Microsoft word - treatments for type 2 diabetes.doc
Treatments for Type 2 Diabetes
The 'first-line' treatment for Type 2 diabetes is diet and exercise. If your blood
glucose level remains high despite a trial of diet and exercise, then tablets to
reduce the blood glucose level are usual y advised. Insulin injections are
needed in some cases if the blood glucose level remains too high despite
taking tablets. Treatments for other related problems may also be advised.
This leaflet mainly discuses treatments which can lower the blood glucose level. It
briefly mentions other treatments which may also be advised if you have Type 2
diabetes. See a separate leaflet cal ed 'Type 2 Diabetes
' for more general information
What is the level of blood glucose to aim for?
Some people with diabetes check their blood glucose level each day. If you do,
ideal y you should aim to keep your blood glucose level between 4 and 7 mmol/l
before meals, and less than 10 mmol/l two hours after meals. This 'tight' control is not
realistic for everybody, and a target level to aim for may be agreed between you and
Not everybody checks their blood so often. Another type of blood test is cal ed
HbA1c. This test may be done every 2-6 months by your doctor or nurse. This test
measures what your recent average blood glucose level has been. (The test
measures a part of the red blood cel s. Glucose in the blood attaches to part of the
red blood cel s. This part can be measured and gives a good indication of your
average blood glucose over the last 2-3 months.) Treatment aims to lower you
HbA1c to below a target level which is usual y agreed between you and your doctor.
The target level is usual y somewhere between 6.5% and 7.5%.
In general, the nearer your blood glucose level (or HbA1c level) is to normal:
• the better you are likely to feel, AND
• the less likely you are to develop complications from diabetes such as heart
disease, eye problems, kidney problems, feet problems, etc.
Diet and exercise
You can usual y reduce the level of your blood glucose if you:
• Eat a healthy balanced diet.
A practice nurse and/or dietician wil give
details on how to eat a healthy diet. The diet is the same as recommended for
everyone. (The idea that you need special foods for diabetes is a myth.)
Basical y, you should aim to eat a diet low in fat, high in fibre, and with plenty
• Lose weight if you are overweight.
Getting to a 'perfect' weight is unrealistic
for many people. But, losing some weight wil help to reduce your blood
glucose level (and have other health benefits too).
• Exercise regularly.
If you are able, a minimum of 30 minutes brisk walking at
least 5 times a week is advised. Anything more is even better. You can
spread the exercise over the day. (For example, three 10 minute spel s per
day of brisk walking, cycling, dancing, etc.) Regular exercise also reduces
your risk of having a heart attack or stroke.
Many people with Type 2 diabetes can reduce their blood glucose to a target level by
the above measures. However, if the blood glucose level remains too high after a trial
of these measures for a few months, then medication is usual y advised. Medication
is used in addition to,
and not instead of, diet and exercise.
Tablets to reduce the blood glucose level
Metformin is a 'biguanide' medicine. It lowers blood glucose mainly by decreasing the
amount of glucose that your liver releases into the bloodstream. It also increases the
sensitivity of your body's cel s to insulin (so more glucose is taken into cel s for a
given level of insulin in the bloodstream.)
Metformin is commonly the first tablet advised if your blood glucose level is not
control ed by diet and exercise alone. It is particularly useful if you are overweight as
it is less likely to cause weight gain than some other glucose-lowering tablets.
Another advantage of metformin is that it does not cause hypoglycaemia (low blood
glucose level) which is a possible problem with some other glucose-lowering tablets.
You can also take metformin in addition to other glucose-lowering tablets if one tablet
does not control blood glucose wel enough on its own.
When metformin is first started, some people feel sick, or have mild diarrhoea. These
are less likely to occur if you start with a low dose and gradual y build up to the usual
dose over a few weeks. If these side-effects do occur, they tend to ease off in time.
Other side-effects are uncommon. (See the leaflet which comes in the medicine
packet for ful details.) You should not take metformin if your kidneys do not work
There are several types of sulphonylurea medicines and include: glibenclamide,
gliclazide, glimepiride, and glipizide. They work by increasing the amount of insulin
that you make by your pancreas. (If you have Type 2 diabetes you stil make insulin
in your pancreas, but not enough to keep the blood glucose level normal.)
A sulphonylurea tends to be used if you cannot take metformin (because of side-
effects or other reasons), or if you are not overweight. The one chosen may depend
on duration of action, your age, side-effects, and whether your kidneys are working
properly or not. Usual y a low dose is started. The dose can be increased if
necessary every few weeks until there is good control of the blood glucose level. You
can take a sulphonylurea in addition to other glucose-lowering tablets if one tablet
does not control blood glucose wel enough on its own.
Possible problems with sulphonylureas
As sulphonylureas 'boost' your level of insulin, hypoglycaemia (low blood sugar or
'hypo') is a possible complication. However, this is an uncommon problem and
unlikely to happen if you: have regular meals, don't miss meals, and don't drink too
much alcohol. Symptoms or hypoglycaemia include: trembling, sweating, anxiety,
blurred vision, tingling lips, paleness, mood change, vagueness or confusion. To treat
hypoglycaemia: take a sugary drink or some sweets. Then eat a starchy snack, such
Some weight gain is common side-effect. Other side-effects are uncommon and are
usual y mild. They include: feeling sick, mild diarrhoea and constipation. (See the
leaflet which comes in the medicine packet for details.)
Thiazolidinediones (commonly called glitazones)
There are two types, pioglitazone and rosiglitazone. They lower blood glucose by
increasing the sensitivity of you body's cel s to insulin (so more glucose is taken into
cel s for a given level of insulin in the bloodstream.) They are not used alone, but are
an option to take in addition to metformin or a sulphonylurea.
Possible problems with thiazolidinediones
There is slight risk of liver damage. Therefore, you should have a blood test to check
on your liver function before starting these medicines. The blood test is then repeated
every two months for the first year, and 'periodical y' thereafter. Some weight gain is
common side-effect, probably due to fluid retention. Hypoglycaemia is a possible, but
uncommon, side-effect. Other possible side-effects are uncommon. (See the leaflet
which comes in the medicine packet for details.)
Nateglinide and repaglinide
These are newer medicines and are not commonly used. They have a similar action
to sulphonylureas. After taking a dose they quickly 'boost' the insulin level, but the
effect of each dose does not last long. Each dose is taken shortly before main meals
(and a dose omitted if you miss a meal). One of these medicines may be an option if
you have meals at irregular times. However, a sulphonylurea is general y preferred
as a 'first choice' to boost the level of insulin throughout the day. As with
sulphonylureas, possible side-effects include weight gain and hypoglycaemia. (See
the leaflet which comes in the medicine packet for details.)
• Nateglinide is licensed to be used in combination with metformin if metformin
alone does not reduce the blood glucose enough.
• Repaglinide can be used alone, or in addition to metformin.
Acarbose works by delaying the absorption of carbohydrates (sugar based foods)
from the gut. So, it can reduce the peaks of blood glucose which may occur after
meals. It is an option if you are unable to use other medication to keep your blood
glucose level down. It can also be used in addition to other glucose-lowering tablets.
However, many people develop gut-related side-effects when taking acarbose (such
as bloating, wind, and diarrhoea). So, it is not widely used.
Insulin injections lower blood glucose. Only some people with Type 2 diabetes need
insulin. It may be advised if the blood glucose level is not wel control ed by tablets.
The dose and type of insulin used varies from person to person. Sometimes insulin is
used alone. Sometimes it is used in addition to tablets (such as metformin or a
sulphonylurea). If you are advised to use insulin your doctor or practice nurse wil
give detailed advice on how and when to use it.
Some weight gain is a common side-effect. Weight gain may be less of a problem if
you use insulin in combination with a glucose-lowering tablet such as metformin.
Hypoglycaemia (low blood sugar) is a possible complication.
• To help prevent heart disease, stroke and poor circulation:
o your blood pressure should be below 140/80 (lower in some cases).
You may need medication for this. See separate leaflet cal ed
'Diabetes and High Blood Pressure
o you may be advised to take tablets to lower your blood cholesterol
o you may be advised to take a daily aspirin.
• To help prevent some serious infections: you are usual y advised to be
immunised against 'flu each year, and have a one-off immunisation against
• Other treatments may be advised if you develop complications from diabetes.
Your treatment should be monitored at regular intervals in a diabetes clinic. You may
need to 'step up' treatment from time to time. For example, your blood glucose may
be wel control ed by diet and exercise alone for a number of years, But, in time, you
may need to add in one tablet. And then at a later time you may need to add in
another tablet to keep your blood glucose level down.
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