Type 2 Diabetes
Type 2 Diabetes
Type 2 diabetes is a condition where the body doesn’t make enough insulin (relative insulin deficiency) or the body is unable to use the insulin properly (insulin resistance), or both.
Type 2 diabetes is a progressive condition. Over time, the beta-cells (the cells in the pancreas that make insulin) are destroyed, thus producing less and less insulin. Insulin resistance is associated with overweight and obesity. Overweight and obesity are one of the possible causes for the beta-cell being destroyed over time.
Initially people with type 2 diabetes are treated with tablets only, but because less and less insulin is produced over time, most people with type 2 diabetes will need to start using insulin to control their blood sugar (glucose) levels.
It is important for people with type 2 diabetes to know and understand that the condition is progressive, and that extra medication needs to be added over time, as many people think that they have “failed” because they need extra / additional medication.
Weight loss and management, healthy eating and exercise are equally as important as taking medication in the treatment of type 2 diabetes.
Symptoms of Type 2 Diabetes
Type 2 diabetes develops over a few years, and many people with type 2 diabetes do not have any symptoms, or they may not recognise these symptoms. Worldwide, up to 50% of people living with type 2 diabetes have not been diagnosed.
Most people with type 2 diabetes are overweight or obese, and the early symptoms of type 2 diabetes may include:
- Recurrent infections like bladder infections, kidney infections and skin infections. In females, recurrent vaginal infections
- Wounds that don’t heal or take a long time to heal
- Fatigue and unexplained tiredness
- Blurred vision
- Increased thirst
- Increased urination, or needing to urinate at night
- Pain or numbness in the feet or hands
- In males, inability to get or maintain an erection, known as erectile dysfunction
Treating Type 2 Diabetes
Because type 2 diabetes has 2 components, insulin resistance (where the body’s cells cannot use the insulin properly), and insulin deficiency (where the beta-cells produce less and less insulin over time), people with type 2 diabetes often treated with more than one medication.
Oral Agents (Oral-Anti-diabetic agents):
These are tablets that are used to treat diabetes. There are different types of tablets that work of different aspects of diabetes. The 2 most commonly used oral drugs used in South Africa to treat type 2 diabetes are called: Sensitizers and Secretagogues
Sensitizers (also known as insulin sensitizers): these are tablets that are used to treat insulin resistance. They help the body’s cells to use the insulin properly. There are 2 types of sensitizers.
Metformin: Metformin’s main function is to improve the action of insulin at the liver, and to stop the liver from producing too much glucose (which will raise your blood sugar levels). Metformin also helps the body’s cells (muscle and fat cells) to use insulin better and thus helps to move sugar (glucose) out of the blood into the body’s cells thus lowering blood sugar levels.
Metformin does not increase the amount of insulin the body produces, and therefore hypoglycaemia (low blood sugar levels) are not common with the use of metformin. Metformin (if used on its own) does not cause weight gain, and in fact some patients may lose weight when using metformin.
Metformin may cause stomach upsets, and should always be taken with meals or even after meals. If you are taking metformin and you often have stomach upsets then you should speak to your doctor.
Thiazolidinedione: Also known as TZDs. TZDs work mainly on the body’s cells to help the body use the insulin better (to overcome insulin resistance). TZDs are not very commonly used oral agents in South Africa.
Insulin Secretagogues: these are tablets that help the beta-cells in the pancreas (the cells that make and release insulin) to make more insulin. In type 2 diabetes, the beta-cells are destroyed over time so the cells do not make enough insulin to control blood sugar (glucose) levels. Insulin secretagogues help the beta-cells to make and release more insulin to help lower the blood sugar (glucose) levels.
There are different types of insulin secretagogues:
Sulphonylureas; Meglitinides (glinides); DPP-4i (dipeptidyl peptidase 4 inhibitors or gliptins)
Sulphonylureas and Meglitinides have a direct effect on the beta-cells of the pancreas. These drugs attached onto special receptors on the edge of the beta-cells and stimulate the beta-cell to produce and release more insulin. Although these drugs increase the amount of insulin when the blood sugar (glucose) level is high, they don’t “switch – off” completely when blood sugar (glucose) levels return to normal, and these drugs can increase the risk of developing hypoglycaemia (low blood glucose).
Sulphonylureas and Meglitinides should always be taken with food, and once you have taken these tablets you should not miss any meals and or snacks.
DPP-4i (DPP-4 inhibitors) are drugs that have an “indirect” effect on the beta-cells. When we eat food, the gut releases hormones called incretins. These hormones are sent to the pancreas to help the beta-cells to produce more insulin. These incretin hormones also inhibit the release of hormones from cells called the alpha-cells, that stimulate the liver to over-produce glucose (sugar) and increase the blood sugar(glucose) levels. The body produces certain enzymes which break down the incretin hormones very quickly so that in people with type 2 diabetes, these hormones don’t work properly. DPP-4i drugs inhibit these enzymes from breaking down the incretin hormones so that they can continue to work and help lower blood glucose levels.
DPP-4i, when they are used on their own, have a very low risk of hypoglycaemia as they only work when you have eaten food.
A third class of drugs is available, but is not commonly used, is called Alpha-glucosidase inhibitors.
Alpha-glucosidase inhibitors are drugs that slow down the rate at which complex carbohydrates are broken down and released from the gut into the blood stream. They work directly on the carbohydrates that are eaten and therefore they have a very low risk of hypoglycaemia. Alpha-glucosidase inhibitors do not have any effect on simple carbohydrates like, fruit, fruit juice, sweetened cold drinks, milk and sweets, so your blood sugar (glucose) levels wills still go up after eating these eating or drinking these foods, and if you do have a hypoglycamic episode, you can still use these as treatment to raise your blood sugar (glucose) levels.
Unfortunately, because they work on the carbohydrates in the gut, a common side effect of using this drug are bloating and flatulence, but if started slowly and your doctor increases the dose slowly, these side effects tend to be less.
Insulin use in type 2 diabetes
There are 2 ways in which insulin can be started (initiated) in people with type 2 diabetes:
- Basal insulin given once-a-day in combination with Metformin and Sulphonylureas – this is also known as Basal-Oral therapy.
- Premix insulin given once or twice a day, normally only in combination with Metformin.
- Basal Plus / Basal-Bolus: Your doctor may choose to act a rapid acting insulin onto of your basal insulin. He may ask you to choose which meal is your biggest meal, and then you will inject your rapid acting insulin just before this meal. You will still inject your basal insulin in the same way / time that you did before. Over time, your doctor may add rapid acting insulin at the other meals as well.
- Premix insulin: If you are using a Premix analogue insulin, and you were only injecting once / twice a day, your doctor may add a second or third injection before each meal.
In type 2 diabetes, as the beta-cells produce less and less insulin, it is necessary to start injecting insulin to increase your body’s levels of insulin to control your blood sugar (glucose) levels, in combination with your oral tablets. You must not stop taking your oral tablets unless your doctor has advised you to do so.
Your doctor may prescribe an intermediate acting insulin(Biosulin® N; Humulin® N; Protaphane®) or he may prescribe a long acting basal insulin(Lantus®; Levemir®).
If your doctor has prescribed an intermediate insulin,you should inject it as close as possible to 10pm. This insulin has a peak action after 4 hours of injecting and if taken too early can increase your risk of over-night hypoglycaemia. Your doctor may suggest that you inject your insulin in the morning with your breakfast. ALWAYS REMEMBER: YOU SHOULD NOT MISS A MEAL ONCE YOU HAVE INJECTED YOUR INSULIN.
Intermediate acting insulinshould always be gently shaken / mixed before injecting, to make sure that all the insulin is mixed up properly in the liquid. The insulin should look “milky” before you inject it. Your doctor will show you how to mix (re-suspend) your insulin.
If your doctor has prescribed a long acting basal insulin, you can inject this in the morning or the evening [any time from dinner time up until bedtime], but once you have decided on a time, you should inject at the same time every day.
Long acting basal insulin is a clear and colourless insulin, so there is no need to shake / mix the insulin before injecting.
Premix insulin is insulin that contains both a short (bolus) acting component and a long (basal) acting component. This means that there is a component (usually 30%) that is short acting and will cover the meal, and a long / basal acting component (usually 70%) that will work in the background between meals, and overnight.
There are 2 types of premix insulin available:
Premix Human insulin: this insulin needs to be injected twice-a-day, 30 minutes before breakfast and 30 minutes before dinner. (Actraphane®; Biosulin® 30/70; Humulin® 30/70; Insuman® Combo 30/70.
Premix Analogue insulin: this insulin can be injected once- twice- or three times a day, and is injected immediately before the meal. (HumalogMix® 25; HumalogMix® 50; NovoMix® 30).
Premix insulin has to be mixed / shaken before it is injected to ensure that all the insulin is mixed into the liquid. The insulin should be “milky” before you inject it. Your doctor will show you how to mix (re-suspend) your insulin.