Health

Standards of Medical Care in Diabetes 2017: Diabetes Medications

Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

I recently reviewed updates to the American Diabetes Association’s (ADA) Standards of Care for 2017.  In this post, I’ll review Section 8 of the standard that talks about different medications for treating diabetes. I will also discuss some of the newer medications used to treat diabetes.

Type 1 Diabetes is always treated with insulin, either through multiple injections or an insulin pump. Type 2 Diabetes can be treated with oral medications (pills by mouth), injections, or both.  The ADA recommends that people with Type 2 diabetes start patients start with the pill metformin, as long as it safe for them to take it.    Taking metformin for a long time may lead to not getting enough Vitamin B12, stomach symptoms, and can affect how well the kidneys work (your care team will monitor your kidneys to be sure they are working properly).

If someone is taking one oral medication at the highest possible dose but their A1C is still not at goal, providers should consider adding additional medications:  another oral medication, long acting insulin (injection), or a non-insulin injectable medication called glucagon-like peptide 1 receptor agonists (GLP-1 receptor agonists).

Examples of GLP-receptor agonists are exenatide (Byetta), liraglutide (Victoza), and dulagultide (Trulicity).  These medications cause food to move through the stomach slower so people feel full sooner. This leads to less glucagon (another hormone made by the pancreas) being released after meals and lowers appetite, which helps with weight loss.  These medications need glucose to work, so there is little chance of hypoglycemia.  Side effects include nausea, vomiting and acute pancreatitis. They may also cause medullary thyroid cancer in animals. It should be noted that these medications are expensive.

People with poorly controlled diabetes and atherosclerotic cardiovascular disease (ASCVD aka heart disease) may benefit from a new medication called empagliflozin (Jardiance), a type of medication called SGLT-2 inhibitor.  These medications work by preventing the body from reabsorbing glucose. This lets more glucose leave the body through urine.  People may have lower blood sugar values after eating and lose some weight.  Studies show empagliflozin helped reduce deaths caused by heart attack, stroke, and cardiovascular disease.  Empagliflozin is the only SGLT-2 inhibitor with these results, but other medications are being studied (liraglutide [Victoza] may have the same results, but other GLP-1 receptor agonists are not used this way).  Potential side effects include hypoglycemia, low blood pressure, dizziness, urinary tract infection, needing to urinate a lot, and increased LDL and creatinine (a waste product filtered out by the kidneys).  Again, these medications are very costly.

There are many medications available for the treatment of diabetes. These standards are general recommendations for medical care.  Always discuss questions about your care plan with your healthcare provider.

Health, Nutrition

Blood Sugar: What Does It Mean for Your Health?

By Felicia Steward, Dietetic Intern

Blood Sugar Defined

Blood sugar is the measurement of the amount of glucose, or sugar, in your bloodstream. This is important because it tells us how much energy our cells and tissues are receiving from the food we eat. Some foods affect blood sugar more than others. Any food that is mostly carbohydrates will affect blood sugar levels. These include dairy (milk and yogurt), all fruits and fruit juices, starches (pasta, bread, rice, and tortillas), and starchy vegetables (corn, peas, beans, potato, and butternut squash). Eating more carbohydrates at a meal can raise blood sugar, so it’s important to think about portion size along with when we eat and what food items we choose to eat together.

Why Care About the Amount of Sugar in My Bloodstream?

 Glucose provides our body with energy, and is needed for the brain to properly function and process information. Therefore, it is important that we choose foods containing small amounts of carbohydrates whenever we have a meal or a snack throughout the day so there’s enough glucose to support our tissues and cells.

When someone with diabetes eats large portions of carbohydrate-rich foods, too much sugar is released into the blood stream and, because there’s either not enough insulin or they have insulin resistance, their body is unable to use this sugar for energy effectively.  It builds up in the blood stream, causing damage to the body.  Over an unhealthy extended period of time, the body will eventually store much of the excess sugar as fat, which can lead to weight gain. Therefore, it is important to be aware of how the food we eat influences the amount of sugar in our bloodstream and how it affects our weight.

How is Blood Sugar Managed?

helthy-plate

 A healthy eating pattern that includes balance and portion control is an important part of managing the amount of sugar in the bloodstream.  Pairing whole grain, carbohydrate-rich foods with protein and fiber helps maintain healthy blood sugar levels. Eating a meal or snack that contains foods that increase blood sugar with those that do not affect blood sugar means the glucose is absorbed slowly into the blood and prevents blood sugar from spiking too high. Paying attention to portion size will also ensure that we are providing our body with exactly what it needs each time we eat. What the body doesn’t use for energy right away can be stored as fat and cause weight gain.

Balanced Lunch Examples:

  • PB&J on whole wheat bread + 1 cup carrot and celery sticks dipped in plain yogurt
  •  2 cups tossed salad + 3 oz. grilled chicken + oil/vinegar dressing + 1 banana
  •  3 oz. salmon + 1 cup brown rice + 1.5-2 cups cooked green beans
  •  2 oz. tuna salad (with light/mayo), lettuce, and tomato on whole wheat bread + 1 small apple + 8 oz. of skim milk
 Content reviewed by Melanie Pearsall, RD, CDE

 

 

Guest Post, My Story

My Story: Overcoming Fears of Starting Insulin

By Kevin

Rock climbing. Photo Credit: Bryan Wintersteen

Writing a blog post on “Overcoming Fears of Starting Insulin” turned out to be harder than I thought. I mean, who knew writing something like this would be that much more difficult than composing an e-mail at work or posting a snarky comment on Facebook? And to be completely honest, after extending (read: missing) my deadline a few times I was starting to feel a bit hopeless that I could actually pull it off.

But then I saw Steve Martin, the actor, comedian, author, and banjo virtuoso (don’t believe me? Check this out, I think you’ll like it) on Late Show with David Letterman and inspiration struck. Martin’s appearance on Letterman reminded me of one of my favorite scenes from his 1986 comedy ¡Three Amigos!

To set the scene, at this point in the film The Amigos (played by Martin, Chevy Chase, and Martin Short) have decided that although they are merely Hollywood actors who play hero gunfighters in the movies, they will help the inhabitants of a small Mexican village confront and defeat the very real bandits and their ruthless leader, El Guapo (played by Alfonso Alau), who have terrorized the town for years. Lucky Day (Martin’s character) attempts to inspire the villagers with this speech.

What on Earth does this have anything to do with “Overcoming Fears of Starting Insulin”? Well, I think for most people with Type 2 diabetes, like yours truly, our “El Guapo” is starting insulin. It’s something we will have to face eventually and something that once we do, we will be better and healthier for it. For me, when my endocrinologist suggested insulin five years ago, there were two very different fears I had to overcome.

The first was the fear of admitting failure. The suggestion that it was time to start insulin was, for me, like admitting that I had failed myself, my wife, my family – everyone who cared about me.  If I had eaten better, I wouldn’t need insulin. If I had exercised more, I wouldn’t need insulin. And now if I needed insulin, then clearly I failed at managing my diabetes.

When I met with my diabetes educator, however, she reminded me that Type 2 diabetes is a progressive disease, moving on to insulin was merely the next step in my treatment, and that it was my previous treatments that were failing to adequately treat the disease. In short, it wasn’t me it was my treatment that was failing. Once I heard this I was much more accepting of insulin as an option. I wanted to feel better than I was feeling at the time, and insulin was just the next phase of my diabetes management.

The second fear was about the administration of insulin. I had visions of not being able to do anything spontaneously with friends or family anymore (“Sorry I can’t make it, I forgot my insulin so I need to head home.”). I was pretty nervous (and admittedly still am) about hypoglycemia after a previous episode with another class of drug. And while not generally afraid of needles, I had never self-administered an injection. How long is the needle we’re talking about here? I thought it was going to be about six inches long. Would it hurt? I was sure it would be agonizing.

Again, a little education went a long way to allaying these fears. Injecting insulin turned out to be pretty anti-climactic, really. It’s had no negative impact on my life whatsoever. Being on insulin has not limited me socially. With help from my health care practitioners I have had no issues with hypoglycemia. The mini-pen needle is about as long as my pinky fingernail and causes no pain at all.

And most importantly, I’m healthier and happier ever since I faced the Type 2 diabetic’s “El Guapo” – and won.

Uncategorized

On Insulin and Weight Gain

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

Does my insulin make me look fat? The answer to this question is …it might. That would make it the wrong answer because none of us want to take a medication that may cause weight gain, especially as maintaining a healthy weight is such a crucial aspect of good diabetes management. The purpose of this post is to discuss how insulin works and how it may affect your weight. I hope after reading this you’ll have fewer reservations about using insulin if it becomes necessary.

Maintaining a healthy weight is so important for general health and is particularly important for people with chronic diseases such as high blood pressure, high cholesterol, heart disease, arthritis, and diabetes. A healthy diet and weight may mean fewer daily medications or a lower dose of medications you still require. Many medications have the potential for side effects; diabetes medications are no different. Weight gain IS a possible side effect of insulin, but it may also happen with oral medications.

Let’s talk about insulin as a first step. It is, simply put, a lifesaving medication. Insulin was discovered in 1921 at the University of Toronto and has been extensively studied and improved upon since. The job of insulin is to move the glucose from the food we eat into our cells so they’re able to stay healthy and work well. It then takes the remaining glucose from the bloodstream and stores it so it can be used for energy later. People with Type 1 Diabetes are totally dependent upon this medication for survival as their pancreas does not produce insulin. People with Type 2 Diabetes can manage their disease many different ways: diet, exercise, oral medications, and insulin. Diabetes is a progressive and chronic disease that as yet does not have a cure. That is why so many people with Type 2 Diabetes will require insulin as part of their management over time.

Two common symptoms of poorly controlled diabetes are significant weight loss and excessive urination. The weight loss happens because stored fat gets broken down to provide enough fuel for bodily functions (heart and lungs, for example) to operate and maintain life. You may start to notice the numbers on the scale decrease, regardless of what you eat or drink. This is because calories consumed aren’t being properly metabolized but rather directly excreted with urination.

The treatment for extreme hyperglycemia is insulin therapy. The insulin corrects the high blood sugar, correcting the excessive weight loss in the process. The insulin is helping the body work correctly; it’s not causing new weight but rather replacing what was lost when the body was in crisis. It’s a sign the body is healing and starting to work more normally again. This is a good thing, but it can also be frustrating for people who struggle with their weight regardless of their level of glucose control. If your weight is still creeping up after your blood sugar is better controlled, there are probably other reasons for this and further investigation is needed.

Frequent episodes of hypoglycemia (low blood sugars) can cause added weight. I’ve discussed hypoglycemia in more detail in the past, but I want to review a couple of points now. Under eating, over exercising, and both oral medicines and insulin are potential causes of this frightening and potentially life threatening condition. Proper treatment is key, but it’s common for people to over treat low blood sugars because they feel so poorly and think more is faster and better. This is not the case, and the extra calories may cause added weight over time.  The strategy I encourage my patients to use is trying things like glucose tablets and gels for treatment more often than juices or regular soda because they are pre-packaged for the correct carbohydrate (15grams). It can be hard to measure out 4 oz of juice or regular soda when you are feeling so poorly and anxious during an episode of low blood sugar. I also strongly encourage all of my patients to see our RD CDE on a regular basis to review meal plans and make any adjustments as needed to assist with better weight control. It is also important to be as active as possible as any type of movement will decrease insulin resistance and improve weight and blood sugar numbers.

Insulin initiation is a daunting prospect for some. Many of my patients, especially those who are really struggling with their weight, have told me the fear of gaining weight is why they refuse insulin. I hope that my explanation helps to minimize this fear. So, this brings us back to where we started. Does my insulin make me look fat? I prefer to answer this way: It makes your body healthy so you look marvelous!!!

Announcements

Diabetes Care Redesign: Update

Mass General Hospital ShieldMass General Hospital is undergoing a process of redesigning care delivery to increase the value and quality of care.  In the area of diabetes care, the emphasis has been on collaboration across disciplines to support patients on insulin.  To this end, the Diabetes Care Redesign Team called together a multidisciplinary team of stakeholders (including representatives from primary care, nutrition and endocrinology among others) to develop a set of best practices for starting patients on insulin.

A pilot program using this new process was developed and tested at three sites in and around the hospital.  This new process creates a diabetes care team, led by a designated diabetes nurse champion, for each practice.  Physicians work in close partnership with nurses and dietitians, making it easier to stay in touch regarding patient care.  Patients are supported between office visits through frequent follow-up phone calls by their care team and use of the Patient Gateway or iHealthSpace internet health portals.  The pilot program helped improve blood sugar control without increasing side effects. It is has now been expanded to all Mass General primary care practices.

The biggest challenge thus far has been wider implementation of this new care model at a time when the hospital is transitioning into the Patient-Centered Medical Home.  To support efforts at sustainability, twice yearly conferences were established to support teams and promote knowledge sharing.  These conferences also serve as a venue for teams to troubleshoot with peers over problems they have encountered, and review best practices.

Last May, the Diabetes Care Redesign Team was one of several groups to receive the Nathanial Bowditch Prize in recognition of their work improving quality of care while reducing cost.  Receiving the award was a gratifying experience, confirming that hospital administration believes in this new care model.  Funds received with the award are being put toward conferences and training to further support program growth.

The Diabetes Care Redesign team will be participating in the MGH/MGPO Care Redesign Fair next Wednesday, September 4th.  All are welcome to come and learn more about the ongoing work to improve care delivery across clinical areas.  The fair will be held 9am to 2pm under the Bulfinch Tent.

Diabetes ABCs

Diabetes ABCs: S

Sulfonylureas
By Eileen B. Wyner, NP
Bulfinch Medical Group

S

Sulfonylureas are a class of medications used to lower blood sugar in people with Type 2 Diabetes.  These oral agents increase the production of insulin from the beta cells of the pancreas. Sulfonylureas are typically taken once or twice daily before meals and can be used alone or in combination with insulin or other Type 2 Diabetes oral medications. This class of medications may cause severe hypoglycemia if taken incorrectly.

Diabetes ABCs

Diabetes ABCs: L

Lantus
By Eileen B. Wyner, NP
Bulfinch Medical Group

L

Lantus (also called Glargine) is a long acting, man-made version of human insulin that is meant to be taken daily to regulate both Type 1 and Type 2 Diabetes. It’s available by prescription and should be taken at about the same time daily to keep the blood sugar stable. It works like a time release capsule, slowly releasing insulin into the blood stream to control blood sugar. The dose can be adjusted as needed to ensure good diabetes control. It should never be mixed with other insulins.