My Doctor Says I Need to Take Diabetes Pills and Insulin... What Do I Do Now? BD Getting Started. Combination Therapy

Transcription

1 My Doctor Says I Need to Take Diabetes Pills and Insulin... What Do I Do Now? BD Getting Started Combination Therapy

2 How Can Combination Therapy Help My Type 2 Diabetes? When you have type 2 diabetes, you may need to control more than just one cause of high blood glucose (sugar). Your body is not making enough insulin or is not correctly using the insulin you are making. Your healthcare provider may ask you to make some lifestyle changes, begin an exercise program and follow a healthy meal plan as a way to start managing your diabetes. After a period of time you may find that you will need to add medications or insulin to better control your blood glucose. Doing whatever it takes by adding medication and insulin to better manage your diabetes is known as combination therapy. 1

3 What is Type 2 Diabetes? This is the most common form of diabetes. People can develop type 2 diabetes at any age, even childhood. Type 2 diabetes occurs when glucose from the food you eat is unable to enter your body s cells. This results in too much glucose in your blood. Treatment usually begins with lifestyle changes like regular exercise and a meal plan developed just for you. Often, after a period of time, this is not enough to control blood sugar and the treatment will change to include adding medication. Causes of High Blood Glucose: 1. Insulin Resistance This is when the fat, muscle and liver cells do not use insulin properly. More insulin than usual is needed to lower blood sugar. If you have insulin resistance, your pancreas responds by producing more insulin. More than enough insulin is present, but your body doesn t use it properly. Over time the pancreas becomes stressed trying to make so much insulin and cannot keep up with the body s need. Being overweight and inactive will increase insulin resistance. 2. Release of Stored Glucose Your liver may also release stored glucose and your body cannot make enough insulin to match it. This often happens at night. This explains why your blood glucose readings in the morning are often the highest of the day. 2

4 What is the Treatment for Type 2 Diabetes? Treatment for type 2 diabetes focuses on keeping blood glucose under control. Type 2 diabetes is a Progressive Disease. People with type 2 diabetes lose about 10 percent of their ability to produce insulin each year. 1 As this happens, a change in your treatment plan will be needed to keep your blood glucose in control. The treatment that worked in the past may no longer be effective because of the lack of insulin. Diabetes Treatment can be thought of as a number of steps leading to diabetes control. When the first step no longer keeps blood glucose in target (the range that your blood glucose should be in most of the time), then you move to the next step. Step 1: Meal Planning and Exercise Following the right meal plan and regular exercise will reduce your insulin resistance. The insulin your body does produce will start to work better at lowering your blood glucose. Your blood glucose levels may fall into the target range you and your health care provider have agreed upon. Step 2: Diabetes Pills When your meal plan and exercise routine can no longer keep your blood glucose in target, your health care provider may recommend that you begin to take 1 United Kingdom Prospective Diabetes Study Group: Overview of Six Years Therapy of Type 2 Diabetes - A Progressive Disease. Diabetes (1995) 44:

5 diabetes pills. These pills are not insulin. They work to make your own insulin work better or to help your body make more insulin. Together with your meal plan and exercise, they may help bring your blood glucose in target range. At first your doctor may ask you to take one type of diabetes pill. If after a period of time, your blood glucose is still not in the target range, another type of pill may have to be added. When at least two types of diabetes pills are taken, this is called combination therapy. Step 3: Injectable Medications: Incretin Mimetics Exenatide (Byetta ) is one of a new class of drugs for the treatment of Type 2 diabetes. When your meal plan, exercise and diabetes pills can no longer keep your blood glucose in target, a drug called Exenatide (Byetta ) may be added. This drug is injected twice a day. Adding Exenatide to some types of diabetes pills has been found effective to lower blood glucose in people with type 2 diabetes. Step 4: Insulin When the pancreas is stressed from making insulin and your diabetes medications, meal plan and exercise are no longer controlling your blood glucose; the next step is to add insulin therapy. Your Health Care Provider may recommend that you take insulin by injection, along with your diabetes pills. By combining pills and insulin you may have a better chance of controlling your blood sugar. Taking more than one kind of diabetes pill and insulin to control your blood glucose may seem to be a lot of work, but preventing the complications of diabetes is worth the effort. 4

6 Controlling Diabetes Can Make a Huge Difference In Your Life! Large research studies 2,3 with people like you have found that keeping your blood glucose within your target range can help prevent complications like blindness, kidney and heart disease. How Will You Know if Your Diabetes Medications are Working? Blood glucose results that are consistently out of target indicates that your diabetes is not under control. Your medications, meal plan, exercise and overall schedule may need to be adjusted. You need to talk to your health care provider to see what changes must be made. Tests That Tell You if Your Blood Glucose is In Your Target Range A1C blood test: This test is performed in your health care provider s office and gives a three-month average of your blood glucose levels. Improving your A1C level to less than 7 percent can help you avoid diabetes complications. (To learn more about the A1C test, read the BD booklet, A1C, What s Your Number?) 5 2 The Diabetes Control and Complications Trial Research group: The effect of intensive treatment of diabetes on the progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine 329: , United Kingdom Prospective Diabetes Study Group: Intensive Blood Glucose Control with Sulphonylureas or Insulin Compared with Conventional Treatment and Risk of Complications in Patients with type 2 diabetes. Lancet (1998); 352:

7 Self Monitoring of Blood Glucose: Using your blood glucose meter to check your blood glucose level at home daily will keep you informed about your day-to-day blood glucose changes. (To learn more about self-monitoring of blood glucose, read the BD booklet, My Doctor Says I Should Monitor My Blood Sugar What Does This Mean?) What Should My Blood Glucose Level Be? Blood glucose goes up and down throughout the day. In people who do not have diabetes, the normal range for a fasting blood glucose is between 70 and 100 mg/dl (fasting: not eating for at least 8 hours). Blood glucose goes up after eating and should return to less than 140 mg/dl 2 hours later. Your healthcare provider will work with you to decide on your personal blood glucose goals or targets. The American Diabetes Association (ADA) recommends the following Target Blood Glucose Ranges: RECOMMENDED TARGET BLOOD SUGAR LEVELS ADA RECOMMENDED TARGETS FOR BLOOD GLUCOSE (SUGAR) CONTROL 4 Normal Target When To Take Action Plasma Glucose Before eating Less than to 130 If less than 90 or greater than hours after Less than 140 Less than 180 If less than eating 80 or greater than 200 Bedtime Less than to 150 If less than 110 or greater than American Diabetes Association: Clinical Practice Recommendations Diabetes Care-Supplement 1. pp. S10, S15, January

8 Knowing if your blood glucose is in target or out of target each day gives you the information you need to make changes in the way you manage your diabetes. Example: Checking blood glucose before eating and two hours after eating lets you learn about the foods and amounts of food that cause your blood glucose to rise. BLOOD GLUCOSE LEVELS BEFORE AND AFTER A MEAL Blood glucose Blood glucose two Food eaten at dinner before dinner hours after dinner *higher than Chicken, mashed goal of < 180 potatoes, bread, broccoli and juice In this example, the blood glucose was in target before the meal, and is out of target after the meal. This may be because: 1. The food eaten was a poor choice; changes should be made to the meal plan. 2. The food portion was too large; a smaller serving should be tried next time. 3. The medication is not enough to cover the carbohydrate (carb) content of the meal. Three of the foods eaten have a high carbohydrate (carb) content (potatoes, bread and juice). They may have caused the blood glucose level to rise higher than expected. Next time, the amount of carbs eaten should be reduced. If this amount of carb is part of the meal plan, the healthcare provider should consider adjusting the medication so that the post-meal blood glucose stays in target. 7

9 Since blood glucose levels are influenced by the action of your pancreas and liver, it makes sense to combine medications that work in these areas to bring high blood glucose to the target range. How do Diabetes Pills Work? Each type of pill works in a different way to lower blood sugar. Some pills work to help your body use glucose better, others force your pancreas to make more insulin. Your health care provider may decide you need to take pills from more than one group of pills to attack your diabetes from different directions. Below, you will find the different groups of the diabetes pills that are available and how they work. Ask your healthcare provider to write in the name and dose of the diabetes medicine you are taking in the correct group below. WHAT DIABETES PILLS DO (Medicines by Function) Group 1: Biguanides (by-gwan-ides) Slow down the glucose made by the liver; help cells use glucose May also lower blood fat and cholesterol Does not cause hypoglycemia (low blood sugar) Name: Directions: Group 2: Thiazolidinediones (THIGH-ah-ZO-li-deen-DYE-owns) or TZDs Helps muscles use glucose better, decreases the insulin resistance Does not cause hypoglycemia Name: Directions: 8

10 Group 3: Alpha-glucosidase inhibitors (AL-fa-gloo-KOS-ih-dayss in-hib-it-ers) Blocks starchy foods from turning into glucose. Causes a slower and lower rise of blood glucose through the day. Does not cause hypoglycemia Name: Directions: Group 4: Sulfonylureas (SUL-fah-nil-YOO-ree-ahs) Helps the pancreas make more insulin May cause hypoglycemia Name: Directions: Group 5: Meglitinides (meh-glit-in-ides) Helps the pancreas make more insulin right before meals Lowers blood glucose most 1 hour after a meal May cause hypoglycemia Name: Directions: Group 6: Combination Medicines Two medicines that work differently, combined together into one pill to help the body use glucose better and/or the pancreas make more insulin Name: Directions: Group 7: DPP-4 Inhibitors Lowers blood glucose only when high, especially after a meal. Reduces the amount of stored glucose that may be released from your liver Does not cause hypoglycemia Name: Directions: 9

11 There may come a point in time that even combining diabetes pills will not keep your blood glucose in target. Your doctor may ask you to consider adding an incretin mimetic (Byetta ) or insulin to your treatment. How Does Exenatide Byetta Work? Increases the release of insulin by the pancreas. Decreases glucagon levels. Slows the emptying of food from the stomach. Makes you feel full. Lowers blood glucose without the risk of low blood glucose. May help some people lose weight. Injected with a pen device Insulin One Step Closer to Control Insulin helps glucose enter the cells of your body to provide energy. If your body is not making enough insulin, then you may need to take insulin. This does not mean you failed or your diabetes is getting worse. There is nothing you did or did not do that is responsible for your needing insulin. It just means that your body needs some help to work better. Because insulin is a protein and is destroyed by the acids in the stomach, it cannot be swallowed like a pill. At present, insulin syringes, insulin pens and insulin pumps deliver insulin. A small number of people may use inhaled insulin. 10

12 Concerns About Insulin If you are worried about taking insulin, you are not alone. Many people with diabetes feel the same way and are worried about: 1. Filling the syringe with insulin and giving themselves a shot; 2. Fear of needles; 3. Hypoglycemia (low blood sugar); 4. Gaining weight; 5. Effect on their lifestyle. The Good News Many people find that once they begin to take insulin, they feel better and have much more energy. It is only then that they realize how poorly they felt before starting insulin. You should also know that insulin needles are very small and thin. If you have been self-monitoring your blood glucose, you may find that giving yourself insulin with a syringe or pen is less painful than drawing a drop of blood from your finger. Drawing and Injecting Insulin A Certified Diabetes Educator (CDE) is a health professional skilled in teaching people how to live with diabetes. A CDE is especially good at teaching people with diabetes how to self-inject with an insulin syringe or pen. A CDE will show you how easy it is to draw up the insulin and give it to yourself. Your healthcare provider may refer you to a CDE in the office or at a nearby Diabetes Center. 11

13 After giving the first injection, most people are surprised how easy it is to self-inject. To learn more about drawing up and giving insulin, read the BD booklet, My Doctor Says I Should Learn to Use Insulin What Do I Do Next? Fear of Low Blood Sugar With the proper education, you will learn how to take simple measures to avoid developing hypoglycemia. These include eating meals on time, taking your medications as prescribed at the same time each day, and understanding at what time of day your insulin will lower your blood sugar the most. When you begin taking insulin, your doctor may ask you to check your blood glucose. For more information about selfmonitoring of blood glucose, read the BD Getting Started booklet, My Doctor Says I Should Monitor My Blood Sugar What Does That Mean? Learning to recognize early signs of low blood glucose reactions will allow you to treat them before they become a problem. Hypoglycemia reactions should be reported to your doctor so that adjustments to your medications or meal plan can be made if needed. For more information about Hypoglycemia, read the BD booklet, My Doctor Says I Should Avoid Low Blood Sugar Reactions How Can I Prevent Them? 12

14 Weight Gain When you are ready to begin insulin, it is wise to meet with a Registered Dietitian to review your meal plan. This can help prevent the weight gain that often occurs when insulin is started. 5 Once you begin taking insulin, your blood glucose levels will improve because your body s cells are now absorbing the glucose you were previously losing through your urine. Unless you change the way you are eating, you will gain weight. Also, if you were eating larger portions of food to avoid a low blood sugar reaction, continuing to eat this way will cause you to gain weight. A Registered Dietitian can help you make the changes to the content and portion sizes of your meal plan to avoid weight gain after insulin is added to your treatment. Quality of Life Studies such as the UKPDS (United Kingdom Prospective Diabetes Study) have shown that adding insulin therapy did not have a negative effect on the quality of life of people with diabetes. 6 New insulin delivery devices are now available that make taking insulin easier 5 United Kingdom Prospective Diabetes Study Group: Conventional (Diet) Treatment Group Data (UKPDS 16). Diabetes United Kingdom Prospective Diabetes Study Group: Quality of Life in Type 2 Diabetic Patients is Affected by Complications, But Not by Intensive Policies to Improve Blood Glucose or Blood Pressure Control. Diabetes Care (1999) 42:

15 and more convenient than ever. Most people are surprised how easy it is to work insulin therapy into their daily routine. Why Combine Insulin With Diabetes Pills? Your health care provider may ask you to add insulin to the diabetes pills that you are taking. The insulin will replace the insulin that your pancreas cannot make and the pill may make you more sensitive to that insulin. The overall effect is that your blood glucose should be in-target. For example, you may be asked to take a long-acting insulin once at night, to help your body throughout the day and a pill that helps your pancreas produce insulin right before you eat, to help with the increase in sugar you may experience after you eat. The decision to combine medications is made by you and your health care provider, based on your individual needs. How Insulin Works: Some types of insulin work very quickly and are usually given before a meal. Others take longer to work and can be taken in the morning or at bedtime. Never substitute one type of insulin for another unless instructed to do so by your health care provider. You should know what kind of insulin you are taking and the time of day it works the hardest to lower your blood sugar. This is the time of day you might experience a hypoglycemic reaction. 14

16 Below, you will find the 5 different groups of insulins that are available. Ask your healthcare provider to write in the medication you are taking in the correct group below and fill in when the medication works. HOW INSULIN WORKS: (Grouped by Speed of Action) QUICK-ACTING INSULIN: This includes short and rapid acting insulin. This type of insulin stays in your body a short period of time, is usually given before a meal. Rapid acting insulin may be given after a meal when directed by your Health Care Provider. Name of Insulin Onset Peak Duration (When it starts (When it lowers blood (How long to work) glucose the most) it works) Directions: INTERMEDIATE-ACTING INSULIN: Stays in your body longer, usually given at night and/or in the morning Name of Insulin Onset Peak Duration Directions: LONG-ACTING INSULIN: Stays in your body longer, usually given at night and/or in the morning. Name of Insulin Onset Peak Duration Directions: COMBINATION INSULIN: Mixture of both long-acting and short-acting insulin. Usually given before a meal. Name of Insulin Onset Peak Duration 15 Directions:

17 Helpful Hints Taking medicine on time every day can be hard work. However, it is very important to take your medication on time in the exact way in which it is prescribed. Following are some suggestions designed to help you take your medicines consistently. Make Medication Part of Your Everyday Routine: Take morning medicine right after you brush your teeth; Leave nighttime medicine next to the lamp you shut off before going to bed; Set watch alarm to remind you when to take your medicine; Leave medicines to be taken with meals on the table where you eat; Ask family members to remind you, such as, Have you had your medicine? (The main responsibility is yours; they are simply the helpers); Ask health care provider what to do if you forget to take your medicines (get separate instructions for each medicine you take). Learn Everything About New Medicine as it is Prescribed: To be taken with present medications or replace ones you are already taking? How and when should it be taken? 16

18 Why is it important to take it? What are some possible side effects? Who should you contact if you have any questions? Don t understand instructions? ASK QUESTIONS! If Experiencing a Side Effect: Contact your health care provider for advice or a substitution before stopping your medicine. Make sure you are taking the medicine as prescribed. (For example, did you take the medicine before a meal instead of with the meal as prescribed? Maybe this is why your stomach is upset.). Adopt a do-whatever-it-takes attitude by deciding that you want to control your diabetes and prevent diabetes complications no matter how many medicines are prescribed Managing your Diabetes Well With Combination Therapy 17 Some people hesitate about starting to take insulin along with their diabetes pills. However, it is very important to take the attitude that you will do whatever you must in order to manage your diabetes in the best way possible. There may be times when you are sick, stressed, or not following your meal plan when you need insulin as well as your diabetes pills to feel better. Sometimes, however, with weight loss, exercise and good management, you can reduce the amount or even not need to take insulin for periods of time. The important thing is that Combination Therapy - adjusting your meal plan, exercise, diabetes pills and insulin as needed, with the help of your health care provider - helps you to do everything necessary to stay in good control and live a full life with diabetes!

19 Blood Glucose (Sugar) Goals: Please Contact Your Physician if: Your Blood Glucose is greater than for You experience unexplained hypoglycemic (low blood sugar less than ) reactions in a week Schedule for Checking Blood Glucose and Medication: Breakfast Blood Test Before Breakfast Lunch Blood Test Before Lunch After Breakfast 1 hour 2 hour After Lunch 1 hour 2 hour Medication/Insulin Medication/Insulin Name Dose Time Name Dose Time Dinner Blood Test Before Dinner After Dinner 1 hour 2 hour Medication/Insulin Name Dose Time Bedtime Blood Test Bedtime 3 AM Medication/Insulin Name Dose Time BD provides this brochure for informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this brochure. Written by: Andrea Zaldivar, RN, MS, ANP, CDE New York, NY We wish to acknowledge the following health professionals for reviewing this publication and providing their valuable insights: Debbie Hinnen, RN, MN, BC-ADM, CDE Witchita, KS Jean Betschart Roemer, RN, CPNP, MSN, MN, CDE Pittsburgh, PA Terri Ryan-Turek, RD, CDE Evergreen, CO BD 1 Becton Drive Franklin Lakes, NJ BDCARES ( ) Byetta is a trademark of Amylin Pharmaceuticals, Inc. BD and BD Logo are trademarks of Becton, Dickinson and Company BD