Diabetes Survival Guide!

You've been told you have Type 2 Diabetes.  Your A1c is something higher that 6.5.  So, now what?  You have three basic tools to control Type 2 Diabetes: medication, exercise and diet.  Using all three, you can control and manage the disease.  But, what in the world is diabetes?

(I have used survival guides most of my professional life.  A survival guide gives you just enough information to 'get your work done' if everything is normal and is a reference resource until you gain experience.  And, I probably should have written this a while back, but it just occurred to me that it might be needed.  Plus, it also helps that I have a number of the pieces in place to which to refer.  Could it be seredipity?)

Your doctor has told you that you will probably have to take some medication to lower your A1c.  No surprise.  The doctor wants to get your A1c down ASAP - think of it as getting the poison out of your system.  So, meds are a very normal route.  In fact, they might start you on metformin, one of the most widely prescribed drugs fo diabetics.

Dr. K has written about metformin, and you should read it to understand the drug and  how it works.

But, what if you don't want to take a medication?  Well, there are those who decide they want to control diabetes through diet and exercise - and some are successful!  Some control and beat back the disease through the diet and exercise route.  But, the number who are successful is limited - very limited.

The first goal is to get your A1c down as soon as you can.  You can always stop taking meds if you see your numbers dropping and getting an A1c under 5.5; there is no rule that states you have to take them forever.  This is a decision you should make after talking with your doctor.  So, think about taking the medication.

For me, it was a no brainer.  I knew diabetes could cause serious damage and could lead to death.  I chose to take the meds to get myself back to 'normal.'  Diabetes normal is not good enough for me.  Normal is normal is normal, even if it's done with the aid of medication!

Regardless if you are taking medication, or not, you should start to exercise.  Read about my post on exercise to get a beginning point.  I still just walk, but a lot faster than I did at the beginning.  If you are going depend on exercise to gain more control, you will need to use cardio exercise and resistance training (aka weightlifting).  And, plan to spend about an hour a day, five or six days a week of exercise time if you have the weights at home.  If you go to a gym during a busy period, figure at least two hours a day.

You are going to have to start glucose testing at least twice per day.  Most of the instruction I have seen is either incomplete, or really cause pain.  For complete instructions on how to get a good reading without pain, read this.

And, you are going to examine your diet. Chances are it will change.  Mine did - a lot.  I started a lower carb diet and over the course of nine months I lost about 60 pounds between diet and exercise.  Diet is so very, very important as you work to control diabetes.

And, to bring it all together, I have strongly recommeded a food diary.  Keeping one was so helpful in the beginning as I was lowering my A1c - it told me what I could and could not eat if I paid attention to my meter readings.  The food diary continues to be a tool for success and something I go back to when I see my numbers creeping up.  You can read about it here and then download it by following the instructions in the post.

Just so you know, I started my diabetes journey with an A1c of 13 - that's pretty high.  My most recent test gave me a 6.1.  Blood pressure 114/80.  Weight seven pounds up over a year's time, which I am losing - I got a bit cocky when I had a test result of 5.9!  I lose the weight, keep up with my diet and meds, and I should be at about a 5.8 or lower when tested again.  I mention all of that just so you know I have first hand knowledge of what you are facing - and KNOW you can be successful!

As always, thank you for reading.  God Bless and know you can beat the enemy; you CAN control diabetes.

Please feel free to send me your comments.

What is Diabetes?

I assumed anyone reading this blog would know what a diabetic is, but I could be wrong.  So, just what is diabetes?

Diabetes is a disease that is caused by too much glucose (sugar) in the blood.  You see, for all of the different types of abuse our bodies survive, they are really pretty delicate chemical factories where thousands of reactions are going on every moment of our lives.  If they get out of balance, there can be problems.  One of them is diabetes.

Diabetes occurs when there is too much sugar floating around in your blood and not enough in your blood cells.  This happens because insulin, which the pancreas produces, is  not working like it should, or is in pretty short supply.  Think of it this way, insulin is a key to a door in the cell wall.  If everything is working right, insulin comes along, opens the cell door and sugar enters the cell and leaves the blood.  All pretty simple, right?

But, in diabetics there is either not enough insulin, or the insulin is not working correctly.  If sugar can't get into your blood cells, then it's floating around in your blood causing all kinds of havoc on your organs - not good at all!  Which is why it's really important for a diabetic to control the disease - because it can to lead to so many other problems.

So, now you have a basic idea of what diabetes is.  And, you know that it's caused by an insulin shortage of some kind.  Which will all make even more sense as you read Dr. K's description of the various diabetes drugs being used today and what they seek to do.  Go back and read her post on Metformin - it will make more sense.

This article provides a decent overview of diabetes and how to deal with it in general terms.  Remember, as you battle to control diabetes, not everything will work the way researchers say it will because they deal with large numbers of folks and do not know you or your body.  Your body chemistry might be different, so you will find a lot of guidelines, but fewer hard and fast rules.  The car manufacturers have a phrase for this kind of difference: "Your mileage may vary."

Your fight with diabetes is a personal fight - one that you must win...and CAN win.  I know you can do it.  I know you can beat back and beat down the disease and have a wonderful life.  I know it. My goal is to help you find the tools you need to win the battle.

You can read more about what makes a diabetic here, on a previous post.

As always, I welcome your comments.

Metformin

As I was considering which diabetes drug to feature in my first 'drug post,' there was only one clear choice. The most prescribed medication for diabetes, and one that literally hundreds of my patients use is...metformin! Metformin is the generic name. Some of the brand names you may be familiar with are Glucophage, Glucophage XR, Fortamet, and Riomet (the liquid form of metformin).

Just a heads-up, remember that I am a pharmacist. So, when describing a drug, I will sound like, you guessed it, a pharmacist. Blame my training. I'll try to make things simple and easy to follow and understand, but if I've ever gone too "scientific" and you'd like things explained another way, or you have questions, feel free to let me know. My email will be available at the end of my post. An important thing to remember before I start: glucose is just a fancy name for sugar. I'll probably use glucose because it is most common for me, so just don't be confused by my terminology - I am referring to sugars. So without further ado...metformin!

How does it lower blood sugar: Something for you to remember: as a diabetic you have sugar (glucose) in your blood - kind of floating around your cells because for some reason it's not getting into them. Sugar in the blood and not in the cell is a bad thing. Normally insulin in your body helps sugar enter your cells, but in diabetics it just isn't doing the trick. Metformin makes your cells more sensitive to allowing sugar to enter - kind of like opening the door for sugar. More sugar in cells means less floating around in your blood, which means lower A1c, which makes for a healthier person.

Is that enough? Ok, so now sugar is going into your cells where it belongs, so we have a perfectly wonderful drug for diabetes and can be happy with that. Do you think that the scientists that made metformin thought that? You guessed it, of course they didn't! They wanted more "bang for their buck," so they thought of another way to keep sugars out of your blood. How did they do that? By not allowing it into your blood in the first place. Metformin is very special - it acts as a sort of bodyguard after you eat a meal. Metformin helps to keep some of the sugars that you eat from entering your bloodstream. If the sugars stay in your stomach and intestines and don't enter your blood, the result is lower blood sugar readings. Pretty simple, huh?

But wait, there's more! Would you believe it - your body actually produces it's own sugar! You see, our bodies need a certain amount of sugar for energy. Your brain lives off of it, as do many other important organs. So your liver has the important job of making sugar when needed. Unfortunately in diabetics, it will do this sometimes even when you have enough already in your blood. So for that reason, the makers of metformin decided to develop their drug so that it would stop the liver from producing that extra sugar.

Look at that - three different ways that metformin helps with diabetes! No wonder it is the drug that is chosen first for most new type 2 diabetics.

The effect on your numbers: So where does that put us? How does this change the numbers you are seeing on your blood tests? With metformin, you can expect to see a decrease in your A1c of at least 1-2% (example: your A1c could decrease from 10 down to 8 or 9 after metformin is started). Remember that A1c tells the story of your average blood sugars over the past 3 months. You could look at the blood sugar readings that you take during the day as photographs, whereas your A1c would be the title of the photo album.

An added bonus of metformin is that it might help to lower your bad cholesterol and increase your good cholesterol. There is a potential for modest weight loss when on metformin, but the average is only about 2.6 pounds, so it is not a "miracle" weight loss drug. However, it is unique because it is a diabetes medication that is weight neutral, meaning it does not cause weight gain. As you will learn later, this is not the case with all diabetes medications.

Dosing: Initially, most patients are started at doses of 500 mg once or twice daily of the immediate release (IR) form of metformin. Immediate release just means that the medication enters your blood all at once, versus slowly releasing all day long (extended release). If a patient is new to metformin and is starting at a dose of 500 mg twice daily, I usually recommend starting at 500 mg once daily for the first three days in order to decrease stomach upset. There is a less commonly used 850 mg dose of metformin that is available, which is started at one tablet daily with breakfast.

For some patients, extended release (ER) metformin is chosen. Metformin ER enters the blood more slowly, which leads to less stomach upset and discomfort. Since metformin ER only needs to be taken once daily, it is a good choice for patients that have trouble with taking a medicine twice daily (can't remember, varied schedules, etc). Patients are generally started on 500 - 1000 mg of metformin ER, taken with the evening meal. Do not cut, crush, or chew metformin ER because it is specifically made to disperse throughout the day, not all at once.

Because of unpleasant stomach upset and side effects, metformin should always be taken with food or immediately following the meal. We start metformin at low doses because of the high potential for side effects. Doses are then increased weekly if needed. Generally we do not see a response with metformin at doses less than 1500 mg per day, so don't be discouraged if your doctor keeps increasing your dosage. It may take up to eight weeks of being on metformin before full effectiveness can be seen, so patience really is a virtue.

Side effects: I have already previewed the major side effect of metformin, which is stomach upset. This includes diarrhea, nausea/vomiting, and gas. As I mentioned, taking the medication with meals and increasing doses slowly over days and weeks can help to minimize this. When starting metformin, patients sometimes complain of an unpleasant or metallic taste. This tends to go away within the first few weeks. More rarely we see skin rashes, itching, and sun sensitivity (sunburning easily) with metformin use.

A very rare (2-10 patients per 100,000 patients on metformin per year) but serious side effect that is caused by metformin is something known as lactic acidosis. Lactic acid is a part of our metabolism that helps us produce energy when we do things like exercising. At high levels, it can be very dangerous. Lactic acidosis can be deadly in up to 50% of cases. If lactic acid levels are too high, dialysis is required to remove the metformin from the body and to correct the increased lactic acid levels. Fortunately physicians and pharmacists are well aware of this side effect, and it is easily preventable if certain patients that are more at risk are not given metformin. Side effects from metformin are very rare and can be easily dealt with and prevented by taking the medicine with food and switching to a different medication if needed.

Last week I had a patient that was switched from metformin to glipizide. While her A1c was okay, her kidneys were not doing very well, which could lead to lactic acidosis. So, her doctor changed her to another medication. This leads me into a discussion of which patients would not be eligible to take metformin.

Who should not take metformin: Patients with kidney disease or kidney failure are more at risk of developing lactic acidosis, since metformin is removed from the body solely by the kidneys (if your kidneys are not good, metformin stays in your body too long, causing problems). Your doctor will do blood tests to determine the health of your kidneys prior to starting you on metformin. If your kidneys are not healthy enough, another medication will be used. As we get older, our kidneys generally do not work as well, so metformin is not recommended in anyone over the age of 80 years old, unless your doctor determines that your kidneys are healthy.

The liver is responsible for regulating lactic acid levels in our bodies, so anyone with liver disease should avoid metformin. Since alcohol has a negative effect on the liver, patients should be advised not to drink in excess (binge drinking, or chronic use of more than two drinks per day or at one sitting). I'm sure that the other effects of alcohol on diabetes will be covered in a future blog post.

Drug interactions: Certain stomach medications used for acid reflux (cimetidine - generic for Tagamet, and ranitidine - generic for Zantac) interact with metformin. Two antibiotics (cephalexin - generic for Keflex, and Bactrim) may increase metformin concentrations. You would think that this is a good thing, but it can lead to more harm than good (increased side effects, stomach discomfort and pain). The fluoroquinolone antibiotics (Levaquin, Cipro) may cause increases or decreases in blood glucose levels, which are also not good things for diabetic patients. There are other medications that I have not included on this list, for sake of space, so please remember to check with your pharmacist or physician, and make sure they are aware of all medications you are taking.

I know this is lot of 'pharmese' so far, but I am a pharmacist so what do you expect? Bottom line is that you need to always let your doctor and pharmacist know what drugs you are taking so any negative interactions can be avoided. Don't forget to ask your pharmacist to check for interactions before you stop to pick up a product from the cough/cold or vitamin section of the pharmacy, because these are also medications and they can interact with other things you are taking. Your doctor and pharmacist should be informed about all prescription and over-the-counter medications that you are using, as well as any allergies you have to medications.

Some folks have more than one doctor - always let all doctors know every medication you are on. And, use only one pharmacy so they can check for interactions. You run risks if you use more than one pharmacy - nobody knows all of the drugs you are taking, so you don't have a safeguard in place. So to sum up: make sure all doctors know about all of your medications, and use one pharmacy. Okay? It's best for you that
way. I'll step off my soapbox now.

Monitoring: Sometimes I have patients ask me why they have to make another appointment with their doctor before they will be given any refills. "I'm a diabetic, and I will be for the rest of my life. Why do they need to see me every year? Aren't they just going to keep me on my meds?"

This is a very valid question. As you can see from what I've been talking about in this post, there are many reasons why metformin (or any other medication) might not be appropriate for a patient. And, our bodies are always changing - what might have been the right medication and dosage for you when you started it might not be appropriate six months or even ten years later. Your kidneys and liver might not be working as well to clear the medication. Your control on diabetes might have improved or, sadly enough, gotten worse.

So at least once yearly, your physician will want you to come in for simple blood testing. This will include a serum creatinine (something that gives us an idea of how well your kidneys are functioning), fasting plasma glucose and A1c (remember the photos and photo album?), and other blood components.

The ADA recommends A1c tests twice a year and a full panel of blood tests once a year. Your doctor should be following that as a minimum. In the early stages of treatment, your doctor might test more often to track progress. And, really, how long does a blood test take? Most labs now allow you to make an appointment online so it's faster and more convenient for you. Sometimes you don't even need to see the doctor - you get lab work and they send in the prescription once they have the results. It's as simple as that. But remember, if they do need to see you, please make the appointment. They really are only trying to make sure they have the right medication and dose for you, and that your diabetes is being taken care of properly. We all want you to live a long and happy and enjoyable life.

Place in therapy for diabetes: Metformin is known as the cornerstone for treatment of type 2 diabetes. The current guidelines that we follow when treating new diabetics state that metformin should be started before any other medication, unless the patient is not able to take it for the few reasons I stated earlier. Metformin is also the only medication that is currently approved for use in pre-diabetics to prevent full-blown diabetes. It is also the only oral diabetes medication approved for use in kids (age 10 and up). Since insulin is the only other diabetes medication that can be used in kids right now (and let's face it, what kid wants to get a shot?!), it is a very popular medication for those very young diabetics. Unfortunately it does not work for type 1 diabetes, which is generally diagnosed in younger people.

If you would like to read more about metformin, here is another good website: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000974/

So there you have it, a review of our most popular diabetes medication, metformin. Next week I will move on to one of the different categories of meds that we use to treat high blood sugars, so you will want to stay tuned.

As a disclaimer, I am your "virtual" pharmacist, here to provide you with information and answers to questions. However, I am not your local pharmacist and could, in no way, be aware of your specific medical needs. Remember to always check with your medical provider and pharmacist before stopping or starting any new medications. My posts are based on general pharmacy principles and should not considered as your "first opinion" when it comes to your health. Please consult with your doctor and pharmacist about anything regarding your health.

Please feel free to email me at drk@solutionsfort2diabetes.com if you have any questions on metformin, diabetes medications, or other pharmacy issues.  I will attempt to answer all inquiries in a timely manner.  Also, if you have a suggestion as to other things you'd like to see me post about, or general pharmacy questions that you think other patients might have, please let me know.  Thanks for reading!

Let's Start at the Very Beginning: Classes of T2 Diabetes Medications

For my first post, I'm going to give a brief overview of the various classes of medications used to treat type 2 diabetes.  Within our bodies, blood sugar levels are controlled by various mechanisms.  This is a good thing, because it allows us to "attack" diabetes from various angles. 

For any of you footbal fans out there, you could compare this to what your favorite coach does.  In order to gain yards and score touchdowns, do they always use the same plays for every team they encounter?  Of course not!  Some plays are more effective against different defensive lines, and all circumstances can change from one snap of the football to the next.

This is the same when it comes to treating diabetes.  Every person is unique and has their own body chemistry.  This is the same reason why an allergy medication might work well for one person, but not another.  Pharmaceutical scientists have studied these differences and have developed a wide variety of drugs to treat the causes of high blood sugar (glucose) at every stage.  In future posts I will breakdown each of the currently available type 2 diabetes medications and give you the "need to know" information.  But for now, let's start with the basics.

Biguanides

Don't let this name intimidate you.  Biguanides, like most other classes of medications, are simply named for the molecule that is part of their chemical structure.  In fact, to make things even simpler for you, the biguanide "class" of medications only contains one diabetic medication.  One!  Metformin, a drug that most type 2 diabetics are very familiar with, is the only biguanide currently available in the US that is used for diabetes. 

Biguanides use a few methods for lowering blood glucose levels.  The first method is by making the cells of your body more sensitive to insulin.  If you are unfamiliar with it, insulin is the hormone made by your pancreas that is responsible for "pushing" glucose into your cells.  More glucose in your liver, muscle, and fat tissue = less glucose floating around in the blood.  Too much glucose in your blood, and not in your cells, is what causes diabetes.  In type 2 diabetics, the body starts to not respond to insulin as well as it should, so metformin helps the cells "recognize" insulin again.

The other way that metformin lowers blood glucose levels is by decreasing the amount of glucose produced by the body.  One of my pharmacy professors liked to use the phrase "the liver is a giver."  Your liver is responsible for a wide variety of functions, among which is production of glucose.  During times of fasting or starvation, the liver does this to prevent dangerous drops in blood glucose.  But in diabetics, the extra glucose is not necessary, so metformin stops this.

Another exciting thing about metformin is its ability to produce small decreases in cholesterol.  This is something that I will discuss in future posts.  As you will see, this is uncommon and part of the reason why metformin is the go-to medication for new diabetics.

Sulfonylureas

Another long name based on a chemical structure.  Glyburide, glipizide, and glimepiride are the most well-known students in this class.  Compared to the two different mechanisms of action of the biguanides, sulfonylureas do not provide as much "bang for the buck."  Their main action comes from the ability to stimulate the pancreas to release more insulin.  This causes glucose to enter the cells, decreasing the amount of glucose in the blood. 

Meglitinides

This is a category of medications that we see used much less commonly than the two previously mentioned.  The two meds in this group are Prandin and Starlix, which are currently only available in their brand name form.  Meglitinides are essentially the same as sulfonylureas, except they don't contain a sulfa molecule.  This is important for our patients with sulfa allergies.  They work the same way as the sulfonylureas (increasing insulin release from the pancreas).

Thiazolidinediones

Sometimes you wonder if we are making these names up, don't you?  It's pretty obvious why we abbreviate this class to the term "TZD".  The two current TZDs available in the US are Avandia and Actos.  The main effect of these medications comes from the ability to sensitize the muscles, liver, and fat tissue to insulin.  This allows more glucose to enter the cells and leave the blood stream.  They also show some effectiveness in decreasing the amount of glucose that is released by the liver.

Alpha-Glucosidase Inhibitors

This is a newer class of medications that contains the drugs Precose and Glyset.  Maybe this shows my "nerdy" side a bit, but I find the mechanism of this class to be quite exciting.  Alpha-glucosidase inhibitors work in the small intestine by delaying and preventing complex carbohydrates from being absorbed from what you eat.  This means that the carbohydrates don't enter the bloodstream, and your after-meal (postprandial) glucose readings are much lower.

DPP-4 Inhibitors

Januvia, Onglyza, and Trajenta are the current US available medications in this category.  These medications cause insulin to be produced and released by the pancreas as blood glucose levels rise.  They also decrease the production of glucagon, a hormone that causes the body to break down glucose storage units and dump glucose back into the blood when blood glucose is too low (during periods of fasting or between meals).  Finally, DPP-4 inhibitors improve the function of beta cells in the pancreas, which allows them to better produce the insulin that is needed to keep blood glucose levels at normal levels.

Insulin

Most people are familiar with the use of insulin in type 1 diabetics.  They require insulin because their bodies are no longer able to produce it.  However, insulin is also used as a very effective treatment in type 2 diabetics when oral medications and lifestyle changes are not effective enough at lowering blood glucose. 

I have already discussed insulin a bit within the other drug categories, but let's cover it as its own category, to be thorough.  At low levels, insulin causes the liver to stop producing glucose.  As you increase the insulin dose, that causes the muscles in your body to start taking glucose out of the blood.

Insulin is categorized based on how fast it starts working in the body, and for how long it works (rapid, intermediate, or long acting).  In a future post I will discuss the different types of insulins and injection regimens, but for now this is a good place to start.

Incretin Mimetics

The injectible drugs Byetta and Victoza are the two drugs currently within this category.  These medications work to lower blood glucose by increasing insulin production in response to high blood glucose levels.  They also are unique because they stop glucagon (mentioned earlier) from being released after you eat. 

Other ways that incretin mimetics work to lower blood glucose are by improving the function of beta cells in the pancreas (responsible for making insulin) and causing a feeling of fullness (making the patient eat less and lose weight).

Amylin Analogs

Currently the injectible drug Symlin is the only amylin analog.  Amylin is a hormone that is released by the body, with insulin, to control glucose levels after you eat.  In diabetics, amylin levels are too low.  Symlin acts like amylin in the body; it causes glucose to be absorbed into the body more slowly from the food you eat and also makes you feel fuller faster, leading to less calories eaten and more weight loss.


---So there we have it, a basic overview of the many classes of medications available for treating type 2 diabetes.  In my next series of posts, I will discuss each medication individually, and give you the most important "need to know" information.  As a reminder, every diabetic is different.  I will continue to present information in a general format, but always consult with your personal physician and pharmacist before making any changes in your medications.  I invite you to feel free to ask me any questions you might have regarding diabetes and medications.  Eventually we might have a section of "frequently asked pharmacy questions" in which I answer your questions or address things that I've read about or been asked within my practice recently.  I'm here for you, as a part of your virtual care "team."  Feel free to help me customize my posts to help your needs. 

Dr. K, PharmD

Welcome!

Thank you for coming to this blog.  I have been thinking about it for weeks before posing my first entry.  You see, by starting this blog, I think I have a responsibility to continue to write and I take that seriously.  My hope is that you will find some value to what I write.

Three things happened recently to propel me to write this blog:

1. My diabetes nurse (part of my Treatment Team) told me I should think about being a Diabetes Trainer because I have been successful, in her mind, at managing diabetes.  
2. I was asked what I would do differently if I had a million dollars.  I don't have that kind of money, but it really caused me to ask myself what I would like to do.  The answer: Make a difference in people's lives.
3. I was talking with a client who told me one of his folks was out with a leg infection.  Of course, I thought diabetes - which I later found out was correct.  After asking about the prognosis, I thought it was totally avoidable - it did not have to happen.  I began to think about ways I could reach out to others to let them know they did not have to be victims.  And, a blog was born. (If you have any ideas on how to get folks to take a look at it, if you find it valuable, I will gladly take the help.)

So, I hope you get a bit of encouragement.  Smile once in a while.  And, comment when you want to.


A bit about me.  I am a diabetic.  I was diagnosed about three years ago when after a routine (what I thought was routine) series of blood tests.  My doctor's office called and told me I needed to come in.  They told me it had to do with the test results.  Well, I had a few days of rampant, raging fear not having any idea what was going on.

After I got into the doctor's office, he came directly to the point.  I had an HBA1c of about 13.1.  I remember looking at him and wondering what that meant.  He said it was a 'bit high' and that I had diabetes and that I would probably have to take pills the rest of my life.  I don't know what the rest of you thought when you heard the news you had diabetes, but I thought of all of the horror stories of lost feet, legs, blindness and organ failure.  To say I was scared is an understatement.

My doctor started me on good ol' Metformin and told me to return in several weeks after another blood test.  He also said that I had to 'lose a little weight.'  I came back and he changed the medication to Janumet - my A1c was not dropping fast enough for him, and I was scared, again.  Two months later my A1c was down to around 7.  He changed my medication back to Metformin and my numbers continued to drop.  My A1c seems to have stabilized around 6 - and sometimes under.

What have I done?  I changed my diet immediately.  I began to exercise.  I looked at the American Diabetes Association website.  Learned about BMI's.  And all sorts of stuff that I was clueless about.

This blog is about my journey toward diabetes management.