type 2 diabetes treatment
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Expert-reviewed by Ashwini S.Kanade, Registered Dietician and Certified Diabetes Educator with 17 years of experience.

Treatment of diabetes

Diabetes is a major lifestyle disorder. With more than 72 million people in India suffering from diabetes, no wonder it is the diabetes capital of the world! [1] But it is possible to lead a healthy and a happy life with diabetes if it is kept under control.

Most treatments aim towards controlling diabetes by keeping blood sugar under check with lifestyle changes, medication or insulin injections. To live a healthy life, the American Diabetes Association recommends to bring down -  

  • HbA1c to less than 7%
  • pre-meal blood sugar levels to 70 -130 mg/dL
  • post-meal blood sugar levels to less than 180 mg/dL

Lifestyle intervention

Diet and exercise are the two main lifestyle changes that could help keep your blood sugar levels in control. Other than that, if you smoke, quit! Also, avoid consuming alcohol. Ask your doctor how much alcohol is safe for you.

1. Diet

Diet for diabetes management is not a one-size-fits-all plan. It is a personalised approach, so work with a dietitian to chalk out a diet plan suitable for you. The main goal of your diet should be to –

Joslin Diabetes Center suggests the following guidelines may help: [16]

  • 40% of your diet should be carbohydrates. Include 20-35 gm of fibre. Avoid processed food.
  • Proteins should make up 20-30% of your diet. However, if you have kidney disease, you may have to reduce the intake as more protein will cause your kidneys to work harder.
  • Include 30-35% of fats in your diet. Best sources of fat are olive oil, nuts, seeds, and fatty fish.

Dietitians in India suggest you divide your daily calories as follows:

  • 50% carbohydrates that include grains, and vegetables and fruits rich in fibre. Make sure that you consume 28-30 gms of fibre.
  • 25% proteins
  • 25% fats

In other words, fill up half your plate with vegetables rich in fibre, and the other half with grains and proteins cooked in 5% of oils/ghee, in equal proportion.

2. Exercise

Exercising is an important component of diabetes management. Researchers suggest that just increasing physical activity is not going to help much in reducing blood sugar levels. Rather supervised structured exercise in the form of aerobic exercise plus resistance exercise is highly beneficial.

The following exercise regimen conducted by researchers was found useful. [17]

  • Exercising six times a week with each session lasting for 45 minutes.
  • Nine resistance exercises performed on alternate days of the week (3 non-consecutive days).
  • Each session consisted of 2 sets of 4 upper body exercises, 3 sets of 3 leg exercises, 2 sets of abdominal crunches and 2 sets back extensions.
  • Aerobic exercise performed on the other 3 non-consecutive days.
  • Exercise consisted of bicycle ergometer or treadmill.

If you find this regimen quite intimidating, talk to your doctor about the exercise regimen you may be more comfortable with. But make sure that you have at least 150 minutes of moderate physical activity a week, that is, about 30 minutes for 5 days.

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Medication

Drugs work only if you have type 2 diabetes. Even then, treatment goals and medication differ from person to person depending on their age, lifestyle and any other health problem.

Two drugs, metformin and sulfonylureas, are most commonly used to treat type 2 diabetes.

1. Metformin

Metformin acts by –

  • decreasing production of sugar by the liver
  • decreasing the amount of sugar absorbed from food
  • improving insulin sensitivity

Metformin can be prescribed as a single dose or as fixed dose combinations (FDC). The following combinations have been approved by the Central Drugs Standard Control

Organization:

  1. glimepiride/metformin
  2. glimepiride/pioglitazone/metformin
  3. glipizide/metformin
  4. glibenclamide/metformin
  5. gliclazide/metformin

However, different dosages of three of the five FDCs have been banned in India since 2016. Check with your doctor if you have been prescribed these medicines.

Dosage:

Metformin comes in three forms:

  • Tablet – 2-3 times a day, usually taken with meals.
  • Liquid – 1-2 times a day, usually taken with meals.
  • Extended-release tablet – Once a day, usually taken with an evening meal.

Who should not take metformin:

Your doctor will not prescribe metformin for you if you –

  • have kidney disease
  • are over 65 years of age
  • have had a stroke or heart attack
  • have heart disease or liver disease
  • drink alcohol regularly or drink sometimes but in very large amounts

Contact your doctor without delay if you are on metformin and you experience –

  • severe diarrhoea
  • severe infection
  • vomiting
  • fever

Side effects of metformin:

In people with kidney problems, metformin can cause a rare but life-threatening condition called lactic acidosis, in which acids build up in the bloodstream causing an imbalance in the pH of the body. Contact your doctor if you have the following symptoms:

  • rapid breathing or shortness of breath
  • rapid or slow heartbeat
  • extreme tiredness or fatigue
  • nausea and vomiting
  • decreased appetite
  • muscle pain

Other side effects include:

  • diarrhoea
  • bloating, indigestion, stomach pain
  • metallic taste in the mouth
  • a headache
  • muscle pain

2. Sulfonylureas

Sulfonylureas act by stimulating the production of insulin by the beta cells in the pancreas. Examples of sulfonylureas include glimepiride, glyburide, glipizide, gliclazide and gliclazide MR. You will find these names below the name of your medicine on the tablet strip.

Sulfonylureas, especially glimepiride, are effective, safe and inexpensive, so they are the most preferred medicine when taken along with metformin in India. [18]

Dosage:

Name of medicineDuration of action in hoursStarting doseMaximum doseNote
Glimepiride241-2 mg/day8 mg/day
Glyburide18-241.5-5.0 mg/day depending on the strength of the tablet used12 mg/day or 20 mg/day depending on the strength of the tablet used
Glipizide18-242.5-5.0 mg/day depending on the strength of the tablet used20 mg/day or 40 mg/day depending on the strength of the tablet used
Gliclazide2440-80 mg/day320 mg/dayDoses more than 160 mg are given in two doses
Gliclazide MR2430 mg/day120 mg/day

Source: (1) http://www.chgsd.com/documents/diabetmedguide.pdf  (2) https://www.mims.com/india/drug/info/gliclazide?type=full&mtype=generic

Side effects of sulfonylureas:

  1. Low blood sugar, also called hypoglycaemia. Symptoms include dizziness, nervousness, confusion, hunger and sweating. However, the risk is reduced if you are taking glimepiride.
  2. Skin rashes or itchy skin may be an allergic reaction during the first 6 weeks in some people.
  3. Weight gain. This can be mitigated if you are taking metformin along with sulfonylureas.
  4. Problems with heart function.

To prevent hypoglycaemia, start the therapy at a low dose and then increase it at intervals of 2-4 weeks till you reach your glycemic target. [19]

Who should avoid the use of sulfonylureas as the first line of treatment:

  • Elderly people
  • Individuals with kidney impairment or disease
  • Individuals with liver disease

Apart from these drugs, other drugs include gliptins, gliflozins, glinides, and glitazones.

  1. Gliptins are safe anti-diabetes medicines that do not cause weight gain or low blood sugar. These are used as the first line or second line treatment of type 2 diabetes. They act by blocking the enzyme DPP4 which destroys the hormone incretin. Incretin helps the body produce more insulin when needed and reduces sugar production by the liver when not needed.
  2. Sodium-glucose co-transporter-2 (SGLT2) inhibitors (gliflozins) are very promising oral drugs used for treating type 2 diabetes. These medications act by causing the kidneys to remove sugar through urine, thus lowering sugar levels.

However, for some people who do not have significantly high blood sugar, the drug may cause ketoacidosis. So, if you experience difficulty in breathing, nausea, vomiting or abdominal pain, stop taking the drug and get in touch with your doctor. [2]

  1. Pioglitazone (glitazones), though banned in the U.S. because it can cause heart disease and bladder cancer in some people, is not banned in India. But it is used with precautions and is not the first line of treatment. The drug is not prescribed to individuals who are above 50 years of age.
  2. Repaglinide is a good insulin secretagogue (trigger insulin secretion from beta cells) and can be safely used in people with diabetes who have kidney disease.

Insulin therapy

Insulin therapy is the only method of controlling blood sugar levels in people with type 1 diabetes. The problem in type 1 diabetes is that blood sugar levels drop to abnormal levels suddenly and frequently, and can occur during day or night, causing significant adverse effects.

People with type 2 diabetes need insulin when the disease has progressed so much that anti-diabetic drugs don’t work anymore.

Insulin used now is either human insulin or an insulin analogue. Analogues are genetically altered in a laboratory to make them more rapid-acting or more long-lasting.

There are different types of insulin based on how they act. [3]

  • Rapid-acting - Rapid-acting or bolus insulin are absorbed quickly into the bloodstream and are usually administered during meals so that they can correct high blood sugar.
    • Rapid-acting insulin analogue (Insulin Lispro) - They start taking effect within 5 - 15 minutes and last for 4 to 6 hours.
    • Regular human insulin - This insulin starts taking effect in about half an hour to one hour and lasts for 6 to 8 hours.
  • Intermediate-acting - They are absorbed more slowly and help control blood sugar overnight, between meals.
    • NPH (Neutral Protamine Hagedorn) human insulin - Also called isophane insulin, it takes effect in 90 minutes and lasts for more than 12 hours.
    • Premixed Insulin - Here NPH is pre-mixed with a rapid-acting insulin (human insulin or analogue). It is a combination of rapid-acting and intermediate insulins. Researchers found that physicians predominantly prescribe premix insulin, followed distantly by basal insulin. [4]
  • Long-acting - Long-acting or basal insulins act very slowly and last for 20-24 hours; they are simple and less intrusive since they require only one injection per day and you don’t need to adhere to a strict meal pattern. Basal insulins include:
    • Detemir - administered in the evening or at bedtime, but at the same time every day.
    • Glargine - administered at any time of the day, but it needs to be at the same time each day.
    • Degludec - injected at any time of the day, but you have to maintain an 8-hour gap.

Insulin glargine and insulin detemir are insulin analogues. They start taking effect in one and half hours to two hours.

Insulin degludec is an ultralong-acting basal insulin with a lower day-to-day variability than insulin glargine U100 and U300. According to a study, patients with type 1 diabetes treated for 32 weeks with insulin degludec, compared with insulin glargine U100, had a reduced risk of hypoglycemia (abnormally low blood sugar levels). [5]

With the development of technology, new devices for administering insulin are now available in India. One such device is i-Port. It is a small injection port that is placed inside your skin so that you don’t have to poke yourself every time you need to take insulin. The port has to be replaced every 3 days. This device is only available via your doctor’s prescription. Consider using the device if -

  • you have type 1 diabetes
  • you have advanced type 2 diabetes and now need to take insulin
  • you are afraid of shots or become emotionally stressed

Stem cell therapy

Stem cells are unique cells that have the ability to develop into different types of specialized cells and also replicate rapidly. Scientists are excited about its potential to regenerate and repair damaged cells.

Stem cells are extracted from –

  • embryos that are 3 to 5 days old
  • amniotic fluid and cord blood
  • bone marrow and, sometimes, fat in adults
  • regular adult cells that can be genetically altered to function as stem cells (induced pluripotent stem cells)

Stem cell therapy is a sort of transplantation, in which instead cells from another person (donor) are used for transplant. Cells are extracted from the body, grown to larger numbers in the laboratory and converted to the required specialized cell type (cell culture). Sometimes, stem cells from healthy donors are also used after being ‘matched’ to prevent rejection by the body. These specialized cells are then implanted in the body.

A lot of research is being conducted on stem cell therapy for diabetes, especially type 1 diabetes. The main technique is to replace damaged beta cells in the pancreas through stem cell therapy.

Stem cell therapy from bone marrow cells and pluripotent stem cells have been found to be most effective for treating type 1 diabetes. [10, 11]

Dr Bhansali and his colleagues found that therapy with self-derived (autologous) bone marrow stem cells significantly improved insulin sensitivity and reduced dependence on insulin doses in people with type 2 diabetes. [12]

However, despite various successful trials, stem cell therapy for diabetes is still in experimental stages! So, you need to proceed with extreme caution and only after you have discussed it with your trusted healthcare professional.

Pancreas transplantation and islet of Langerhans transplantation

Till date, the only viable alternative to insulin injections for type 1 diabetes is beta cell replacement. This is possible through pancreas and islet transplantation. Its advantages include:

  • they produce beta cells
  • they help manage blood sugar
  • they delay diabetes complications

However, in children and adolescents, pancreas transplantation is not done because of surgical complications, whereas islet transplantation causes problems with the body’s immune response called immune suppression. [13]

The Edmonton protocol is the technique of implanting islet cells (alpha-cells in the pancreas which produces the hormone glucagon that raises the blood sugar levels) for treating type 1 diabetes in adults. Researchers believe that islet transplantation using the Edmonton protocol is a safe procedure that can successfully restore insulin production by the body and improve glucose homeostasis. [14]

However, this procedure has its hurdles.

  • Insulin production by the body is not permanent.  
  • Lack of donors.
  • The requirement of more than 2 donors, from 340 to 750 million islet cells are needed for the transplant.
  • Lifelong immunosuppression is needed. [11]

Scientists are now desperately trying to resolve this issue. Very recently, researchers from the Netherlands found that if collagen, a fibrous protein surrounding the cells, is added to the islets enveloped in ‘immunoisolating capsules’ (capsules that do not allow the passage of cells of the immune system), the islets can survive much longer. [15]

Stem cell therapy and islet cell therapy are two procedures that are moving towards the direction of making it possible to cure diabetes. However, a permanent cure is still elusive! Both therapies are still evolving.

Ultimately, you will need to make an informed decision on the treatment you want, taking into account the cost of treatment, effectiveness, and ease of access. Last, but not least, the doctor you trust can suggest the right treatment for you!

References:

  1. International Diabetes Federation. India. https://www.idf.org/our-network/regions-members/south-east-asia/members/94-india.html.
  2. U.S. Food & Drug Administration. Sodium-glucose Cotransporter-2 (SGLT2) Inhibitors. https://www.fda.gov/Drugs/DrugSafety/ucm446852.htm.
  3. University of California. Types of Insulin. https://dtc.ucsf.edu/types-of-diabetes/type2/treatment-of-type-2-diabetes/medications-and-therapies/type-2-insulin-rx/types-of-insulin/#onset.
  4. M.P. Baruah, S. Kalra, S. Bose, J. Deka. An audit of insulin usage and insulin injection practices in a large Indian cohort. Indian J Endocr Metab. 2017. 21:443-52 DOI: 10.4103/ijem.IJEM_548_16.
  5. W. Lane, T.S. Bailey, G. Gerety, et al. Effect of Insulin Degludec vs Insulin Glargine U100 on Hypoglycemia in Patients With Type 1 Diabetes: The SWITCH 1 Randomized Clinical Trial. JAMA. 2017. 318(1):33–44. doi:10.1001/jama.2017.7115.
  6. K. Samaras, C.S. Hayward, D. Sullivan, R.P. Kelly, L.V. Campbell. Effects of postmenopausal hormone replacement therapy on central abdominal fat, glycemic control, lipid metabolism, and vascular factors in type 2 diabetes:a prospective study. Diabetes Care. 1999. 22:1401–1407.http://dx.doi.org/10.2337/diacare.22.9.1401.
  7. I. Bitoska, B. Krstevska, T. Milenkovic, S. Subeska-Stratrova, G. Petrovski, S.J. Mishevska, et al. Effects of Hormone Replacement Therapy on Insulin Resistance in Postmenopausal Diabetic Women. Open Access Macedonian Journal of Medical Sciences. 2016;4(1):83-88. doi:10.3889/oamjms.2016.024.
  8. D. Donnelly. The structure and function of the glucagon-like peptide-1 receptor and its ligands. British Journal of Pharmacology. 2012. 166(1):27-41. doi:10.1111/j.1476-5381.2011.01687.x.
  9. S. Handgraaf, R. Dusaulcy, F. Visentin, J. Philippe, Y. Gosmain. 17-β Estradiol regulates proglucagon-derived peptide secretion in mouse and human α- and L cells. JCI Insight. 2018.3(7):e98569. doi:10.1172/jci.insight.98569.
  10. S. Madani, B. Larijani, A.A.Keshtkar, A. Tootee. Safety and efficacy of hematopoietic and mesanchymal stem cell therapy for treatment of T1DM: a systematic review and meta-analysis protocol. Systematic Reviews. 2018. 7:23. doi:10.1186/s13643-017-0662-9.
  11. A. El-Badawy, N. El-Badri. Clinical Efficacy of Stem Cell Therapy for Diabetes Mellitus: A Meta-Analysis. Quaini F, ed. PLoS ONE. 2016. 11(4):e0151938. doi:10.1371/journal.pone.0151938.
  12. S. Bhansali, P. Dutta, V. Ku3mar, M.K. Yadav, A. Jain, S. Mudaliar et al. Efficacy of Autologous Bone Marrow-Derived Mesenchymal Stem Cell and Mononuclear Cell Transplantation in Type 2 Diabetes Mellitus: A Randomized, Placebo-Controlled Comparative Study. Stem Cells Dev. 2017. Apr 1;26(7):471-481. doi: 10.1089/scd.2016.0275.
  13. R. Bottino, M. Trucco. Clinical implementation of islet transplantation: A current assessment. Pediatr Diabetes. 2015. Sep;16(6):393-401. doi: 10.1111/pedi.12287.
  14. A.M. Shapiro, C.  Ricordi, B.J. Hering, H. Auchincloss, R. Lindblad, R.P. Robertson, et al. International trial of the Edmonton protocol for islet transplantation. N Engl J Med. 2006. 355:1318–1330. DOI: 10.1056/NEJMoa061267.
  15. L.A. Llacua, A. Hoek, B.J. de Haan, P. de Vos. Collagen type VI interaction improves human islet survival in immunoisolating microcapsules for treatment of diabetes. Islets. 2018. 10(2):60-68. doi:10.1080/19382014.2017.1420449.
  16. O. Hamdy, A. Campbell. Diet and Diabetes: A Personalized Approach. Joslin Diabetes Center. http://www.joslin.org/info/diet_and_diabetes_a_personalized_approach.html.
  17. N.B. Sanghani, D.N. Parchwani, K.M. Palandurkar, A.M. Shah, J.V. Dhanani. Impact of lifestyle modification on glycemic control in patients with type 2 diabetes mellitus. Indian J Endocr Metab. 2013. 17:1030-9.
  18. T.V. Devarajan, S. Venkataraman, N. Kandasamy, A. Oomman, H.K. Boorugu, S.K.P. Karuppiah, D. Balat. Comparative Evaluation of Safety and Efficacy of Glimepiride and Sitagliptin in Combination with Metformin in Patients with Type 2 Diabetes Mellitus: Indian Multicentric Randomized Trial - START Study. Indian Journal of Endocrinology and Metabolism. 2017. 21(5), 745–750. http://doi.org/10.4103/ijem.IJEM_176_17.
  19. D. Sola, L. Rossi, G.P.C. Schianca, P. Maffioli, M. Bigliocca, R. Mella, et al. Sulfonylureas and their use in clinical practice. Archives of Medical Science : AMS. 2015. 11(4), 840–848. http://doi.org/10.5114/aoms.2015.53304.

 

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Disclaimer: The information we share is verified by experts and scientifically validated. However, it is not a replacement for a doctor’s advice. Please always check with your doctor before trying anything suggested on this website.