You are on page 1of 7

Microalbuminuria is an accumulation of protein in the blood, which can signal th

e onset of kidney disease (nephropathy).


kidney Damage (Nephropathy)
is a very serious complication of diabetes. With this condition, the tiny filte
rs in the kidney (called glomeruli) become damaged and leak protein into the uri
ne. Over time this can lead to kidney failure. Urine tests showing microalbuminu
ria (small amounts of protein in the urine) are important markers for kidney dam
age.Treatment and Prevention of Nephropathy. Tight control of blood sugar and bl
ood pressure is essential for preventing the onset of kidney disease.A doctor ma
y recommend a low-protein diet for patients whose kidney disease is progressing
despite tight blood sugar and blood pressure control. Protein-restricted diets c
an help slow disease progression and delay the onset of end-stage renal disease
(kidney failure).Diabetic nephropathy occurs in about 20 40% of patients with di
abetes and is the leading cause of end-stage renal disease (ESRD).--> 13 times t
he risk of death compared to other patients with type 1 diabetes.

Neuropathy
Diabetes reduces or distorts nerve function causing a condition called neuropath
y. Neuropathy refers to a group of disorders that affect nerves. The two main ty
pes of neuropathy are:
Peripheral (affects nerves in the toes, feet, legs, hand, and arms)
Autonomic (affects nerves that help regulate digestive, bowel, bladder, heart, a
nd sexual function)
Peripheral neuropathy particularly affects sensation. It is a common complicatio
n that affects nearly half of people with type 1 or type 2 diabetes after 25 yea
rs. The most serious consequences of neuropathy occur in the legs and feet and p
ose a risk for ulcers and, in very severe cases, amputation. Peripheral neuropat
hy usually starts in the fingers and toes and moves up to the arms and legs (cal
led a stocking-glove distribution). Symptoms include
Tingling
Weakness
Burning sensations
Loss of the sense of warm or cold
Numbness (if the nerves are severely damaged, the patient may be unaware that a
blister or minor wound has become infected)
Deep pain
Autonomic neuropathy can cause digestive problems (constipation, diarrhea, nause
a, vomiting), bladder infections, and erectile dysfunction. In some cases, neuro
pathy may mask angina, the warning chest pain for heart disease and heart attack
. Patients with diabetes should be aware of other warning signs of a heart attac
k including sudden fatigue, sweating, shortness of breath, nausea, and vomiting.
Blood sugar control is the only treatment for neuropathy. Studies show that tigh
t control of blood glucose levels delays the onset and slows progression of neur
opathy. A 2005 study also suggested that heart disease risk factors can increase
the likelihood of developing neuropathy. Lowering triglycerides, losing weight,
reducing blood pressure, and quitting smoking may help prevent the onset of neu
ropathy.
Foot Ulcers and Amputations
Perhaps the most serious consequences of diabetic neuropathy occur in the lower
limbs. An estimated 15% of patients with diabetes experience serious foot proble
ms. They are the leading cause of hospitalizations for these patients.
Retinopathy and Eye Complications
Diabetes accounts for 12,000 - 24,000 of new cases of blindness annually and is
the leading cause of new cases of blindness in adults ages 20 to 74. The most co
mmon eye disorder in diabetes is retinopathy. People with diabetes are also at h
igher risk for developing cataracts and certain types of glaucoma.
Description of Retinopathy. Retinopathy is a condition in which the retina becom
es damaged.
severe and even moderate vision loss is largely preventable with tight control o
f blood glucose levels.
Mental Function and Dementia
type II memory and attention problems
infections
/flu pnemonia and urinary tract infections
depression
double the risk for depression
bone quality
quality and density in the bones-
type I reduced density -> osteoprosis
type II increased density -> fractures and falling

Fast-Acting Insulin. Insulin lispro (Humalog) and insulin aspart (Novo Rapid, No
volog) lower blood sugar very quickly, usually within 5 minutes after injection.
Insulin peaks in about 4 hours and continues to work for about 4 hours. This ra
pid action reduces the risk for hypoglycemic events after eating (postprandial h
ypoglycemia). Optimal timing for administering this insulin is about 15 minutes
before a meal, but it can be also taken immediately after a meal (but within 30
minutes). Fast-acting insulins may be especially useful for meals with high carb
ohydrates.
Regular Insulin. Regular insulin begins to act 30 minutes after injection, reach
es its peak at 2 to 4 hours and lasts about 6 hours. Regular insulin may be admi
nistered before a meal and may be better for high-fat meals.
Intermediate-Acting Insulin. NPH (neutral protamine Hagedorn) insulin has been t
he standard intermediate-acting form. It works within 2 to 4 hours, peaks 4 to 1
2 hours later, and lasts up to 18 hours. Lente (insulin zinc) is another interme
diate-acting insulin that peaks between 4 to 12 hours and lasts up to 18 hours.
Long-Acting (Ultralente) Insulin. Long-acting insulins, such as insulin glargine
(Lantus), are released slowly. Insulin glargine matches parts of natural insuli
n and maintains stable activity for more than 24 hours. Studies suggest that it
poses less of a risk for hypoglycemia and weight gain than NPH. It has a higher
incidence of pain at the injection site than NPH. Ultralente insulin peaks at 10
hours and lasts up to 20 hours but varies greatly in activity from day to day.
Combinations. Regimens generally include combinations of short and longer-acting
insulins to help match the natural cycle. For example, one approach in patients
who are intensively controlling their glucose levels uses 3 injections of insul
in, which includes a mixture of regular insulin and NPH at dinner. Another appro
ach uses 4 injections, including a separate short-acting form at dinner and NPH
at bedtime, which may pose a lower risk for nighttime hypoglycemia than the 3-in
jection regimen.
Supplementary Drugs
Pramlintide (Symlin) is a new type of injectable drug that can help control post
prandial hyperglycemia, the sudden increase in blood sugar after a meal. Pramlin
tide is injected before meals and can help lower blood sugar levels in the 3 hou
rs after meals. Pramlintide is used in addition to insulin for patients who take
insulin regularly but still need better blood sugar control. The FDA approved t
his drug in 2005 for adults with type 1 and type 2 diabetes. Pramlintide and ins
ulin are the only two drugs approved for treatment of type 1 diabetes.
Pramlintide is a synthetic form of amylin, a hormone that is related to insulin.
Side effects may include nausea, vomiting, abdominal pain, headache, fatigue, a
nd dizziness. Patients with type 1 diabetes have an increased risk of severe low
blood sugar (hypoglycemia) that may occur within 3 hours following a pramlintid
e injection. This drug should not be used if patients have trouble knowing when
their blood sugar is low or have slow stomach emptying (gastroparesis).

type II medications

it may be difficult for patients with type 2 diabetes to control their blood sug
ar levels--particularly if they are overweight.
Metformin (Glucophage), an oral anti-hypoglycemic drug, helps control blood gluc
ose levels, does not produce weight gain, and also has heart benefits. In compar
ison with other diabetic drugs, including insulin, it is the only drug proven to
improve survival rates. A number of other oral drugs are also available that ar
e beneficial, alone or in combinations. Insulin therapy may eventually be requir
ed when natural insulin reserves become depleted.
Managing risk factors for heart disease and stroke, particularly strict control
of blood pressure, may be more important for improving survival than strict cont
rol of blood glucose levels for some patients. Such goals also seem to be more a
ttainable for many patients with type 2 diabetes.
Oral Anti-Hyperglycemic Drugs. Many oral anti-hyperglycemic drugs are available
to help patients with type 2 diabetes control their blood sugar levels. Most of
these drugs are aimed at using or increasing sensitivity to the patient's own na
tural stores of insulin. Metformin is the only drug to date that achieves lower
mortality rates:
Biguanides (metformin). Metformin increases tissue sensitivity to available insu
lin. Metformin also has beneficial effects on cholesterol, blood pressure, and c
lotting factors. It does not cause weight gain or hypoglycemia. Metformin produc
es lower mortality rates than other drugs, including insulin, and should be cons
idered as first-line therapy for most patients with type 2 diabetes.
Combinations of drugs, particularly with metformin, are often used to increase e
ffectiveness.
Metformin may be particularly helpful for patients with unhealthy cholesterol le
vels and poor control of their blood sugar levels. Some experts recommend a metf
ormin combination as first-line treatment.
Biguanides (Metformin)
Metformin (Glucophage) is a biguanide, which works by reducing glucose productio
n in the liver and by making tissues more sensitive to insulin. It is now consid
ered by many experts to be the first choice for most type 2 patients who are ins
ulin resistant, particularly if they are overweight. Metformin achieves lower mo
rtality rates from diabetes and all causes than other drugs. In one comparison s
tudy, it achieved the lowest mortality rates (8%) compared to insulin (28%), a s
ulfonylurea (16%), and a thiazolidinedione (14%). Combinations with insulin-secr
eting drugs, other insulin-sensitizing drugs, or insulin itself are particularly
effective.
Metformin does not cause hypoglycemia or add weight, so it is particularly well-
suited for obese patients with type 2 diabetes. (In some studies, in fact, patie
nts lost weight.) Metformin also appears to have beneficial effects on cholester
ol and lipid levels and may help protect the heart. Some research has suggested
that it significantly reduces the risk for heart attack. It is also the first ch
oice for children who need oral drugs and is proving to be very effective for wo
men with polycystic ovary syndrome and insulin resistance.
Side Effects. Side effects include:
~A metallic taste
~Gastrointestinal problems, including nausea, and diarrhea
~Interference with absorption of vitamin B12 and folic acid, (which are importan
t for protection against heart disease)
~Rare reports of lactic acidosis, a potentially life-threatening condition, part
icularly in people with risk factors for it. Major studies, however, found no gr
eater risk with metformin than with any of the other drugs used for type 2 diabe
tes.
~Certain people should not use this drug, including anyone with heart failure or
kidney or liver disease.
~It is rarely suitable for adults over age 80.

Sulfonylureas (glyburide, glipizide, and glimepiride). Stimulate insulin secreti


on.
~For adequate control of blood glucose levels, the drugs should only be taken 20
- 30 minutes before a meal.
Side Effects and Complications.
~In general, sulfonylureas should not be used by women who are pregnant or nursi
ng or by individuals who are allergic to sulfa drugs.
~Side effects may include:
~~Weight gain (some sulfonylureas, such as glimepiride, may produce less weight
gain than others)
~~Water retention
~Although sulfonylureas pose a lower risk for hypoglycemia than insulin does, th
e hypoglycemia produced by sulfonylureas may be prolonged and dangerous.
~The newer sulfonylureas, such as glimipiride, have much less risk of hypoglycem
ia than older sulfonylureas.
~Some sulfonylureas may pose a slight risk for cardiac events.
~Sulfonylureas interact with many other drugs, and patients should be sure to in
form their doctor of any medications they are taking, including alternative or o
ver-the-counter drugs.
Meglitinides (repaglinide,(Prandin), (nateglinide,(Starlix). Stimulate insulin s
ecretion. These newer drugs are better than sulfonylureas in controlling glucose
spikes after meals.
Meglitinides stimulate beta cells to produce insulin. They include repaglinide (
Prandin), nateglinide (Starlix), and mitiglinide. These drugs are rapidly metabo
lized and short-acting. If taken before every meal, they actually mimic the norm
al effects of insulin after eating. Patients, then, can vary their meal times wi
th this drug. (Nateglinide appears to work more quickly and is shorter-acting th
an repaglinide). These drugs may be particularly helpful in combination with met
formin or other drugs. They may also be a good choice for people with potential
kidney problems.
do not take with insulin!!!!!!
~~Side Effects. Side effects include
~diarrhea and headache.
~ As with the sulfonylureas,(Prandin, repaglinide) poses a slightly increased ri
sk for cardiac events.
(Newer drugs, such as nateglinide, may pose less of a risk.)
People with heart failure or liver disease should use them with caution and be
monitored.

Thiazolidinedione
Thiazolidinediones include rosiglitazone (Avandia) and pioglitazone (Actos). The
y improve insulin sensitivity by activating certain genes involved in fat synthe
sis and carbohydrate metabolism. These drugs are usually taken once or twice per
day; however, it may take several days before the patient notices any results f
rom them and several weeks before they take full effect. Thiazolidinediones are
usually taken in combination with other oral drugs or insulin.
~~Side Effects.
~Thiazolidinediones can have serious side effects. They tend to increase fluid-b
uild up, which can cause or worsen heart failure in some patients. Combinations
with insulin increase the risk. They should not be used by patients with existin
g heart failure.
~eports of rosiglitazone causing or worsening diabetic macular edema. This is an
eye condition associated with diabetic retinopathy that causes swelling in the
macular area of the retina. Symptoms include blurred vision and decreased color
sensitivity. Most patients who had this side effect also had swelling in the fee
t and legs (peripheral edema). The condition resolved or improved when patients
stopped taking the drug.
----Alpha-glucosidase inhibitors, including acarbose (Precose, Glucobay) and mig
litol (Glyset)
ombinations, such as with metformin, insulin, or a sulfonylurea, increase their
effectiveness.
side effects--
These medications need to be taken with meals.
Unfortunately, about a third of patients stop taking the drug because of flatul
ence and diarrhea, particularly after high-carbohydrate meals. The drug may also
interfere with iron absorption.

Insulin for type II

Insulin replacement is the best treatment for strict control of blood glucose an
d is required once natural insulin reserves are depleted. Because type 2 diabete
s is progressive, most patients eventually require insulin, typically starting i
t in combination with an oral anti-hyperglycemic drug. However, when a single or
al drug fails to control blood sugar it is not clear whether it is better to add
insulin replacement or to add a second or third oral drug.
Some experts advocate using insulin as early as possible for optimal control. Ho
wever, in patients who still have insulin reserves, there is concern that extra
natural insulin will have adverse effects. Low blood sugar (hypoglycemia) and we
ight gain are the main side effects of insulin therapy.
~One approach is to combine insulin with metformin, which achieves blood glucose
control without added weight gain.
++Fast-Acting Insulins for Surges. Insulin lispro and aspart are fast-acting ins
ulins. They mimic insulin's response to food intake. They are taken before meals
, and their short action reduces the risk for hypoglycemia afterward.
++Slower Insulins for Base Levels. Intermediate forms (including NPH and lente)
and long-acting forms (glargine, ultralente) were developed to provide a steady
level of insulin throughout the day. To date, glargine (Lantus) seems to be the
most successful in achieving this goal in type 2 diabetes.
new drugs=
Pramlintide (Symlin) is a new type of injectable drug that may help patients who
take insulin but still need better blood sugar control.
Exubera is an inhaled form of insulin. It is approved for adults but should not
be used by patients who smoke or have quit smoking within the past 6 months. no
w/ asthma, bronchitis, or emphysema.

type II complications--
Heart disease and stroke are the leading causes of death in these patients. All
lifestyle and medical efforts should be made to reduce the risk for these condit
ions.
~~~Anti-hypertensive drugs that block or reduce angiotensin are the first option
for many people with diabetes. Angiotensin is a natural chemical that influence
s all aspects of blood pressure control and also interferes with insulin's norma
l metabolic signaling. In fact, angiotensin may be the common factor linking dia
betes and high blood pressure.
~~Statins are the best cholesterol-lowering drugs. They include atorvastatin (Li
pitor), lovastatin (Mevacor, generics), pravastatin (Pravachol), simvastatin (Zo
cor, generics), fluvastatin (Lescol), and rosuvastatin (Crestor).
People with type 2 diabetes are also at risk for nerve damage (neuropathy) and a
bnormalities in both small and large blood vessels (vascular injuries) that occu
r as part of the diabetic disease process. Such abnormalities produce complicati
ons over time in many organs and structures in the body. Although these complica
tions tend to be more serious in type 1 diabetes, they still are of concern in t
ype 2 diabetes. All people with diabetes should aim for fasting blood glucose le
vels of less than 110 mg/dL and hemoglobin A1C of less than 7%.

You might also like