 hours.

A similar test is the intravenous (IV) glucose tolerance test (IGTT). It is rarely used, and is never used to diagnose diabetes. In one version of the IGTT, glucose is injected into your vein for 3 minutes. Blood insulin levels are measured before the injection, and again at 1 and 3 minutes after the injection. The timing may vary. This IGTT is almost always used for research purposes only.

A similar test is used in the diagnosis of growth hormone excess (acromegaly) when both glucose and growth hormone are measured after the glucose drink is consumed.

How to Prepare for the Test

Make sure you eat normally for several days before the test.

DO NOT eat or drink anything for at least 8 hours before the test. You cannot eat during the test.

Ask your health care provider if any of the medicines you take can affect the test results.

How the Test will Feel

Drinking the glucose solution is similar to drinking very sweet soda.

Serious side effects from this test are very uncommon. With the blood test, some people feel nauseated, sweaty, lightheaded, or may even feel short of breath or faint after drinking the glucose. Tell your health care provider if you have a history of these symptoms related to blood tests or medical procedures.

When the needle is inserted to draw blood, some people feel moderate pain. Others feel only a prick or stinging. Afterward, there may be some throbbing or a slight bruise. This soon goes away.

Why the Test is Performed

Glucose is the sugar the body uses for energy. People with untreated diabetes have high blood glucose levels.

Most often, the first tests used to diagnose diabetes in people who are not pregnant are:

• Fasting blood glucose level: diabetes is diagnosed if it is higher than 126 mg/dL (7 mmol/L) on 2 different tests
• Hemoglobin A1c test: diabetes is diagnosed if the test result is 6.5% or higher

Glucose tolerance tests are also used to diagnose diabetes. The OGTT is used to screen for or diagnose diabetes in people with a fasting blood glucose level that is high, but is not high enough (above 125 mg/dL or 7 mmol/L) to meet the diagnosis for diabetes.

Abnormal glucose tolerance (blood sugar goes too high during the glucose challenge) is an earlier sign of diabetes than an abnormal fasting glucose.

Normal Results

Normal blood values for a 75 gram OGTT used to check for type 2 diabetes in those who are not pregnant:

Fasting — 60 to 100 mg/dL (3.3 to 5.5 mmol/L)

1 hour — Less than 200 mg/dL (11.1 mmol/L)

2 hours — This value is used to make the diagnosis of diabetes.

• Less than 140 mg/dL (7.8 mmol/L).
• Between 141mg/dL and 200 mg/dL (7.8 to 11.1 mmol/L) is considered impaired glucose tolerance.
• Above 200 mg/dl (11.1mmol/L) is diagnostic of diabetes.

The examples above are common measurements for results of these tests. Normal value ranges may vary slightly among different laboratories. Some labs use different measurements or test different samples. Talk to your provider about the meaning of your specific test results.

What Abnormal Results Mean

A glucose level that is higher than normal may mean you have pre-diabetes or diabetes:

• A 2-hour value between 140 and 200 mg/dL (7.8 and 11.1 mmol/L) is called impaired glucose tolerance. Your provider may call this pre-diabetes. It means you are at increased risk of developing diabetes over time.
• Any glucose level of 200 mg/dL (11.1 mmol/L) or higher is used to diagnose diabetes.

Serious stress to the body, such as from trauma, stroke, heart attack, or surgery, can raise your blood glucose level. Vigorous exercise can lower your blood glucose level.

Some medicines can raise or lower your blood glucose level. Before having the test, tell your provider about any medicines you are taking.

Risks

You may have some of the symptoms listed above under the heading titled “How the Test will Feel.”

There is little risk involved with having your blood taken. Veins and arteries vary in size from one person to another and from one side of the body to the other. Taking blood from some people may be more difficult than from others.

Other risks associated with having blood drawn are slight, but may include:

• Excessive bleeding
• Multiple punctures to locate veins
• Fainting or feeling lightheaded
• Hematoma (blood buildup under the skin)
• Infection (a slight risk any time the skin is broken)

Images

References

American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021 Jan;44(Suppl 1):S15-S33. PMID: 33298413 pubmed.ncbi.nlm.nih.gov/33298413/.

Mojica A, Weinstock RS. Carbohydrates. In: McPherson RA, Pincus MR, eds. Henry’s Clinical Diagnosis and Management by Laboratory Methods. 24th ed. Philadelphia, PA: Elsevier; 2022:chap 17.

Sacks DB. Diabetes mellitus. In: Rifai N, ed. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 6th ed. Philadelphia, PA: Elsevier; 2018:chap 57.

Antidiabetic drugs – Knowledge @ AMBOSS

Last updated: July 27, 2021

Summary

Antidiabetic drugs (except insulin) are all pharmacological agents that have been approved for hyperglycemic treatment in type 2 diabetes mellitus (DM). If lifestyle modifications (weight loss, dietary modification, and exercise) do not sufficiently reduce HbA1c levels (target level: ∼ 7%), pharmacological treatment with antidiabetic drugs should be initiated. These drugs can be classified according to their mechanism of action as insulinotropic or noninsulinotropic. They are available as monotherapy or combination therapies, with the latter involving two (or, less commonly, three) antidiabetic drugs and/or insulin. The exact treatment algorithms are reviewed in the treatment section of diabetes mellitus. The drug of choice for all patients with type 2 diabetes is metformin. This drug has beneficial effects on glucose metabolism and promotes weight loss or at least weight stabilization. In addition, numerous studies have demonstrated that metformin can reduce mortality and the risk of complications. If metformin is contraindicated, not tolerated, or does not sufficiently control blood glucose levels, another class of antidiabetic drug may be administered. In patients with moderate or severe renal failure or other significant comorbidities, most antidiabetic drugs are not recommended or should be used with caution. Oral antidiabetic drugs are not recommended during pregnancy or breastfeeding.

Overview

Classification

• Insulinotropic agents
• Noninsulinotropic agents

Overview

See “Antihyperglycemic therapy algorithm for type 2 diabetes” for the treatment of type 2 DM with the antidiabetic drugs listed below.

Almost all antidiabetic drugs listed above are oral drugs, except for amylin analogues and GLP-1 analogues, which are injectable.

To remember the important oral antidiabetic drugs, think: “My Pancreas Needs Fitting Treatment!” – Metformin, -gliPs, -gliNs, -gliFs, -gliTs

Common contraindications of antidiabetic agents

Sulfonylureas are associated with the highest risk of hypoglycemia. All other substances do not carry a significant risk of hypoglycemia when used as monotherapy. Combination therapy, particularly with sulfonylurea, significantly increases the risk of hypoglycemia.

Biguanides (metformin)

Active agent

Clinical profile

• Mechanism of action: enhances the effect of insulin
• Indications: drug of choice in all patients with type 2 diabetes
• Clinical characteristics ^[8]
  • Glycemic efficacy: lowers HbA1c by 1.2–2% over 3 months
  • Weight loss (often desired) or weight stabilization
  • No risk of hypoglycemia
  • Beneficial effect on dyslipidemia
  • Reduces the risk of macroangiopathic complications in patients with diabetes
  • Must be paused prior to surgery
  • Cost-effective
• Important side effects
• Contraindications
• Important interactions: sulfonylureas

Metformin treatment must be paused prior to the administration of a contrast medium or scheduled surgery to reduce the risk of lactic acidosis!

Because of its favorable risk-benefit ratio, metformin is the drug of choice for monotherapy and combination therapy in all stages of type 2 DM.

Thiazolidinediones (glitazones, insulin sensitizers)

Active agents

• Pioglitazone
• Rosiglitazone

Clinical profile

Sulfonylureas

Active agents

• First generation
  • Chlorpropamide
  • Tolbutamide
• Second generation
  • Glyburide (long-acting agent)
  • Glipizide (short-acting agent)
  • Glimepiride

Clinical profile

^[12]

• Mechanism of action
• Indications
  • Patients who are not overweight, do not consume alcohol, and adhere to a consistent dietary routine
  • Generally not frequently used
• Clinical characteristics
• Important side effects
• Contraindications

Beta-blockers may mask the warning signs of hypoglycemia (e.g., tachycardia) and decrease serum glucose levels even further (see hypoglycemia). Since sulfonylureas also increase the risk of hypoglycemia, the combination of these two substances should be avoided!

Meglitinides (sulfonylurea analogue)

Active agents

Clinical profile

• Mechanism of action (similar mechanism of action to that of sulfonylureas)
• Indications: : particularly suitable for patients with postprandial peaks in blood glucose levels, but overall rarely prescribed
• Clinical characteristics
• Important side effects
• Contraindications: severe liver failure
• Interactions: sulfonylureas

Glucagon-like peptide-1 receptor agonists (incretin mimetics)

Active agents

• Exenatide
• Liraglutide
• Albiglutide
• Dulaglutide

Clinical profile

^[15][16][17]

• Mechanism of action
• Clinical characteristics
  • Glycemic efficacy: lowers HbA1c by 0.5–1.5% over 3 months
  • Subcutaneous injection
  • Weight loss (may be wanted)
  • No risk of hypoglycemia
• Side effects
• Contraindications

Dipeptidyl peptidase-4 inhibitors (gliptins)

Active agents

• Sitagliptin
• Saxagliptin
• Linagliptin

Clinical profile

^[15][19][20]

Sodium-glucose cotransporter 2 inhibitors (gliflozins)

Active agents

• Dapagliflozin
• Empagliflozin
• Canagliflozin

Clinical profile

^[21][22]

Alpha-glucosidase inhibitors

Active agents

Clinical profile

• Mechanism of action
  • Inhibit alpha-glucosidase (a brush border enzyme expressed by intestinal epithelial cells) → delayed and ↓ intestinal glucose absorption and ↓ carbohydrate breakdown, resulting in ↓ hyperglycemia after food ingestion
  • Particularly effective in controlling postprandial blood glucose levels
  • The undigested carbohydrates reach the colon, where they are degraded by intestinal bacteria, resulting in the production of intestinal gas.
• Clinical characteristics
• Important side effects: gastrointestinal symptoms (flatulence, bloating, abdominal discomfort, diarrhea)
• Contraindications

Related One-Minute Telegram

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References

1. ONGLYZA (saxagliptin) tablets, for oral use.

2. BYETTA® (exenatide) Injection.

3. FARXIGA (dapagliflozin) tablets, for oral use.

4. PRECOSE® (acarbose tablets).

5. ACTOS (pioglitazone hydrochloride) tablets for oral use.

6. SYMLIN® (pramlintide acetate) injection for subcutaneous use.

7. Madiraju et al. Metformin suppresses gluconeogenesis by inhibiting mitochondrial glycerophosphate dehydrogenase. Nature. 2014; 510
   (7506): p.542-546.
   doi: 10.1038/nature13270 . | Open in Read by QxMD

8. American Diabetes Association. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2018; 42
   (Supplement 1): p.S90-S102.
   doi: 10.2337/dc19-s009 . | Open in Read by QxMD

9. Sola et al. State of the art paper Sulfonylureas and their use in clinical practice. Archives of Medical Science. 2015; 4
   : p.840-848.
   doi: 10.5114/aoms.2015.53304 . | Open in Read by QxMD

10. Triplitt C. Drug Interactions of Medications Commonly Used in Diabetes. Diabetes Spectrum. 2006; 19
    (4): p.202-211.
    doi: 10.2337/diaspect.19.4.202 . | Open in Read by QxMD

11. Maedler K, Carr RD, Bosco D, Zuellig RA, Berney T, Donath MY. Sulfonylurea Induced β-Cell Apoptosis in Cultured Human Islets. The Journal of Clinical Endocrinology & Metabolism. 2005; 90
    (1): p.501-506.
    doi: 10.1210/jc.2004-0699 . | Open in Read by QxMD

12. Armoni M, Kritz N, Harel C, et al. Peroxisome Proliferator-activated Receptor-γ Represses GLUT4 Promoter Activity in Primary Adipocytes, and Rosiglitazone Alleviates This Effect. J Biol Chem. 2003; 278
    (33): p.30614-30623.
    doi: 10.1074/jbc.m304654200 . | Open in Read by QxMD

13. Astapova O, Leff T. Adiponectin and PPARγ.
    Elsevier
    ; 2012
    : p. 143-162
14. Katzung B,Trevor A. Basic and Clinical Pharmacology.
    McGraw-Hill Education
    ; 2014

15. Hinnen D, Nielsen LL, Waninger A, Kushner P. Incretin mimetics and DPP-IV inhibitors: new paradigms for the treatment of type 2 diabetes. J Am Board Fam Med. 2006; 19
    (6): p.612-620.

16. Dulaglutide.
    https://www.drugs.com/ppa/dulaglutide.html.
    Updated: February 23, 2017.
    Accessed: February 23, 2017.
17. FDA Drug Safety Communication: FDA warns that DPP-4 inhibitors for type 2 diabetes may cause severe joint pain.
    https://www.fda.gov/Drugs/DrugSafety/ucm459579.htm.
    Updated: August 28, 2015.
    Accessed: February 23, 2017.
18. FDA Drug Safety Communication: FDA investigating reports of possible increased risk of pancreatitis and pre-cancerous findings of the pancreas from incretin mimetic drugs for type 2 diabetes.
    https://www.fda.gov/Drugs/DrugSafety/ucm343187.htm.
    Updated: March 14, 2013.
    Accessed: February 23, 2017.
19. DPP-IV Inhibitors.
    https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Diabetes_Guide/547042/all/DPP_IV_Inhibitors.
    Updated: December 3, 2018.
    Accessed: January 20, 2019.
20. Highlights of Prescribing Information – Janumet.

21. Empagliflozin.
    https://www.drugs.com/ppa/empagliflozin.html.
    Updated: June 23, 2019.
    Accessed: September 23, 2019.

22. Fioretto P, Zambon A, Rossato M, Busetto L, Vettor R. SGLT2 Inhibitors and the Diabetic Kidney. Diabetes Care. 2016; 39
    (Supplement 2): p.S165-S171.
    doi: 10.2337/dcs15-3006 . | Open in Read by QxMD

23. Fralick M, Kim SC, Schneeweiss S, Everett BM, Glynn RJ, Patorno E. Risk of amputation with canagliflozin across categories of age and cardiovascular risk in three US nationwide databases: cohort study.. BMJ. 2020; 370
    : p.m2812.
    doi: 10.1136/bmj.m2812 . | Open in Read by QxMD

Arpimed

What you need to know before using Metformin

If you have any of these conditions, consult your doctor before using Metformin.

You must stop taking Metformin for a period of time before and after your examination or surgery. If necessary, your doctor will prescribe another treatment for you for this period of time. It is important that you follow your doctor’s instructions exactly.

Special instructions and precautions

Risk of developing lactic acidosis

Metformin can cause a rare but very serious complication of lactic acidosis, especially in renal impairment.The risk of developing lactic acidosis is increased in the case of uncontrolled diabetes, serious infections, prolonged fasting, alcoholism, dehydration (see information below), liver failure, and any pathology in which hypoxia is observed (for example, severe heart disease).

If you have any of these conditions, check with your doctor before using metformin.

Stop taking metformin for a short time in conditions that run the risk of dehydration (significant loss of body fluid than necessary), such as severe vomiting, diarrhea, fever, exposure to high temperatures or insufficient fluid intake.

If you have any questions, consult your doctor,

If you develop symptoms of lactic acidosis, stop taking metformin and immediately inform your doctor or go to the nearest hospital, as lactic acidosis can lead to coma.

Lactic acidosis symptoms:

• vomiting
• abdominal pain
• muscle spasms
• General poor health, accompanied by severe fatigue
• shortness of breath
• Decrease in body temperature and heart rate

Lactic acidosis requires emergency medical attention.

If you are about to have major surgery, you must stop taking metformin during and after the surgery.

Your doctor will advise you when to stop and restart your treatment.

Metformin as monotherapy does not cause hypoglycemia (lowering blood glucose levels). However, with simultaneous use with other antidiabetic drugs (sulfonylurates, insulin, meglitinides), there is a risk of hypoglycemia.

If you have symptoms of hypoglycemia, such as weakness, dizziness, increased sweating, heart palpitations, blurred vision or concentration, you should immediately drink or eat something sugar-containing.

Kidney function during metformin treatment should be closely monitored at least once a year, or even more often if you are an elderly person or have deteriorating kidney function.

Drug interactions

If you need intravascular administration of iodine-containing contrast media, for example, for X-ray diagnostics, you must stop taking metformin before or during this procedure.Your doctor will tell you when to stop or when to resume taking metformin.

Tell your doctor if you are taking, have recently taken or could take any other medicines. You may need more frequent blood glucose testing and an assessment of your kidney function, or your doctor may need to adjust your metformin dose.

The following drugs are especially important:

• Medicines that increase urine production (diuretics).
• Medicines with analgesic and anti-inflammatory effects (NSAIDs and COX-2 inhibitors such as ibuprofen and celecoxib).
• Certain medicines for the treatment of high blood pressure (ACE inhibitors and angiotensin II receptor antagonists).
• beta-2 adrenergic receptor agonists such as salbutamol or terbutaline (drugs used to treat bronchial asthma).
• Corticosteroids (used to treat various conditions such as severe skin inflammation or bronchial asthma).
• Medicines that can affect blood levels of metformin, especially in renal impairment (eg, verapamil, rifampicin, cimetidine, dolutegravir, ranolazine, trimethoprim, vandetanib, isavukonazole, crizotinib, olaparib).
• other medicines used to treat diabetes mellitus

Metformin and alcohol

Avoid excessive alcohol consumption while taking metformin, as this can cause the development of lactic acidosis (see.”Special instructions and precautions”).

Pregnancy and breastfeeding

During pregnancy, you need insulin to treat diabetes mellitus.

Consult your healthcare professional if you are pregnant, think you may be pregnant, or planning to become pregnant before taking this drug, as it may change your treatment.

It is not recommended to take metformin while breastfeeding.

Ascensia Diabetes Care – MY DIABETES

>> ​​Introduction

>> ​​What is diabetes mellitus?

>> ​​What is the cause of my diabetes?

>> ​​Control over hyper- and hypoglycemia

>> ​​Blood glucose monitoring

>> ​​Lifestyle change and therapy

>> ​​Who Can Help Control Diabetes?

>> ​​Complications of diabetes mellitus

>> ​​Self Care

Have you been diagnosed with diabetes? You are not alone

You have been diagnosed with diabetes, and you may feel lonely alone with this disease.New information from experts will inspire you. This site was created to give you the most useful information about various aspects of diabetes – from diagnosis to disease control – to give you the strength and confidence to fight diabetes.

You are not alone: ​​in 2011, 90,012 366 million 90,013 people worldwide were diagnosed with this. It is estimated that this number will increase to 90,012,552 million 90,013 by 2030. This means that about three people develop diabetes every ten seconds. ¹ (see fig. A)

This site has been created to provide you with information about diabetes and diabetes management. Each section leads to additional information that you can access either from the page or from the navigation bar on each page.

Diabetes mellitus is a term for a group of conditions that are united by a high concentration of glucose in the blood. This condition is also known as hyperglycemia. ² In people without diabetes, blood sugar is naturally lowered by the hormone insulin.In people with type 1 diabetes, the cells that produce insulin (beta cells in the pancreas) are damaged, so insulin is not produced enough. In people with type 2 diabetes, the body cannot make or respond to enough insulin, or both. ²

Sooner and later you will ask yourself how diabetes affects your daily life. It is important to know that people with diabetes can lead fulfilling and active lives if they keep their condition under control.This includes: maintaining a healthy lifestyle (a healthy diet, regular physical activity, weight control, and quitting smoking). ³ As well as understanding how to keep diabetes under control day after day. Depending on the type of diabetes you have (type 1 or type 2), you may need to get some medication, such as monitoring your blood glucose with a glucometer and taking regular medications. These can be pills or insulin injections.

Monitoring your blood glucose with self-tests can help you achieve and maintain proper glucose levels and effectively manage your diabetes. ⁴

• Diabetes is a chronic progressive disease that affects millions of people worldwide
• Learning to effectively control the disease means living long and fully

References:

1. IDF Diabetes Atlas 2013 (http: // www.idf.org/diabetesatlas/5e/the-global-burden)
2. ADA 2012: Diagnosis and Classification of Diabetes Mellitus http://care.diabetesjournals.org/content/35/Supplement_1/S64.extract
3. WHO Factsheet 312 http://www.who.int/mediacentre/factsheets/fs312/en/
4. IDF 2011 Guideline for Management of PostMeal Glucose in Diabetes

What is diabetes?

Diabetes is a condition where your body cannot make enough insulin, or it cannot use that produced insulin effectively. ¹ It is a chronic disease that, unfortunately, cannot be cured, but with proper treatment and control, people with diabetes can live normal, healthy lives. In this section, you will learn about the different types of diabetes, as well as the causes and risk factors for the disease.

What are the interrelation rates of glucose, insulin and of the pancreas in the norm?

Insulin (secreted by the pancreas) regulates your blood glucose ² .When you eat, food breaks down into simple substances such as sugar, also called glucose. It does this right in non-diabetic people:

• When blood glucose levels rise (for example, after eating), it causes the pancreas to release insulin to lower your blood glucose levels (see figure B)

• When blood glucose levels are low (for example, after exercise), it causes the pancreas to release the hormone glucagon from cells called alpha cells.This causes glucose to be released from the liver, where it is located, to help blood glucose rise (see figure B)

If you have diabetes, your pancreas is either not producing enough insulin or your body is not responding to it. Gyucose enters the bloodstream instead of being deposited in tissues or in your liver. As a result, blood glucose levels rise. This condition is called hyperglycemia. ¹ Over time, hyperglycemia can damage your body tissues and other complications of diabetes. ^2,3,4,5

What types of diabetes are there?

There are three main types of diabetes:

Type 1 diabetes, type 2 diabetes, gestational diabetes mellitus, and a condition called pre-diabetic that can lead to type 2 diabetes.

Prediabetes

Some people have a blood glucose concentration higher than normal, but not as high as in diabetics. ⁶ The rise in blood glucose after meals is due to impaired glucose tolerance (IGT]).And if this happens on an empty stomach or in the morning, it is called impaired fasting glycemia [IFG]). People who do this are in so-called prediabetes and are at risk of developing type 2 diabetes. ²

Prediabetes is generally associated with obesity (especially if fat is concentrated in the abdomen or around internal organs, as well as high cholesterol or fat in the blood (also known as dyslipidemia) and high blood pressure. ⁶

Although prediabetes is similar in many ways to type 2 diabetes, it does not necessarily lead to it. Diabetes can be prevented by reducing your weight by at least 7% and increasing your physical activity by 150 minutes per week. This can be, for example, walking at a brisk pace. There are also drugs that regulate glucose tolerance and lower glucose levels.

Diabetes mellitus 1 type

Type 1 diabetes, also called insulin-dependent diabetes, and childhood diabetes.This type of disease affects 5-10% of diabetics. The cause of type 1 diabetes is unknown. In this type of diabetes, the body’s defense system attacks and destroys the beta cells in the pancreas that produce insulin. As a result, insulin synthesis becomes impossible. The rate of destruction of insulin beta cells varies: in children and infants it usually happens very quickly, in adults it is more often slower. ¹ If you have type 1 diabetes, you need to take insulin all your life to keep your blood sugar normal.

Diabetes mellitus 2 type

Type 2 diabetes, which is commonly called adult or non-insulin-dependent diabetes mellitus, affects about 90-95% of the total number of diabetics. In type 2 diabetes, the pancreas can produce insulin, but it is either not enough or the body does not respond correctly to its release (this is called insulin resistance). As a result, the concentration of glucose in the blood rises. ¹

Diabetes mellitus type 2 more often affects people with a hereditary predisposition to it. ¹ It can also occur as a result of obesity or lack of physical activity. Adults are more likely to suffer from type 2 diabetes. However, in recent years, it has been increasingly diagnosed in children and adolescents. ² Most patients with type 2 diabetes are obese, and it is being overweight that causes them to resist insulin. ¹ (see table A below)

Symptoms of type 2 diabetes are often less noticeable than symptoms of type 1 diabetes. ² Many have no symptoms at all.Many people live for many years without knowing their condition, and only serious complications reveal their diagnosis. ^1.2

If you have type 2 diabetes, you may not need insulin treatment in the early stages, but later, when the disease progresses, you cannot do without it, as well as without pills. Also, a special diet and physical activity are required.

Nutrition, physical activity and drug therapy work together to reduce blood glucose levels.Self-monitoring of your blood glucose will help you manage type 1 and type 2 diabetes. The information you gain from self-monitoring of your blood will help you make decisions about your diet, exercise, and treatment to keep your blood sugar levels normal. ⁶ This information is also important for your healthcare provider, based on which he will regulate your course of treatment. ^6.7 Talk to your doctor about your normal blood glucose level. For most patients (excluding pregnant women), it should be less than 6.1 mmol / L (according to blood plasma) before meals and less than 7.8 mmol / L after meals. ⁸

Gestational diabetes

Gestational diabetes mellitus (GDM) is a condition where the concentration of glucose in the blood is increased (hyperglycemia) during pregnancy.GDM can be diagnosed during routine screening between 24 and 28 weeks of gestation. ⁶ GDM accompanies approximately 7% of pregnancies ¹ and poses a risk to both the mother and the baby due to the increased concentration of glucose in the mother’s blood. ⁶ GDM can be controlled through lifestyle changes (such as a healthy diet) or insulin therapy.

In most women with GDM, blood glucose levels return to normal after the birth of a baby.However, GDM can subsequently lead to the development of type 2 diabetes. Therefore, a woman should be tested for prediabetes and type 2 diabetes every three years after giving birth. ⁶

• Today, type 1 diabetes cannot be prevented or cured, but it can be successfully controlled lifelong with insulin injections
• People with type 2 diabetes can control their illness with proper diet and increased physical activity.When it is not possible to adequately control blood glucose levels through a healthy lifestyle alone, insulin pills and / or injections are required
• Self-measurement of blood glucose helps people with both type 1 and type 2 diabetes successfully manage their disease ⁶

References:

1. ADA 2012: Diagnosis and Classification of Diabetes Mellitus http://care.diabetesjournals.org/content/35/Supplement_1/S64.extract
2. WHO Factsheet 312 http: // www.who.int/mediacentre/factsheets/fs312/en/
3. Stratton IM et al. BMJ 2000; 32: 405-12
4. Rydén L et al. European Heart Journal 2007; 28: 88-136
5. Nathan DM et al. Diabetes Care 2009; 32: 193-203
6. ADA 2013: Standards of Medical Care in Diabetes http://care.diabetesjournals.org/content/36/Supplement_1
7. IDF 2009: SMBG in Non-insulin Treated Type 2 diabetes http://www.idf.org/webdata/docs/SMBG_EN2.pdf
8. Algorithms for specialized medical care for patients with diabetes mellitus, Pod.ed. I.I. Dedova, M.V. Shestakova, Moscow, 2013

Why me? What is the cause of my diabetes?

The cause of type 1 diabetes is unknown, but heredity (genetics) and environmental factors play a role. (See Table B) Heredity and lifestyle also affect the development of type 2 diabetes, but it is often difficult to isolate a single risk factor to identify a single cause of type 2 diabetes. For example, obesity is commonly associated with type 2 diabetes.The obesity factor can be hereditary (genetic risk factor). Also, people belonging to the same family usually have the same eating and behavioral habits (risk factor “lifestyle”). ¹

• Inherited genes, environmental triggers and lifestyle – factors that may affect the development of diabetes and 2 type
• In people with diabetes type 2 may have been prediabetes at for many years before of this

References:

1. ADA website 2013: Genetics of diabetes (http: // www.diabetes.org/diabetes-basics/genetics-of-diabetes.html)
2. ADA 2012: Diagnosis and Classification of Diabetes Mellitus http://care.diabetesjournals.org/content/35/Supplement_1/S64.extract
3. WHO website 2013: diabetes complications http://www.who.int/diabetes/action_online/basics/en/index3.html
4. Stratton IM et al. BMJ 2000; 32: 405-12
5. Rydén L et al. European Heart Journal 2007; 28: 88-136

>> ​​Control over hyper- and hypoglycemia

High and low rates in diabetes – control of hyper and hypoglycemia

Diabetes mellitus can lead to many complications, the most common of which are hyper and hypoglycemia.We can help you understand these conditions, their causes, symptoms and treatment approaches.

What are hyperglycemia and hypoglycemia?

Hyperglycemia is an increase in blood sugar. Indicators below normal are called hypoglycemia. Hyperglycemia can lead to macrovascular (from large blood vessels) and microvascular (from small blood vessels) complications. ^2.3.4 (see table B below)

Sources: ADA 2012 ⁶ ; WHO 312 ⁷ ; ADA websites 2013: hyper- and hypoglycemia ^8.9 ; Fowler 2008 ¹⁰

What is hypoglycemic ignorance?

Some diabetics do not feel or do not recognize the symptoms of hypoglycemia.Hypoglycemic unawareness is more common in people who have frequent hypoglycemia. They may not feel anything until their blood glucose levels are very low. ⁵ If you have hypoglycemic ignorance, this is very dangerous. This can lead to confusion, fainting, seizures, and even death. ⁵ Such people need constant monitoring and help from loved ones in order to recognize the disease in time.

How to avoid high and low readings?

Monitoring your blood glucose level is an important part of managing your diabetes, as it allows you to know in time if your glucose level is too high or to a dangerous level and to take the necessary measures to avoid spikes. ⁵ Regular self-monitoring is the only way for people with diabetes to check if their glucose levels are normal. ¹

You can perform blood glucose self-monitoring:

• In the morning when you wake up. If your fasting blood glucose level is high, it means you need to take immediate steps to bring it back to normal. ¹¹
• Before and after meals

– If your glucose level is high before a meal, you can adapt your diet by lowering carbohydrates, or figure out how much insulin to use

– if your pre-meal glucose level is low, your diet must be adapted, the amount of carbohydrates increased, this will lead to the fact that the blood glucose level will rise

– Checking your glucose level after a meal (after about 2 hours) can help you understand if the actions you have taken have helped.If not, further action needs to be taken

• Before and after physical activity

– Exercise will help lower blood glucose levels if elevated

– If your glucose level is low before exercise, you need to eat more carbohydrate-rich foods. Then physical activity will be within your power

– determine your blood glucose after exercise, and you will understand if there is a risk of hypoglycemia at the moment

• To avoid a possible episode of hypoglycemia at night, eat a carbohydrate-rich meal before bedtime
• The importance of regular monitoring of blood glucose levels is especially important for people with hypoglycemic unawareness, as this is the only way not to miss a hypoglycemic episode. ^5.13

What is ketoacidosis?

In people with diabetes, glucose cannot enter the cells of the body and supply them with energy. Instead, they take energy from fat stores in their tissues. When these stores are broken down, a huge amount of metabolic products called ketone bodies are released. They can build up in the blood and harm the body. This is called ketoacidosis (or diabetic ketoacidosis). ¹⁴

People with type 1 diabetes mellitus are more likely to suffer from ketoacidosis. ¹⁵ However, people with type 2 diabetes can also develop ketoacidosis. ¹ Stress, illness, injury, or surgery can make blood glucose more difficult to control, and this can also lead to ketoacidosis. ¹ During these periods of life, it is recommended to monitor blood glucose more frequently than usual. ¹

Symptoms of ketoacidosis usually develop gradually and typically include:

• Nausea and vomiting
• Dehydration
• Heavy, rapid breathing
• Confusion of consciousness, sometimes coma. ¹⁵

If you have any of these symptoms, you need immediate medical attention.

• Hyperglycemia means there was a glucose release in your blood
• Hypoglycemia means there is too little glucose in your blood
• Regular self-monitoring can help reduce the risk of hyper and hypoglycemia and help you avoid complications of diabetes ¹

References:

1. ADA 2013: Standards of Medical Care in Diabetes http: // care.diabetesjournals.org/content/36/Supplement_1
2. Stratton et al. BMJ 2000; 32: 405-12
3. Rydén L et al. European Heart Journal 2007; 28: 88-136
4. WHO website 2013: diabetes complications http://www.who.int/diabetes/action_online/basics/en/index3.html
5. ADA / Endocrine Society / Seaquist ER et al. Diabetes Care 2013; 36: 1384-95
6. ADA 2012: Diagnosis and Classification of Diabetes Mellitus http://care.diabetesjournals.org/content/35/Supplement_1/S64.extract
7. WHO Factsheet 312: http: // www.who.int/mediacentre/factsheets/fs312/en/
8. ADA website 2013: Hyperglycemia http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hyperglycemia.html
9. ADA website 2013: Hypoglycemia http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html
10. Fowler M Clinical Diabetes 2008; 26: 170-3
11. ADA website 2013: Fasting blood sugar levels http://www.diabetes.co.uk/diabetes_care/fasting-blood-sugar-levels.html
12. IDF 2011: Guideline for Management of PostMeal Glucose in Diabetes http://www.idf.org/2011-guideline-management-postmeal-glucose-diabetes
13. IDF 2009: SMBG in Non-insulin Treated Type 2 diabetes http://www.idf.org/webdata/docs/SMBG_EN2.pdf
14. Diabetes UK Position Statements / Savage MW et al. Diabetic Medicine 2011; 28: 508-515
15. Diabetes UK website 2013: Diabetic ketoacidosis http://www.diabetes.co.uk/diabetes-complications/diabetic-ketoacidosis.html

Blood glucose monitoring – why is it so important?

Regular blood glucose measurements should be a natural part of your diabetes management. There are several very important reasons for this: ^1.2

• Hypoglycemia should be recognized and prevented
• Hyperglycemia should be avoided
• understand if the body has adapted to lifestyle changes and treatment
• It is important to know if the blood glucose level has changed after stress or illness that develops in parallel with diabetes

Your healthcare professional will tell you how much your blood glucose should fluctuate.

Like When do I need to measure blood glucose in ?

Most people with type 1 diabetes should have their blood glucose measured several times a day, every day. Some people with type 2 diabetes (both insulin dependent and non-insulin dependent) are also advised to have their blood glucose measured every day. ¹ In any case, your doctor should develop a regimen and frequency of tests for you.

Self-monitoring of blood glucose is done using a glucometer.Ask your doctor to show you how to use it and do the test. You will see a number on the meter display indicating the amount of glucose in your blood. The doctor will also tell you how often and at what time of the day to take the test. The timing and frequency of self-monitoring depends on your treatment and your personal blood glucose values. ³

Self-monitoring of blood glucose is also necessary if you are at risk of developing hypoglycemia. ⁴ If you are being treated with insulin injections, you should also do a test before and after physical activity, if symptoms of low glucose appear and before driving. ¹ The test results will help you make the right decision to reduce the risk of hypoglycemia and understand how much medication to take. ¹ It is very important that your meter gives a correct and accurate reading, ⁵ especially in case of hypoglycemia, and also not to inject the wrong dose of insulin. ⁶

Blood glucose level in before and after meals

People with diabetes mellitus have higher blood glucose levels after meals than healthy people.It can stay high for up to 2-3 hours. Research has shown that there is a link between high post-meal glucose levels and a higher likelihood of cardiovascular complications. ³

Therefore, it is important to measure blood glucose before and 2 hours after meals and calculate the dose of medication to avoid hyperglycemia. Your doctor will determine your individual blood glucose targets. ³

What other measures can I use to control diabetes ?

In addition to self-monitoring of blood glucose, you will need to donate blood at the clinic for glycated hemoglobin (HbA1c). ¹ The HbA1c test measures the average blood glucose level over several months and allows you and your doctor to understand how well your diabetes is being controlled. This is usually measured twice a year if you have good glucose control. If you do not control it very well, or your treatment is not very effective, or you have changed something in the course of treatment, then you will need to take HbA1c a little more often (usually every 3 months). ¹

Continuous glucose monitoring is an innovative technique for measuring glucose levels.This test measures your interstitial fluid, the substance that is found around the cells in your body. ¹ This test uses a sensor placed under your skin, a monitor, and a storage device. A sensor sits under your skin for several days and measures glucose levels in your interstitial body fluids every 5-10 minutes. He transmits the results to an electronic device. They are either displayed in real time or downloaded by your doctor. ³ Due to the difference in glucose concentration in blood and interstitial fluid, the sensors require additional testing with a glucometer test. Together, both tests are needed for hypoglycemic ignorance or for frequent episodes of hypoglycemia. ¹

What else should I do?

It is very important for people with diabetes to improve clinical health indicators along with quality of life and keep blood glucose levels under control. For this you need:

• Lead a healthy lifestyle, eat right, stay physically active, control your weight
• Regular self-monitoring of your glucose levels so that you can make timely and appropriate treatment decisions with your doctor.

References:

1. ADA 2013: Standards of Medical Care in Diabetes http://care.diabetesjournals.org/content/36/Supplement_1
2. IDF 2012: Global Guideline for Type 2 Diabetes http://www.idf.org/global-guideline-type-2-diabetes-2012
3. IDF 2011: Guideline for Management of PostMeal Glucose in Diabetes http://www.idf.org/2011-guideline-management-postmeal-glucose-diabetes
4. ADA / Endocrine Society / Seaquist ER et al. Diabetes Care 2013; 36: 1384-95
5. Bode BW US Endocrine Disease 2007; 46-48
6. Raine CH et al.Journal of Diabetes Science and Technology 2007; 2: 205-210

What therapy and lifestyle changes do I need to control my diabetes?

There are a number of lifestyle factors that can affect your diabetes. Insulin and pills will help treat your diabetes, while diet and physical activity will help you keep the disease under control.

Physical activity

Before embarking on a new exercise regimen, consult your physician.Especially if you have type 1 diabetes, you may need additional blood glucose tests and advice when you are not advised to exercise.

Exercise is an important part of your diabetes management plan. Regular exercise will help you achieve better blood glucose levels, reduce the risk of cardiovascular diseases and their complications, help you lose weight and improve your overall physical condition. Physical activity can also help avoid the development of type 2 diabetes in people who already have this risk.

It is important to consult your healthcare professional before starting. In general, it is usually recommended for all people to devote at least 150 minutes a week to aerobic activity. These loads can be divided into 3 days a week, the break should be no more than two days.

Glycemic index ³

The glycemic index (or GI) shows how much carbohydrate food increases the level of glucose in your blood. Foods with a high glycemic index raise glucose levels faster than foods with a medium or low GI because they break down more easily.Your diet, if you are diabetic, should be low to medium GI foods, or combined with high GI foods to balance your meals. Low-GI carbohydrate foods include, for example: dried legumes, all non-starchy vegetables and some starchy vegetables, most fruits, and many whole grains and cereals. Meat and fats do not have a glycemic index, as they do not contain carbohydrates.

• Self-monitoring of blood glucose will reduce the risk of episodes of hyper and hypoglycemia
• Improving postprandial blood glucose levels will reduce the risk of micro and macrovascular complications of diabetes

Calculation of the amount of carbohydrates ⁴

Carbohydrate counting is a good meal planning technique to control your blood glucose.By knowing the type and amount of carbohydrates you eat, you can keep your glucose levels within the normal range. The amount you need depends on many things, such as how active you are and what medications you are taking. You should aim for 45-60 grams of carbohydrates per meal. Your doctor will recommend the amount of carbohydrates you need based on your individual needs.

Medicines

Prescribed Are there any medications to treat prediabetes?

If you have been diagnosed with prediabetes, you will most likely not be prescribed any medication right away.The main remedy in this case is a change in lifestyle. It is a change in your diet for a healthier one and an increase in physical activity. If, despite this, your blood glucose remains high, you will probably be prescribed an oral antidiabetic medication to help improve your insulin resistance. ¹

What drugs are used to treat type 1 diabetes?

If you have type 1 diabetes, the beta cells in your pancreas, which are supposed to make insulin, are destroyed.And your body cannot make insulin. Therefore, the main medicine for type 1 diabetics is insulin.

Most people with type 1 diabetes should:

• receive insulin injections (3-4 shots per day of basal and prandial insulin) or continuous subcutaneous insulin infusion (insulin pump therapy)
• Learn how to combine prandial insulin with carbohydrate food, what should be the blood glucose level before meals and physical activity
• Use insulin analogs to reduce the risk of hypoglycemia ¹

There are several types of insulin for patients with type 1 and type 2 diabetes.

Prandial insulin – is used to prevent a rise in blood glucose after a meal. Bolus insulin is usually given before meals, but your doctor will ask you if you need to get it with or immediately after meals.

• Ultra short-acting (e.g. aspart, glulisine, lispro)
• Short-acting (e.g. human soluble insulin)

Basal Insulin – Also known as background insulin, it keeps glucose levels stable on an empty stomach, for example when you sleep.Basal insulin is usually used once or twice a day. ⁵

• Medium duration of action (e.g. NPH – insulin) acts for 12 hours, it is prescribed twice a day
• Long-acting (e.g. insulin glargine, insulin detemir) should be used once a day

Your doctor will tell you which type of insulin and which dose is right for you. Perhaps he will prescribe you a ready-made mixture of insulin , which consists of ultra-short insulin with medium-acting insulins (there are different formulas with different dosages of both drugs). ⁶ Ready mix is ​​very convenient, you do not need to be confused in dosages. But you won’t be able to vary the dosage. The doctor will tell you which option is best for your situation, and will also advise you to closely monitor your blood glucose levels so that the course of treatment can be adjusted.

How should I take insulin?

It is best to discuss this question with your doctor-endocrinologist.

Insulin pump therapy and blood glucose monitoring

An alternative to syringes and insulin pens is insulin pump therapy.With this method, insulin is delivered to the body 24 hours a day through a special catheter placed under the skin. ⁸ If hypoglycemia is your primary concern, pump therapy is the way to go. ¹⁰

If you are on pump therapy, you will need to have your blood glucose tested throughout the day, regardless of your treatment plan. Self-monitoring of blood glucose should be done at least before meals, sometimes after meals, before bed, before exercise, and before driving. ¹ The key to successful treatment involves regular self-monitoring of blood glucose to be sure that it is normal. ¹¹

Yes Are there other drugs for type diabetes type 1 ?

For people with type 1 diabetes mellitus, who have a poor HbA1c test, the synthetic form of the hormone amylin has proven its effectiveness; it is administered by injection separately from insulin. ^{12, 9}

Treatment of diabetes mellitus 2 type

If you have type 2 diabetes, the main treatment is usually diet, weight loss, and increased exercise. Sometimes these measures are not enough to normalize blood glucose levels. Therefore, the next step may be to take oral medications to lower your glucose levels.

There are seven main classes of drugs you may be prescribed:

• Sulfonylurea
• Meglitinides
• Biguanides
• Thiazolidinediones
• Alpha-glucosidase inhibitors
• Inhibitors of dipeptidyl peptidase -4 (DPP-4)
• Glucagon-like peptide receptor agonists -1
• SGLT-2 inhibitors

Your doctor will find the appropriate drug therapy for you, if necessary. ^{1, 11}

Sources: Stumvoll 2005 ¹³ ; Nathan 2009 ¹⁴ ; instructions for use of preparations

People who have only recently been diagnosed with type 2 diabetes and have very high blood glucose levels and poor HbA1c readings may be started on insulin with or without additional oral medications. If one drug in the maximum dosage did not give the desired effect, the doctor will add another drug or insulin to the course of treatment.

Since type 2 diabetes is a progressive disease, insulin therapy (as described above for type 1 diabetes) may eventually be necessary. ¹

Yes Are there other drugs for type 2 diabetes ?

There is another class of drugs that act in the same way as DPP-4 inhibitors, causing the beta cells of the pancreas to release the right amount of insulin. Natural hormones, incretins help the body increase post-meal insulin production and also reduce the amount of glucose that is released in the liver, thus keeping blood glucose levels under control.However, incretins such as the glucagon-like peptide (GLP-1) can be destroyed by another substance produced by the body. It is called dipeptidyl peptidase – 4. A new class of drugs – analogs of GLP-1, copy the effect of real GLP-1, and also reduce appetite. This class includes drugs: exenatide and liraglutide, both available in the form of injections. ^{12, 9}

Point at fig. C to find out more.

References:

1. ADA 2013: Standards of Medical Care in Diabetes http: // care.diabetesjournals.org/content/36/Supplement_1
2. ADA / Endocrine Society / Seaquist ER et al. Diabetes Care 2013; 36: 1384-95
3. ADA website 2013: Glycemic index: http://www.diabetes.org/food-and-fitness/food/planning-meals/glycemic-index-and-diabetes.html
4. ADA website 2013: Carbohydrate counting: http://www.diabetes.org/food-and-fitness/food/planning-meals/carb-counting/
5. Diabetes UK website 2013: Basal bolus http://www.diabetes.co.uk/insulin/basal-bolus.html
6. IDF 2011 Guideline for Management of PostMeal Glucose in Diabetes http://www.idf.org/2011-guideline-management-postmeal-glucose-diabetes
7. Diabetes UK website 2013: Long-acting insulin http://www.diabetes.co.uk/insulin/long-acting-insulin.html
8. ADA website 2013: Insulin Routines http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/insulin/insulin-routines.html
9. Diabetes UK website 2013: Injecting Insulin http: //www.diabetes.co.uk/insulin/diabetes-and-injecting-insulin.html
10. Fowler M Clinical Diabetes 2008; 26: 170-3
11. Ryden L et al. European Heart Journal 2007; 28: 88? 136
12. ADA website 2013: Other injectable medications http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/other-injectable-medication.html
13. Stumvoll M et al. Lancet 2005; 365: 1333–46
14. Nathan DM et al. Diabetes Care 2009: 32; 193-203
15. Diabetes UK website 2013: Incretin mimetics

Who can help me manage my diabetes?

Diabetes Support Group

You will receive qualified medical care and professional advice from your doctor ¹ , but your family and loved ones should play a significant role in controlling the disease.It is they who will help maintain a proper diet and measure blood glucose levels, as well as provide you with moral support.

Who can be part of my support group ?

Your support team may consist of:

• Diabetologist or Endocrinologist: advises you on your daily diabetes management, shows you how to measure your blood glucose, how to use your insulin pump, and more.
• Dietitian: explains how the food you eat affects your blood glucose levels, your weight; develops a meal plan for you and makes recommendations for lifestyle changes.
• Therapist: you need to go to him for general health checks, as well as if you get sick (for example, have a cold).
• Pharmacist: will explain which drugs and how will affect your blood glucose levels.
• Podiatrist: Provides advice on how to treat foot problems and how to avoid infections.
• Oculist: It is important for diabetics to visit an ophthalmologist at least once a year in order to prevent any vision problems in time. ^2.1

• The diabetes support group consists of of your family and loved ones plus specialist doctors

References:

1. ADA 2013: Standards of Medical Care in Diabetes http://care.diabetesjournals.org/content/36/Supplement_1
2. Ryden L et al.European Heart Journal 2007; 28: 88-136

>> ​​Complications of diabetes mellitus

What complications can I develop later?

If you are diabetic and your blood glucose is not under control (often above normal), you are at an increased risk of developing serious micro and macrovascular complications. ^1,2,3 Good blood glucose control can prevent or delay these complications. ⁴

What are the most common complications of diabetes?

Microvascular complications (damage to small blood vessels) includes: ⁴

• Diabetic retinopathy (eye disease), which can lead to blindness.
• Diabetic nephropathy (kidney disease) which can lead to kidney failure, kidney failure.
• Diabetic neuropathy (damage to the nervous system) which can lead to limb amputation.

Cardiovascular disease (CVD) is a complex of diseases of the heart and blood vessels. This is the main macrovascular complication of diabetes mellitus. ³

The main forms of CVD are: ⁴

• Stroke: damages the brain.
• Heart attack: can lead to heart attack or stroke.
• Peripheral vascular disease: Disrupted blood flow in the legs and feet, increasing the risk of heart attack or stroke (see figure D)

What should be done to prevent or reduce complications risk?

• Change your lifestyle: diet and exercise more.
• Follow your healthcare provider’s treatment plan
• Maintain blood glucose levels as close to normal as possible

– The key to maintaining your glucose level is regular self-monitoring: you can self-test your blood for glucose and, depending on the results, adjust your course of treatment to keep glucose within the normal range.

Point at fig. D for more information.

• Microvascular complications of diabetes mellitus include in themselves: retinopathy, kidney disease and neuropathy.
• Macrovascular complications of diabetes are stroke, heart attack and narrowing of the arteries.

References:

1. Stratton IM et al. BMJ 2000; 32: 405-122.
2. Stumvoll M et al. Lancet 2005; 365: 1333–46
3. Ryden L et al.European Heart Journal 2007; 28: 88-136
4. WHO website 2013: diabetes complications http://www.who.int/diabetes/action_online/basics/en/index3.html
5. Fowler M Hypoglycemia. Clinical Diabetes 2008; 26 (4): 170-3

Self Care

Knowing how to control your diabetes is the first step to better well-being and a long, healthy life. From going to the grocery store to how to cope with your emotions – in this section, we will help you walk the path of recovery and good mood.

How to deal with emotions

You have been diagnosed with diabetes and are overwhelmed by a variety of feelings, from anger and denial to despair. This is normal and is part of your acceptance of the disease, control of the disease or complications. Your support team should be there to support and help you.

• Talk to friends and family
• Ask your physician or diabetologist (endocrinologist) for advice

Y traverse

Teeth

• If you have poor blood glucose control, you are more likely to develop gum disease and tooth decay.Alternatively, gum disease can lead to impaired glycemic control. You should brush your teeth after every meal and have your teeth cleaned professionally at least once a year. ¹
• Most oral complications occur in patients who have poor control over their diabetes and glucose levels: they often have gum disease, tooth decay, dry mouth and fungal infections. It is very important to monitor not only your diabetes, but also your mouth. ²
• Some diabetics with a tendency to periodontal disease simply do not maintain the necessary oral hygiene and insufficiently control their diabetes. ³

Leather ⁴

• Thorough cleansing of the skin may be contraindicated for you, the protective barrier on the skin may be damaged, and you should not wash with soap with aggressive PH.
• Moisturizing, non-irritating cleansers are the right choice for you.You may need cosmetics that improve the condition of the skin, as well as decorative cosmetics that hide some of the skin imperfections associated with diabetes.

Legs

Tips for foot care: ⁵

• Inspect and wash your feet every day.
• Try to keep the skin on your legs soft and tender.
• Gently moisten the calluses.
• If you can see and reach your toenails, take care of them and cut them in time.
• Always wear socks and shoes.
• Avoid hypothermia and overheating of the feet.
• Watch for normal circulation in the legs.
• Try to lead an active lifestyle.
• Call your doctor if you find a cut, sore, callus, or sore on your leg that takes more than a day to heal.

Good Shopping Tips ⁶

A diet that includes carbohydrates found in fruits, vegetables, whole grains, legumes, and low-fat milk is beneficial for the health of a diabetic.Products containing sucrose should be replaced with other carbohydrates. Fiber-rich foods are good for everyone.

Carbohydrates: food with low glycemic index

• Oat and pearl barley, bulgur, beans, lentils, pasta, rye bread, apples, oranges, milk, yoghurts and ice cream have a low glycemic index.
• Fiber, fructose, lactose and fats are dietary components that can reduce the glycemic response.

Food with high fiber:

• Lentils, cereals with fiber, fruits, vegetables and whole grains

– Fiber foods contain vitamins, minerals and other health benefits.

– A fiber-based diet reduces the likelihood of high blood glucose levels.

Sweeteners

• Consumption of sucrose and sugar-containing products is not necessarily prohibited.
• Sucrose can be substituted for other carbohydrate sources.
• Other nutrients that are consumed with sucrose, such as fat, should be restricted to avoid excess calories.
• Fructose is not recommended as a sweetener.

Edible fats and cholesterol

• Saturated fat should be limited to <7% of total calories.
• We need to minimize the amount of trans fats.
• Dietary cholesterol intake should be limited to <200mg per day.
• Fish should be eaten 2 or more times a week.

– Fish contains polyunsaturated fatty acids.

Protein

• Proteins can be consumed in the same quantities as other people.
• High protein diet is not recommended for weight loss.

References:

1. NDEP 2009: http: // ndep.nih.gov/publications/PublicationDetail.aspx?PubId=108 American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2008 Jan; 31 Suppl 1: S61–78.
2. Daniel R et al. Diabetes and periodontal disease. J Pharm Bioallied Sci 2012; 4 (Suppl 2): ​​S280-2.
3. Katz PP et al. Epidemiology and prevention of periodontal disease in individuals with diabetes. Diabetes Care. 1991; 14: 375–85.
4. Pierard GE et tal.The skin landscape in diabetes mellitus. Focus on dermocosmetic management. Clin Cosmet Investig Dermatol. 2013: 15; 6: 127–35.
5. NDEP. Feet Can Last a Lifetime. A Health Care Provider’s Guide to Preventing Diabetes Foot Problems. http://ndep.nih.gov/media/feet_hcguide.pdf
6. ADA 2008

What is type 2 diabetes?

What causes type 2 diabetes

It has been found that lifestyle, diet, and ethnicity can have a direct impact on how likely a person is to develop type 2 diabetes.Studies have shown that people of African and Creole descent have a 3 times higher risk of developing this disease, and in people from South Asia it is almost 6 times higher than ⁶ .

For more information, see the Type 2 Diabetes Causes page.

Prevention of type 2 diabetes

The most important thing is to maintain a positive attitude and be ready for change. Try to wean yourself from potential bad habits and think about what gives you pleasure – this will help you move towards a healthier lifestyle.You can start walking more or try new, healthier recipes – whatever you want, as long as you do it with enthusiasm.

If you are in an age group with a higher risk of developing diabetes, or if you have a poor family history, this is not a cause for concern. Just check out this article and try to enjoy a healthy lifestyle.

What are the symptoms and signs of type 2 diabetes?

Another important factor that distinguishes type 1 and type 2 diabetes is that type 1 diabetes appears within a few weeks, and type 2 diabetes develops slowly over a longer period of time.In this regard, gradually manifesting symptoms are often overlooked.

For more information, see the Type 2 Diabetes Symptoms page.

Side effects of type 2 diabetes

People with this condition can have short-term and long-term complications that affect various organs – the heart, blood vessels, nerves and eyes – which can lead to more serious complications over time. Effectively controlling blood sugar levels with a pen or insulin pump can help prevent the effects of diabetes to a large extent.

Some of the most common complications of type 2 diabetes are:

• Damage to the heart and blood vessels
  Diabetes dramatically increases the risk of a variety of cardiovascular problems, including coronary heart disease and hypertension, which can ultimately lead to heart attack.
• Injury to eyes and feet
  Diabetes can have a significant effect on the blood vessels of the eyes, which can lead to cataracts and glaucoma and, in severe cases, even blindness.The feet also often suffer from nerve damage and poor blood flow. Because diabetic patients have slower wound healing processes, any small damage to the foot can quickly develop into severe damage.
• Nerve damage
  High blood sugar (glucose) levels over a long period of time can damage the capillaries that are responsible for nerve endings in the extremities, such as the legs. As a result, tingling or numbness may occur, which ultimately leads to loss of sensation in the affected areas.

If you have any questions about complications of type 2 diabetes, please contact the Medtronic MiniMed Care team

Blood sugar level in type 2 diabetes

Understanding what your blood sugar should be is a difficult but necessary part of living with diabetes. As you gain experience, you will begin to recognize the warning signals before a bout of high (hyperglycemia) or low (hypoglycemia) blood sugar, but if you or someone you love has been diagnosed recently, it is advisable to become familiar with the acceptable range of blood sugar levels in advance.

The average blood sugar level in type 2 diabetes usually changes depending on the following factors:

1. Age
2. Floor
3. Time of day
4. Before or after meals

Before a meal, a person with type 2 diabetes should have a sugar level in the range of 4-7 mmol / L (72-126 mg / dL). After eating (after 90 minutes) – do not exceed 8.5 mmol / l (153 mg / dl).

For a more accurate individual range table, contact the Medtronic MiniMed Care team.

Treatment of type 2 diabetes

If traditional approaches – diet, exercise, or antidiabetic medications – do not work to achieve the desired effect and improve your diabetes, alternative methods may be used. Currently, a significant decrease in the level of hemoglobin HbA1c in patients with type 2 diabetes when using an insulin pump ⁷ has already been clinically proven.

Clinical pharmacologist to assist the endocrinologist: the choice of oral antihyperglycemic therapy | # 03/16

Currently, there is a wide arsenal of inpatient and outpatient drugs capable of affecting almost all known links in the pathogenesis of type 2 diabetes mellitus (DM). There are many classifications of them, including the division according to the main effect, according to the points of application, according to the mechanism of action, according to the duration, etc.d.

Allocate hypoglycemic agents and antihyperglycemic agents. The purpose of hypoglycemic drugs (sulfonylurea derivatives and meglitinides) is to stimulate the synthesis of endogenous insulin, as a result of which negative events occur among the positive aspects of treatment: weight gain and an increased risk of developing hypoglycemic conditions.

Antihyperglycemic drugs (α-glucosidase inhibitors, biguanides, thiazolidinediones, incretinimetics) improve peripheral glucose utilization, but do not have a stimulating effect on pancreatic β-cells.Due to this, the level of insulin in the blood does not increase and the decrease in blood glucose below normal does not occur [1].

Sugar-lowering drugs that affect the small intestine prevent the complete absorption of carbohydrates in the intestine by inhibiting the α-glucosidase enzymes that affect the pancreas (secretogens) – cause its β-cells to secrete endogenous insulin, and affecting hepatocytes, adipose and other peripheral tissues (sensitizers) – increase the sensitivity of target organs to insulin.

Examples of secretogenic hypoglycemic drugs are sulfonylureas (glibenclamide, gliclazide, glimepiride) and prandial glucose regulators – meglitinides (nateglinide, repaglinide). Sensitizers are represented by biguanides (metformin) and thiazolidinediones (pioglitazone, rosiglitazone).

A relatively new class of antihyperglycemic drugs is incretinimetics (vildagliptin, saxagliptin, exenatide, liraglutide), the insulinotropic effect of which is glucose-dependent and is realized only with an increased level of glycemia.When normoglycemia is reached, the insulin concentration returns to the basal level, which helps to reduce the risk of hypoglycemia while taking these drugs. The mechanism of action of these drugs is glucose-dependent and does not interfere with the normal glucagon response to hypoglycemia [2]. The main classes of oral glucose-lowering drugs and their mechanisms of action are presented in table. 1 and fig. 1.

Before the reader there are dozens of names of medicines belonging to different pharmacological groups with their own mechanism of action, evidence base and cost.With such an abundance of drugs, within the framework of a short mode of communication with the patient, as well as in conditions of comorbidity and forced polypharmacy, it is very difficult to choose the right medication in an adequate dosing regimen – it is almost impossible, which dictates the need to designate the clinical and pharmacological niches of these drugs, as well as their advantages and disadvantages (Fig. 2-8).

Α-Glucosidase inhibitors should be used mainly for the prevention of type 2 diabetes mellitus in patients with initial manifestations of insulin resistance.In addition, they are the drugs of choice for persons with prediabetes, accompanied precisely by postprandial hyperglycemia at normal fasting levels (decrease in the level of HbA _1c by 0.5–0.8%).

The indications for the appointment of glinides are type 2 diabetes mellitus with ineffective diet and exercise. They are also intended to preferentially reduce postprandial hyperglycemia (decrease in the level of HbA _1c by 0.5-1.5%).

The clinical niche for the prescription of glitazones (thiazolidinediones) is reduced to type 2 diabetes mellitus, either as monotherapy or in combination with sulfonylureas, biguanides or insulin in the absence of effect from diet therapy, exercise and monotherapy with one of the above drugs (decrease in HbA levels _1c by 0.5-1.4%).

Biguanides are the drugs of choice for both persons with prediabetes, fasting hyperglycemia and normal post-meal sugar levels, which indirectly indicate insulin resistance, and for patients with type 2 diabetes mellitus. Their appointment is possible in the form of monotherapy and in combinations, primarily with secretogens (when the latter do not give a complete correction of hyperglycemia) and with insulin (in the presence of insulin resistance) (decrease in the level of HbA _1c by 1–2%).

Prescription of sulfonylurea derivatives, as a rule, is associated with the presence of type 2 diabetes in cases where diet and exercise, the appointment of α-glucosidase inhibitors and biguanides were ineffective (decrease in the level of HbA _1c by 1–2%).

Drugs with incretin activity (Fig. 7), affecting mainly GLP1, are prescribed for type 2 diabetes as an adjunct to therapy with biguanides, sulfonylurea derivatives, thiazolidinediones in case of inadequate glycemic control (decrease in the level of HbA _1c by 0.8– 1.8%).

Another type of incretinomimetics are drugs that affect DPP4 (Fig. 8), which are advisable to prescribe in type 2 diabetes mellitus as monotherapy in combination with diet therapy and exercise; in combination with biguanides as an initial drug therapy in case of insufficient effectiveness of diet therapy and exercise; as well as as part of a two-component combination therapy with biguanides, sulfonylurea derivatives, thiazolidinediones or insulin in case of ineffectiveness of diet therapy, exercise and monotherapy with these drugs (decrease in HbA1c level by 0.5–1.0%).

The mechanism of action of DPP4 inhibitors is as close as possible to natural processes occurring in a healthy human body. Under their action, there is a decrease in the frequency of protective snacks, which patients use to avoid hypoglycemia, a decrease in the absorption of fat from the intestine, an increase in energy expenditure, and an increase in lipid oxidation during meals [3]. In addition, in diabetes mellitus, as a result of increased apoptosis, β-cells lose their mass, which is expressed in significant violations of their functions, the main of which is insulin synthesis.The physiological effect of this group of drugs supports the viability of pancreatic β-cells, increases their mass by 75% and reduces apoptosis by 65% ​​[4]. Comparison of the main representatives of DPP4 inhibitors is presented in table. 2.

The cardiovascular effects of DPP4 inhibitors are reduced to a decrease in myocardial remodeling, an improvement in endothelial function, a decrease in atherogenic lipoprotein fractions, a decrease in blood pressure (BP), a decrease in the symptoms of circulatory insufficiency, protection of the myocardium from ischemia, as well as functional recovery of the myocardium after ischemia and an increase in the number of receptors to insulin in cardiomyocytes [5].Cardiometabolism of DPP4 inhibitors is presented in table. 3.

Summary data reflecting the advantages and disadvantages of the main classes of antihyperglycemic drugs are presented in table. 4.

As you can see from the presented table:

• in case of cardiovascular diseases, patients should avoid drugs with a high probability of developing hypoglycemia, which can be very dangerous for them;
• overweight patients should be prescribed antihyperglycemic drugs that do not contribute to further weight gain;
• when treating women of childbearing age, the possibility of pregnancy should be taken into account, in which tableted antihyperglycemic drugs are contraindicated;
• all tableted antihyperglycemic drugs are contraindicated for persons with diabetic ketoacidosis;
• in patients with alcoholic visceropathy and liver cirrhosis, the choice of hypoglycemic therapy should be based on the characteristics of the drug metabolism, as well as the duration of its action;
• in patients with CKD (incl.including as a result of diabetic nephropathy), the correction of glycemia should be carried out under the control of the glomerular filtration rate (GFR).

The impossibility of maintaining compensation for carbohydrate metabolism in patients on monotherapy, as well as the high risk of developing acute and chronic complications of diabetes mellitus in comorbid patients are sufficient grounds for combined treatment. In the case of combined hypoglycemic therapy, an improvement in the effectiveness of treatment is a consequence of the addition of the mechanisms of action of drugs (for example, secretogens and sensitizers) [6].Combination therapy is accompanied by an improvement in the quality of life of patients and is well tolerated by them, which is associated with a parallel effect on different links in the pathogenesis of diabetes and with a decrease in the amount of simultaneous administration of tablets with a simultaneous improvement in compensation for carbohydrate metabolism (Fig. 9).

However, the evolution of oral glucose-lowering drugs continues – back in November 2012, the first representative of the newest class of oral inhibitors of sodium glucose cotransporter type 2 (SGLT2), dapagliflozin, was approved in Europe, and in March 2013, it was approved.The Food and Drug Administration (FDA) has approved canagliflozin for the treatment of adult patients with type 2 diabetes. US, European and Asian regulatory authorities have also filed applications for empagliflozin, ipragliflozin and luseoglyflozin, and large-scale research is ongoing.

Their mechanism of action is as follows. Due to the active reabsorption system, this glucose is almost completely reabsorbed in the proximal tubule of the nephron.The urine entering the Henle loop is glucose-free. An increase in the concentration of glucose in blood plasma leads to an increase in its filtration in the glomeruli. With an increase in the rate of glucose entry into the proximal tubule above 260–350 mg / min / 1.73 m ² , for example, in patients with diabetes, excess glucose exceeds the reabsorptive potential, and it begins to be excreted in the urine. In a healthy adult, this corresponds to a blood glucose concentration of about 10-11 mmol / L (180-200 mg / dL). Since glucose is not able to freely penetrate the cell membrane, sodium-dependent glucose transporters (SGLT1 and 2) are involved in its absorption in the intestine and reabsorption in the kidneys [7].Accordingly, SGLT inhibitors reduce the concentration of glucose in the blood by stimulating its excretion in the urine.

The opinion of experts about the registered SGLT2 inhibitors, which have become an alternative to metformin, including in the case of intolerance, is ambiguous. On the one hand, drugs of this class offer new possibilities in the treatment of diabetes: first of all, a new, insulin-independent mechanism of action, no negative effect on body weight and even a slight decrease in body weight, favorable pharmacokinetic properties, and generally good tolerance [8].On the other hand, the mechanism of action of SGLT2 inhibitors is aimed at the clinical manifestations of diabetes, and not at its cause [9]. Due to the inhibition of SGLT2, the degree of glucosuria depends on renal function, and since in patients with diabetes it decreases with the progression of the disease, the effectiveness of these drugs in the long-term period remains unknown. In addition, the presence of glucose in urine has always been considered an undesirable phenomenon, and many doctors are not ready to prescribe drugs that cause glucosuria.The latter is also the cause of the most common side effects – urinary tract infections and fungal infections of the genitals [10].

The clinical and pharmacological niches of this class of drugs will set the time, and the answers to many questions should dispel the results of clinical trials of these drugs, but today there is no doubt about the postulate that, when choosing a hypoglycemic drug, the doctor needs to remember that in each specific case adequate therapy for diabetes is possible only when taking into account the age, sex, gender characteristics, body weight of the patient, as well as the etiological and pathogenetic mechanisms of the development of the disease.

Literature

1. De Fronzo R. Pharmacologic therapy for type 2 diabetes mellitus // Ann Inter Med. 1999; 131: 281-303.
2. Dedov II, Shestakova MV Incretins: a new milestone in the treatment of type 2 diabetes mellitus. M., 2010. S. 55–62.
3. Rosenstock J. Comparison of vildagliptin and rosiglitazone monotherapy in patients with type 2 diabetes: double-blind, randomized trial // Diabetes Care.2007, 30 (2): 217-223.
4. Matikainen N. Vildagliptin therapy reduces postprandial intestinal triglyceride-rich lipoprotein particles in patients with type 2 diabetes // Diabetologia. 2006, 49: 2049-2057.
5. Duttaroy A. The DPP-4 inhibitor vildagliptin increases pancreatic beta-cell neogenesis and decreases apoptosis / Poster No. 572 presented at ADA, 2005.
6. Balabolkin M.I., Klebanova E.M., Kreminskaya V.M. Combined hypoglycemic therapy and the possibility of achieving long-term compensation of carbohydrate metabolism in patients with type 2 diabetes // Russian medical journal. 2007, No. 17, p. 492-496.
7. Hardman T. C., Dubrey S. W. Development and Potential Role of Type-2 Sodium-Glucose Transporter Inhibitors for Management of Type 2 Diabetes // Diabetes Ther. 2011; 2 (3): 133-145.
8. Experts Express Mixed Thoughts on Canagliflozin Approval.Medscape Medical News. Apr 18, 2013. http://www.medscape.com/viewarticle/782712.
9. Kim Y., Babu A. R. Clinical potential of sodium-glucose cotransporter 2 inhibitors in the management of type 2 diabetes // Diabetes Metab Syndr Obes. 2012; 5: 313-327.
10. Ushkalova EA A new class of antidiabetic drugs – inhibitors of sodium-glucose cotransporters // Farmateka. 2013, No. 16, p. 33-36.

A.S.Skotnikov * ^{, 1} , Candidate of Medical Sciences
M.G. Selezneva **

* GBOU VPO First MGMU im. I. M. Sechenov, Moscow
** GBUZ GKB No.