The best medicines for diabetes

Dear Dr. Ong,

After reading your article, I had my fasting blood sugar checked. My FBS is 122. I woke up from my complacency, because just like you said, I have to be treated early. Both my mom and dad are also diabetic. I’m only 32 so I’m still in denial till you woke me up.

Princess

Hi, Princess!

This article is for you and all those in denial. And for those who are confused as to the best medicines to take, here’s my honest take on what’s best for you. However, there may be a slight difference of opinion between some doctors.

There are two categories of drugs for diabetes: 1) medicines for prevention of diabetes complications and 2) medicines for blood sugar control.

Note: All these drugs require a doctor’s guidance. Do not take them on your own.

Best Medicines To Prevent Diabetes Complications

• Aspirin: If you have a history of stroke, high blood pressure, high cholesterol or smoking, then aspirin at 80mg daily is very good for you. If you’re diabetic and not taking aspirin, ask your doctor why.

• ACE inhibitor or angiotensin receptor blocker: Based on the latest American Diabetes Association recommendations, all diabetes patients should be given either an ACE inhibitor or an angiotensin receptor blocker. This works in two ways: by protecting the kidneys and controlling the blood pressure.

Examples of famous Ace-inhibitors are enalapril (brand name Hypace and Renitec), while popular angiotensin receptor blockers include irbesartan (Aprovel) and losartan (Lifezar).

• Vaccines: Patients with diabetes will benefit from an annual influenza shot and a pneumonia vaccine every five years. This will help prevent or limit the severity of the flu or pneumonia, should the patient get them.

• Statins: For diabetics, even if their total cholesterol is just a shade over 200mg/dl, they will already benefit from the statin drugs. These include the likes of Simvastatin, Rosuvastatin. and Atorvastatin. Statins preserve the elasticity of the arteries, which are easily affected in diabetes.

Best Medicines For Blood Sugar Control

Here is a summary of commonly-used diabetes drugs:

• Drug class of biguanides (generic name of metformin): If you are diabetic and overweight, then your doctor will prescribe you metformin. Metformin is ideal for overweight patients because it can reduce appetite (hear this), and lower triglyceride levels. Metformin acts by telling our muscles to take up more glucose and preventing the liver from releasing glucose to the body. Side effects include gassiness, abdominal pain, and diarrhea.

Drug rating: Excellent!

• Usual brand names — Neoform, glumet, glucophage, sulfonylurea class (like Gliclazide and Glimepiride): If you are not overweight, your doctor may choose the sulfonylureas. These tablets are also offered to patients who cannot tolerate metformin. Sulfonylureas act by telling the beta cell in our pancreas to secrete more insulin. Insulin is like the key needed by the body’s cells to take up glucose. Side effects to watch out for include low blood sugar (hypoglycemia), hunger, and weight gain.

Drug rating: Good.

• Usual brand names — gliclazide (Glubitor, Diamicron); glimepiride (Norizec, Solosa); alpha-glucosidase inhibitor (like Voglibose and Acarbose): Some diabetics have problems with high blood sugar after they eat a large meal. This is called post-meal hyperglycemia. One technique doctors use is to give drugs that block an enzyme involved in the digestion of carbohydrates. If you block this enzyme, you slow down the absorption of the carbos you just ate. These are drugs to be taken with meals and are safe to use. Just watch out for gassiness.

Drug rating: Good.

• Usual brand names — voglibose (Basen) and acarbose (Glucobay); glitazones or thiazolidinediones (like Pioglitazone): Pioglitazone acts innovatively by making our muscle cells more responsive to insulin, thus making these cell take up more glucose. Once our body uses up the glucose, our blood sugar goes down. Recently, glitazones have been tainted by links with congestive heart failure.

New studies show that Pioglitazone has a better safety profile (less heart complications) compared to Rosiglitazone.

Drug rating: Fair for Pioglitazone (brand name Actos, Piozone, Prialta).

• DPP-4 inhibitors: If you want to know the in thing for diabetes, it’s the DPP-4 inhibitors. But the truth is, Galvus and Januvia are just the newest kids on the block. Can these drugs live up to all the hype? I don’t know. Maybe.

Galvus and Januvia work by stimulating the pancreas to secrete insulin. Known side effects include high blood pressure, constipation, and symptoms of cold and flu. Who should take them? It’s still not clear yet, but doctors are giving them as a second option to patients with poor blood sugar control.

Drug rating: Unknown. Maybe in a year or two, we will know more.

• Available brand names — vildagliptin (Galvus) and sitagliptin (Januvia); strategies for treating milder cases of diabetes: Now that we know about diabetes drugs, how then do doctors use them? Fortunately, there are guidelines we can follow.

For patients with a fasting blood sugar of less than 140mg/dL and 2 hr post-meal blood sugar less than 180mg/dL, doctors usually start by giving one drug only. As mentioned above, first-line choices include the following:

1) Metformin (like Glumet), which is ideal for obese patients and those with high triglycerides.

2) Sulfonylurea (like Glubitor), which is ideal for lean patients, early in disease.

Alternative methods for treating diabetes are the following:

3) Glitazones (like Actos), which is given for patients with side effects from the above two drugs.

4) Alpha glucosidase inhibitor (like Basen), which is ideal for post-meal high blood sugar.

Treatment of More Severe Diabetes

For patients with a fasting blood sugar of greater than 140mg/dl and 2 hr post-meal blood sugar greater than 180mg/dL, doctors may give a combination of two or three drugs.  The usual combinations are a) metformin plus sulfonylurea, b) metformin plus glitazones, and c) metformin plus sulfonylurea plus glitazones.

Finally, consider using insulin injections early if blood sugar control is not achieved with the above drugs. Insulin should not be looked at as a last resort but can be used early to help prevent complications. Consult your doctor about your blood sugar. Take care!

* * *

Cardiologists of the Philippine Heart Association (PHA) will be the frequent guests and co-hosts of Cheryl Cosim’s show Magandang Gabi Dok at DZMM Teleradyo, Mondays to Fridays, 7:45 p.m. According to PHA president Dr. Efren Vicaldo, this is in keeping with the organization’s mission to enlighten the public regarding heart diseases. Congratulations to all the directors of the PHA!

* * *

E-mail questions to drwillieong@gmail.com.