Treatment of Type 2 Diabetes Mellitus: Breaking Down the Guidelines for Patients

Diabetes mellitus affects 25.8 million people in the United States, which is 8.3% of the population. Eighteen million people are diagnosed with diabetes mellitus while the remainder of affected people have undiagnosed diabetes. Diabetes mellitus is the 7th leading cause of death in the country¹. 

In January 2013, the American Diabetes Association published the newest treatment guidelines².

Guidelines for Treatment of Type 2 Diabetes

The proper management of diabetes involves a myriad of lifestyle changes from diet to self-testing.

Type 2 Diabetes Diet and Carbohydrate Counting

The reality is that no matter how much you counsel your patients to eat better and make healthier choices, they will go home and eat what they want. In three months’ time, it will be no surprise to see the HbA1c higher or unchanged since you last counseled them. The problem is not your counseling technique. Have you personally tried carbohydrate counting? It’s difficult to do and depressing to know that everything you know and love has as much carbohydrates as a Snickers Bar.

Think about your morning breakfast of a Venti Mocha Frappuccino with nonfat milk and a plain bagel with cream cheese. The total amount of carbohydrates is 134 grams of carbohydrates (84 grams from the beverage and 50 grams from the bagel). The 79 grams of sugar from the drink will be enough to get your “energy” and blood sugar up for the next one to two hours. If you are diabetic, the post-prandial rise lasts longer. The lighter version of the popular drink is not as innocent as it sounds either. Mocha Frappuccino light with nonfat milk has 41 grams of carbohydrates, which includes 38 grams of sugar.

Strategies to Help Manage a Type 2 Diabetes Diet

Ask the patient what they normally like to eat.

Explain what carbohydrates are and how many are found in their favorite foods.

Amount of Carbohydrastes in Popular Foods

Suggest better food choices if their food choice is extremely poor. You should always recommend the best alternative. For example, water instead of high caloric drinks. However, patients will not likely switch their taste buds for water overnight. Be reasonable and realistic. For example, instead of drinking a can of Coke, suggest a Coke Zero or Diet Coke. They have no calories or carbohydrates.

Offer solutions if they refuse to change their diet. For example, if they want to eat their usual two servings of spaghetti with meat sauce every night, suggest eating one cup of noodles with a double serving of sauce. If they will not give up their loaf of garlic bread, advise to eat no more than two slices and rip off the crust.

Record accurately and truthfully on their food journal. It will be a waste of your time and their time if a patient records partial or false information about their diet. Don’t shun them if they document a chocolate donut every morning (32 grams of carbohydrates) or two scoops of ice cream (30 grams of carbohydrates) every night. It just means that these patients need a little more patience and further education.

Exercise: Moderate Intensity Workouts Three Times a Week

Specifically, patients should exercise at least 150 minutes per week, divided over three days. The heart rate should increase up to 50% to 70% of the maximum heart rate. Resistance training should be done at least twice a week.

Explain to your patients that it is not enough to take a walk around the block during their lunch break. After moderate exercise, patients should be sweating and their heart rate racing in the 50% to 70% range of their maximum heart rate (maximum heart rate= 220-age). For example, a 40-year old patient should increase their heart rate up to 90 to 126 beats per minute while they exercise. Going to the gym before or after work for 50 minutes should suffice. By exercising, tissue sensitivity to insulin is heightened and hence, blood sugar levels will decline. If the patient is overweight, a weight loss program should be implemented. Patients can aim to lose up to two pounds per week.   

Stop Smoking: Smoking Increases Risk of Cardiovascular and Stroke Events in Diabetics

Physicians can prescribe behavioral therapy and medications to safely wean patients from smoking such as nicotine gum, nicotine patches, nicotine inhaler, and nicotine nasal spray. They deliver a small amount of nicotine to satisfy cravings. As the body adapts to the lower amount of nicotine, the body will crave less for it. To block withdrawal symptoms and reduce cravings, physicians may also prescribe Chantix (varenicline) and Zyban (buproprion SR).  

Type 2 Diabetes Medications: Take Them as Directed

Noncompliance is a sad part of our reality. Patients have dozens of reasons for not taking their medications. If they have an issue with their medications, ask them why. It’s better to know if they are going to take the medication or not. In my experience, the most common reason for noncompliance is the fear of side effects. The following list of diabetes medications and common side effects is not comprehensive.

Type 2 diabetes medications and their common side effects

Metformin

Stomach upset: Take with a snack.

Sulfonylureas

Hypoglycemia (low blood glucose): Take medication before meal.  

Meglitinides (repaglinide, nateglinide)

Hypoglycemia: Take medication before a meal.

Thiazolidinediones (pioglitazone, rosiglitazone)

May worsen heart failure (CHF): Monitor for new onset or worsening of edema (water retention).

Alpha-glucosidase inhibitors (acarbose, miglitol)

Stomach upset: Medications slow the breakdown of complex carbohydrates; diarrhea and flatulence are common side effects.

GLP-1 analogs (exenatide, liraglutide)

Hypoglycemia: Inject one hour before a meal.

Amylin analogue (pramlintide)

Hypoglycemia: Inject immediately before meals.

SGLT2-inhibitor (Canagliflozin- Invokana)³

May precipitate hypoglycemia if used with insulin: Take before first meal.

Hyperkalemia: Monitor potassium and creatinine clearance.

Symptomatic hypotension: Medication causes intravascular volume contraction in elderly patients, those with preexisting low systolic blood pressure, and those on ARBs or ACE-inhibitors.

Type 2 Diabetes Medication Timing is Everything

Type 2 diabetes medications do not require meal time administration except for those which directly affect post-prandial levels.

Meglitinides: Take 15 to 30 minutes before meal.

Sulfonylureas: Take 30 minutes before meal.

Alpha-glucosidase inhibitors (acarbose, miglitol): Take with the first bite of each meal.

Rapid-acting insulins (insulin lispro, insulin aspart): Take immediately before meal or with meal.

Short-acting insulins (regular insulin): Take 30 minutes before meal.

GLP-1 analogs (exenatide, liraglutide): Inject one hour before a meal.

Amylin analogue (pramlintide): Inject immediately before meals.

Self-testing of blood sugar levels: How to Interpret Them

Current guidelines recommend frequent testing; patients should test before meals and snacks, after meals on occasion, at bedtime, and when the patient feels hypoglycemic. It is frustrating to see partial records of blood sugars but as professionals, we need to learn to optimize the situation and make use of what is done.

Timing and Interpretation of blood sugar tests

Morning

Fasting blood sugar level (Goal= 70-130 mg/dl)

If a long-acting insulin was given the night before, then this level is reflective of the insulin’s effect. If the patient is planning to eat breakfast, estimate the number of carbohydrates to be consumed and administer a dose of rapid-acting insulin (See Calculate mealtime bolus/snack-time bolus based on carbohydrates consumed).

Example: If a patient wants to eat two pancakes plus syrup and eggs, he/she will need to inject enough rapid-acting insulin to cover 50 grams of carbohydrates.

Blood sugar levels one or two hours after breakfast (Goal = <180 mg/dl)

Post-prandial blood sugar level will rise from breakfast carbohydrates. If a rapid-acting insulin was given before breakfast, then this level is reflective of the insulin’s peak effect

Blood sugar levels before lunch (Goal = 70-130 mg/dl)

Pre-prandial blood sugar level; If above goal range, it is necessary to administer a dose of rapid-acting insulin to reduce the level to goal. 

The insulin sensitivity factor (ISF) should be calculated first. (TDD = Total Daily Dose)

Divide 1800/TDD = _______

If a patient is using Humalog, divide 1800/TDD

If patient is using regular insulin, divide 1500/TDD

ISF is the amount of glucose in mg/dl that is reduced with 1 unit of insulin.

Example: if TDD is 34 units then the ISF is 53 mg/dl

Patient is very-sensitive to Humalog.

To reduce a pre-prandial sugar of 200 mg/dl to a goal of 130 mg/dl, then the patient needs to inject 1.32 or 1 unit of Humalog.

Measured blood sugar level - goal blood sugar =  X

Divide X/insulin sensitivity factor = ____ units

If the patient is planning to eat lunch, estimate the number of carbohydrates to be consumed and administer a dose of rapid-acting insulin (See Calculate mealtime bolus/snack-time bolus based on carbohydrates consumed).

Afternoon

Blood sugar levels one or two hours after lunch (Goal = <180 mg/dl)

Post-prandial blood sugar level will rise from carbohydrates in lunch meal. If rapid-acting insulin was given before lunch, then this level is reflective of the insulin’s peak effect.

Evening

Blood sugar levels Before dinner (Goal = 70-130 mg/dl)

Pre-prandial blood sugar level; if above goal range, it is necessary to administer a dose of rapid-acting insulin to lower the level to goal (using the ISF). If the patient is planning to eat dinner, estimate the number of carbohydrates to be consumed and administer a dose of rapid-acting insulin (See Calculate mealtime bolus/snack-time bolus based on carbohydrates consumed).

Bedtime

Fasting blood level (Goal = 70-130 mg/dl)

If NPH was given in the early evening, then the bedtime level will reflect its peak effect.

When reviewing blood sugar records, you are looking for severe hypoglycemic episodes (<50 mg/dl), severe hyperglycemia (>240 mg/dl), and trends. If the records are accurate, blood sugar trends should coincide with the HbA1c. Frequent self-testing is recommended initially, at the onset of diagnosis or insulin use. After patients have stabilized their blood sugars, it is acceptable to reduce the number of tests.

Self-dosing of Insulin Using Blood Sugars and Carbohydrates Consumed

Finally, we save the hardest teaching principle for last. How much insulin does a patient need? There are a variety of formulas and equations based on studies. The problem is that there is no formula that will guarantee the perfect amount of insulin for the patient. There are two ways of calculating insulin that are acceptable to initiate. It is imperative that the diabetic educator and/or physician modify the dose based on the reported blood sugar readings.

Calculate total daily dose (TDD) based on weight

This is a common way of dosing new patients on insulin. The total insulin is based on weight. For newly diagnosed type II diabetics, the total dose is 0.5 to 0.8 units per kilogram per day. Divide the total dose in half. Reserve one half of the dose for the basal insulin using long-acting insulin. Take the other half and divide it in thirds. The calculated result is the amount of insulin to be given before each meal. Here is an example.

Your patient weighs 150 pounds or 68 kg. 

Total daily dose: 34 units

TDD = 68 kg x 0.5 units/kg

Basal insulin dose (using insulin glargine or detemir): 17 units at night

If the morning blood sugars are above goal, then it means that the patient may need a higher dose of glargine or detemir. It is acceptable to increase the dose by 1 to 2 units at a time.

If NPH is used instead, then the initial dose is NPH 9 units every 12 hours.

Mealtime bolus (using insulin aspart or lispro): 6 units with breakfast, lunch, and dinner

The problems with the mealtime insulin bolus are that there is an assumption that 1) each meal will contain the same amount of carbohydrates and 2) the patient will consume 100% of the meals.

The best alternative is to calculate the mealtime insulin dose based on carbohydrates consumed.

Calculate mealtime/snack-time insulin dose based on carbohydrates consumed (Insulin to Carb ratio)

Divide 500/TDD = ________________

TDD is the total daily dose of insulin.

The calculated answer is the insulin to carb ratio.

Example:

TDD is 34 units per day

Insulin to Carb ratio = 500/34 = 15

For every 15 grams of carbohydrates, inject 1 unit of rapid-acting insulin.

Remember the patient who wants to eat 2 pancakes with eggs for breakfast? There is 50 grams of carbohydrates in that meal so the patient will need 4.5 units of rapid-acting insulin before eating.

If the post-prandial blood sugar level is above range (>180 mg/dl), then the patient did not inject enough insulin. The diabetic educator and/or physician needs to readjust the insulin to carb ratio.

More examples:

One full-sized Snickers bar (36 grams of carbohydrates) will require 2.4 units or 2.5 units of rapid-acting insulin.

Two 2 scoops of ice cream (30 grams of carbs) will require 2 units of rapid-acting insulin.

One glazed donut (32 grams of carbohydrates) will require 2 units of rapid-acting insulin.

Conclusion

After careful and accurate documentation of food intake, insulin doses, and blood sugar levels, it is up to the diabetic educator, physician, or nurse to help titrate insulin doses and recommend changes to the diet or timing of the self-testing.

Ultimately, the goal is to help the patient reasonably manage their diabetes and achieve results near or at goal. Just be patient with your patient.

References:

1.  www.diabetes.niddk.nih.gov/dm/pubs/statistics/#fast

2.  American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66.  

3.  www.pharmacistsletter.com

About the Author

Dr. Karine Wong has a 10 year history of working in hospital management and 2 years as a hospital pharmacist and outpatient pharmacist. She recently published a children's book called Don't Sit on Her.

This article is for information only and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.