Oral Diabetes Medications

The best treatment for type 2 (non-insulin-dependent) diabetes is losing weight and exercising. But sometimes these measures are not enough. The next step is taking a medicine that lowers blood glucose levels. There are two kinds of medicines: insulin shots and oral medications (pills). Diabetes pills are not insulin. Most of the diabetes pills sold today in Malaysia are members of a class of drugs called sulphonylurea drugs. Another class of drugs, biguanides, is also available. Sulphonylurea Drugs Sulphonylurea drugs were discovered in the 1940s. Several have been used to treat people with type 2 diabetes since then. First-generation sulphonylureas have been used for about 25 years. They are chlorpropamide (Diabinese), tolazamide (Ronase, Tolinase), tolbutamide (Orinase, Oramide), and the rarely used acetohexamide (Dymelor). A second generation of sulphonylureas came on the market in 1984. These medicines are glipizide (Minidiab), gliclazide (Diamicron) and glibenclamide (Daonil). These new drugs can be taken in smaller doses than the first-generation drugs. All sulphonylurea drugs have similar effects on blood glucose levels. But they differ in side effects, how often they are taken, and interactions with other drugs. In the 1970s, a study of diabetes pills linked one sulphonylurea drug, tolbutamide, with increased risk of death from heart disease. But that study, known as the UGDP study, has been criticized by many diabetes experts. They believe that major flaws in its design negate the results. Any link between tolbutamide and heart disease seems iffy at best. The recently published UK Prospective Diabetes Study has finally shown that there is no increased risk of death from heart disease when using sulphonylurea. In fact, good control obtained with using sulphonylurea reduces the risk of microvascular complications as well as risk of a heart attack or stroke. Biguanides Another type of medication used to treat type 2 diabetes is the group of drugs called biguanides. Biguanides were banned in the United States in the 1970s because their use was linked to problems such as lactic acidosis. However, a safer biguanide called metformin is now in use. It works as well as the sulphonylurea drugs. It seems to lower levels of bad (VLDL) cholesterol. Also, unlike sulphonylurea drugs, metformin does not cause too-low levels of blood glucose (hypoglycaemia). How They Work In people with diabetes, blood glucose levels are too high. These high levels occur because glucose remains in the blood rather than entering cells, where it belongs. But for glucose to pass into a cell, insulin must be present and the cell must be hungry for glucose. People with insulin-dependent (type 1) diabetes don't make insulin. For them, insulin shots are the only way to keep blood glucose levels down. People with type 2 diabetes, on the other hand, tend to have two problems. They don't make quite enough insulin. Plus, the cells of their bodies don't seem to take in glucose as eagerly as they should. Exactly how diabetes pills work is not completely clear. Sulphonylurea drugs seem to improve both problems. They boost the pancreas's production of insulin and make body cells more receptive to glucose. Metformin may make cells more receptive, and it may also decrease glucose production in the liver. Can Diabetes Pills Help Me? Only people with type 2 diabetes can use pills for their diabetes. The pills can't do anything for a person with type 1 diabetes, whose pancreas has lost all ability to make insulin. Pills are an option only for people with type 2 diabetes who have not gotten good blood glucose control through better eating habits and exercise alone. In fact, the very best treatment for type 2 diabetes is diet and exercise. Together, they can often bring blood glucose levels down to normal. If you're overweight, losing even a few pounds may have this effect. So don't just pay lip service to diet. It's worth giving diet a real try. But if after a sincere attempt, your blood glucose is still too high, it may be time to add drug treatment. This can be either insulin or a pill. What to Expect Taking a diabetes pill does not mean you can forget good eating and exercising habits. Pills work with diet and exercise, not in place of them. Drugs cannot help you much if you don't eat right, exercise, and lose weight. Diabetes pills don't work for everyone. Although the blood glucose levels of most people with type 2 diabetes drop when they begin taking pills, the decrease may not be enough. Only in about one-half to two-thirds of people do diabetes pills lower glucose to near-normal levels. What are the chances that diabetes pills will work for you? Your chances are low if you are underweight, have had diabetes for more than five years, or already take more than 20 units of insulin each day. On the other hand, your chances are good if you developed diabetes recently or have so far needed little or no insulin to keep blood glucose under control. You should also know that diabetes pills sometimes stop working after a few months or years. The cause is often unknown. Sometimes, it may be because you gain weight or get an illness that makes diabetes worse. Switching to another pill especially from a first-generation to a second-generation agent can sometimes help. Even if diabetes pills do bring your blood glucose under control, you may still need to take insulin when you have a severe infection or need surgery. Pills may not be able to control blood glucose during these stressful times, when blood glucose levels shoot up. Also, if you become pregnant, you will need to switch to insulin until the baby is born. Doctors once hoped that pills could be used in place of diet as a treatment for diabetes. Sadly, they don't work that way. If you're overweight, as about 80 percent of people with type 2 diabetes are, you'll have to keep trying to lose those pounds. What About Insulin? Although it is a common practice to try pills before insulin, your doctor may go straight to insulin, depending on several factors. These factors include how long you have had diabetes, how high your blood glucose level is, what other medicines you take, and your overall health. Because diabetes pills seem to help the body use insulin better, some doctors combine them with insulin shots in people with hard-to-control type 2 diabetes. The idea behind this 'combination' therapy is to try to make insulin work better. If this method gives you your best blood glucose control, combination therapy may be for you. Using Diabetes Pills Wisely In general, these pills are safe and work well. But like any other drug, they must be used with care. To select the best diabetes pill for you and guide you in its use, your doctor will look at several factors. Although the following list of cautions may seem long, remember that few people who take diabetes pills actually have any of these problems. So your chances of getting into trouble are small indeed. Any sulphonylurea drug may cause a skin rash. Rashes occur most often in people who are allergic to sulfa antibiotics. The rash is seldom serious and goes away when the drug is stopped. All diabetes pills can interact with other medicines. Interaction is less of a problem with the second-generation sulphonylureas. Because of the chance of drug interactions, your doctor will ask what medicines you are taking. And while you're taking diabetes pills, you should check with your doctor before starting anything new even over-the-counter items like aspirin or vitamins. Any sulphonylurea can cause too-low blood glucose levels. But this problem is more common with chlorpropamide, glipizide, and glyburide. These drugs are convenient because they need to be taken only once or twice a day. But they are also quite strong. Hypoglycaemia brought on by these pills is quite uncommon, but if it occurs it may last so long that you need to go into the hospital. Because of this chance, doctors sometimes avoid using these three drugs in elderly people. Doctors may also not prescribe them for someone who might take too many pills or skip meals or whose kidneys or liver may not be working up to par. You should know that alcohol and diabetes pills may not mix. Every so often, chlorpropamide, and even more rarely tolbutamide, can interact with alcohol to cause vomiting and flushing or even to make you very sick. If you're taking either of these, your doctor will probably warn you about this effect. The Cost of Care Costs vary widely among the different pills. And even the same drug can vary in price from store to store. Call around to find the best price for the one you take. Generic versions of chlorpropamide and glibenclamide are available. These cost less than the brand-name products and in general are reliable. However, many patients and doctors feel better using a medicine that has been made by the same company for many years. Diabetes pills aren't perfect, and they are not replacements for diet and exercise. But they remain a good alternative to insulin for people who need extra help in controlling their type 2 diabetes.