Diabetes Treatment

with Archana Bindra, M.D., Endocrinologist, Columbia St. Mary's

Posted: Nov. 1, 2004

Summed up in one word, a diagnosis of diabetes means this: change.

“For many people, it's like a whole new life,” said Archana Bindra, M.D., an endocrinologist with Columbia St. Mary’s.

What is diabetes?

Archana Bindra, M.D., Endocrinologist, Columbia St. Mary’s "If your blood sugar levels are controlled close to the normal range, the risk of complications from diabetes that affect the eyes, kidneys and nerves is significantly reduced."

In a healthy person who does not have diabetes, the pancreas manufactures and secretes insulin, a hormone that regulates the amount of glucose in the blood, keeping blood sugar levels at a normal, healthy level.

If the pancreas begins to produce less insulin, blood sugars may be consistently elevated, leading to complications of diabetes such as blindness, kidney impairment and nerve damage. The risk of having heart attacks and strokes also increases with uncontrolled sugars.

Diabetes may be treated with oral medications as well as injections with insulin. The patient may either be on oral medications alone or insulin alone or a combination of the two. Proper diet and exercise are also extremely important.

People with Type 2 diabetes are commonly diagnosed several years after their actual disease process begins, Dr. Bindra explained. They may already have complications of diabetes at the time of diagnosis and should be evaluated accordingly. It is vital that the blood sugars be controlled in a timely fashion. The endocrinologist can to help restore and maintain the sugars within the normal range.

Role of the endocrinologist
One of the first things an endocrinologist will request is a very specific blood test called the Hemoglobin AIC. This test reflects the blood sugar in the body over the last three months. The goal is less than 6.5%.

Dr. Bindra usually evaluates those with newly diagnosed diabetes on a frequent basis until their blood sugars are under better control. She sees these patients every two to four weeks; fully stabilized patients come in four times a year for checkups and more often if something requires additional monitoring.

Every situation is different, Dr. Bindra said, particularly with the increase in type 2 diabetes in younger patients. “Nowadays with obesity on the rise in the young, type 2 diabetes is occurring in much younger individuals. These patients usually have adequate amounts of insulin in their body but because of the obesity, their insulin does not work. This entity is called insulin resistance and leads to high blood sugars.”

Medications
The first medication Dr. Bindra uses in most patients with type 2 diabetes is metformin, which helps maintain stability with weight.

Some patients take medication that increase sensitivity such as Actos and Avandia (TZD's). These medications may cause fluid retention, so she doesn’t prescribe TZD's for patients who have heart failure or who tend to have extra fluid already. A baseline liver function test is necessary for patients on TZD's. Patients who tolerate TZD's well have their liver function tested every six months.

Another class of drugs, such as glyburide and glipizide, are secretagogues. If the pancreas is still functioning, these drugs help the pancreas secrete insulin.

If, after the initial treatment, Dr. Bindra sees that post-meal sugar levels are high, she adds meglinitides to the prescription list. They’re different from the other pills in that they’re only taken with meals, she explained.

“I usually start with metformin at first, and then slowly increase the dose,” she said.. “Typically, you want to take metformin with meals because it may cause gastrointestinal distress.”

After a week, she increases the prescription, and at the end of the second week may add another medication, then increase them both over the next month or two.

If a patient’s blood sugar is still too high after an adequate amount of time on oral medication, insulin is the next step.

Insulin
“Insulin comes in different types,” Dr. Bindra said. “Type 2 diabetics can take a long-acting insulin called Lantus, which is a 24-hour injection taken at night. It acts like your basal insulin for the whole day and can be added to the oral medications.”

For those with Type 1 diabetes, Lantus is taken at bedtime, and then short-acting injectable insulin is taken with meals. All injections should be administered in the abdomen, Dr. Bindra said, because it’s from that area that insulin is best absorbed.

Insulin pumps are a good option for diabetics who are conscientious and who lead particularly busy lives. The pump is an external device that contains a supply of insulin. The insulin is delivered to the body by a thin catheter and a small flexible needle that is placed in the abdomen. It’s convenient because it can hold an extended supply of insulin and can be programmed to deliver just the right amount of insulin. Pump users who like to exercise can decrease or turn off the flow of insulin while exercising, which reduces their risk of having their blood sugar drop too low, causing hypoglycemia.

Specific concerns
All patients found to have either type 1 or type 2 diabetes must visit an ophthalmologist yearly to look for complications of diabetes that might affect their eyes.

Their kidney function should be evaluated with the help of a urine check, which may require seeing a kidney specialist if problems are found.

The feet of a person with diabetes are especially important. The nerves may get damaged and the patient might experience symptoms of tingling and numbness. These patients are especially vulnerable to sores that may not heal. Therefore a periodic visit to a podiatrist is encouraged.

Sessions with a diabetes education team are encouraged. The team helps with meal planning, exercise, monitoring, insulin administration, stress management and can help people make important lifestyle changes.

The endocrinologist plays an important and ongoing role the care of the person with diabetes. It is critical that the endocrinologist be someone with whom the patient is comfortable. With proper care many of the complications of diabetes can be prevented.

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