Pharmacotherapy

ROLE OF MEDICINES

 

1.    Why do few patients take pills, and few others take insulin?

For patients with type 1 diabetes, it is necessary to take insulin by injection or pump. This is because insulin is not produced in patients with type 1 diabetes. No other therapies can restore insulin in a person with type 1 diabetes within giving them the hormone from outside.

In type 2 diabetes, most patients can control their blood sugar levels with one or more pills for their diabetes, usually for several years. Oral medications either improve the pancreas’s ability to produce insulin or make body tissues more sensitive to insulin. Usually, a combination of different classes of oral drugs is prescribed depending on their blood glucose control and HbA1c levels. People with type 2 diabetes can remain off insulin for many years. If the blood glucose levels remain uncontrolled, then they are put on insulin.

One of the other reasons for putting on insulin is that there is a partial form of type 1 diabetes in few people with type 2 diabetes. This condition is called LADA (latent autoimmune diabetes of the adult). It usually occurs in adults more than 30 years of age, presence of any islet cell autoantibody and those with absence of insulin requirement for at least 6 months after diagnosis. People with LADA usually respond better to insulin than to pills. However, the usual treatment with type 2 diabetes is to start with medications and do close monitoring of blood glucose levels. The patient should meet the doctor at least once in 3 months to adjust the dosages of drugs.

 

2.    Can the medicines for diabetes stop if blood sugar is in control?

Diabetes is a progressive disease. If better controlled, there are chances to reduce the doses of the medications but rarely stopped completely.  Nevertheless, you need strict monitoring of blood glucose levels and regular follow-up visits to the doctor. Sometimes, people stop taking medicines once the symptoms subside, but this is not advisable.

However, if you are newly diagnosed, not on insulin, only on one class of medicine, and following a strict lifestyle regimen, there are chances for you to stop the oral medications. However, this may not last forever. It is advisable to have a close monitoring of glucose and regular follow up with the doctor.


 

3.    Why are patients with diabetes prescribed supplements such as vitamin D and B12?

Research has shown that the medication used for controlling blood sugar levels (metformin) may reduce vitamin B12 absorption in the body. The patients may get vitamin B12 deficiency if continued for a prolonged period. Vitamin D plays a vital role in managing blood glucose levels. Research studies have shown that type 2 diabetes patients with low vitamin D levels, when supplemented with vitamin D, significantly improved their fasting blood glucose levels. Patients with diabetes must have adequate levels of vitamin D for better control of blood sugar levels. Therefore, doctors generally provide Vitamin B12 and Vitamin D supplements along with medicines for diabetes.

 

4.    Are the unprescribed home remedies effective for blood sugar control? Can it be used over medicines?

Many traditional remedies (such as neem leaves, jamun seed powder, cinnamon, jeera, bitter gourd, fenugreek, barley water, and others) are known to be effective treatment for lowering blood glucose levels. [For additional traditional myths and facts visit our self-care management document in Chapter 5 of this course]
The beneficial effects of these are generally mild and can be more effective in some people with diabetes than in others. There is generally a little disadvantage in trying some of these supplements, as long as the glucose level is carefully monitored and conventional medications are also taken. There is not sufficient evidence for a few remedies, and one should not rely on them alone. These traditional and unprescribed remedies should not be used as replacement medications for diabetes.
Few anti-diabetic compounds like Garcinia Cambogia, aloe vera and others are also marketed widely in India. Since these remedies are not labelled or approved by Food and drug administration for their use in diabetes, there is no specific standardization of their formulations, which can therefore vary widely between manufacturers. Sometimes, exaggerated claims may be made for their effectiveness while at the same time a disclaimer is offered acknowledging that such compounds are not intended to diagnose or treat any disease!
 

5.    Who needs insulin injections?

When one’s own body doesn’t produce enough insulin, one can take man-made insulin to help control blood glucose. People with type 1 DM and many patients with type 2 DM require insulin therapy for good glycemic control.
In type 1 diabetes mellitus, there is no or little insulin produced by beta cells of pancreas. This is because one’s own immune system destroys the insulin producing cells in pancreas. In such cases, insulin injections can act as a replacement for one’s body insulin and help in controlling


blood glucose levels. In type 2 diabetes mellitus, some people get the blood glucose level well in control however, the likelihood of using insulin increases with the duration of diabetes over time. Some situations like when blood sugar level management is necessary when oral medications, weight loss, exercise don't work.

1.    How to take insulin injections?

People with type 1 diabetes and some with type 2 diabetes would require insulin injection. Most commonly syringes are used for injecting/delivering insulin into one’s body. However, there are other options like insulin pens and pumps.

Figure 1: Body sites to inject insulin
The four main areas to inject insulin are:

1.    Abdomen
2.    Thighs
3.    Hips/Buttocks
4.    Back of arms

Insulin injected into the abdomen is absorbed the most quickly and hence, it is recommended. It is suggested to give insulin shots around the same area and not exactly at the same place. Insulin site rotation should be followed to ensure adequate delivery and action of insulin and to avoid development of lipohypertrophy (abnormal accumulation of fat beneath the skin), pain and infection.  Also, one has to ensure that insulin delivery should be timed with meals to effectively process the glucose uptake by the cells.





  General tips:
•    Do not use expired insulin
•    Insulin to be given at room temperature. Please ensure you take out the insulin 30 minutes before use in case you have it stored in your refrigerator.

 

7.    What are different types of insulin injections?

Insulin is a peptide hormone, when taken orally it is destroyed by gastric acid. The common route of insulin administration is subcutaneous insulin injections. Prior to taking insulin, blood glucose levels must be checked to help to know the dose of insulin required. People can take insulin through needles and syringes, a cartridge system, or pre-filled pen systems. Insulin pumps, and quick acting insulin devices are also available these days.

Insulin gets absorbed the most when it is injected into the belly fat just underneath the skin and not into muscle. The better places include arms, thighs and buttocks. It is proven better to inject insulin at the same area of one’s body, however, can change up the injection spot.

 

8.    Is it possible to stop insulin once started?

The most common reason for discontinued insulin is due to fear of hypoglycemia, lack of support and cost.
For people with type 1 diabetes, particularly those diagnosed in childhood and adolescence, lack of insulin leads to DKA (diabetic ketoacidosis). Lack of insulin in these individuals leads to breakdown of fat and production of ketone bodies. These are organic acids and increasing levels may lead to severe acidosis. These build up in the blood stream and show up in urine and blood.
 


Symptoms may include vomiting, hyperventilation (rapid breathing) and finally leading to coma.
However, in case of type 2 diabetes one may need insulin to treat temporary high blood sugar caused due to
●    Surgery
●    Pregnancy
●    On medical emergency
●    Over time, long term diabetes causes damages to the cells that produces insulin and thus making one’s body less responsive to insulin
●    Lifestyle changes like dietary changes, an oral drug may not help in controlling blood glucose level
In case if one can lose weight, change diet, increase physical activity or change medications, one may be able to stop insulin therapy under doctor’s supervision.