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(7) Diabetes

Tablets

I understand that there are different sorts of ‘diabetic’ tablets. Can you tell me what they are and what the difference is between them?

There are five different types of tablets that may be prescribed for people with diabetes. They work in different ways.

• Sulphonylureas (including gliclazide, chlorpropamide, glibenclamide, glipizide, glimepiride, gliquidone and tolbutamide): they act by increasing the amount of natural insulin produced by your pancreas.

• Biguanide (metformin [Glucophage]): this works by reducing the release of glucose from your liver and increasing the uptake of glucose into muscle.

• Alpha glucosidase inhibitor (acarbose [Glucobay]): this slows the digestion of carbohydrates in your intestine and suppresses the rise in blood glucose after meals.

• Thiazolidenediones (rosiglitazone [Avandia] and pioglitazone [Actos]): they target ‘insulin resistance’ and are used in people who have been unable to control their blood glucose levels with metformin or a sulphonylurea. Rosiglitazone is also available in combination with metformin (Avandamet).

• Prandial glucose regulators (repaglinide and nateglinide): these stimulate the release of insulin from your pancreas and are given with meals (prandial means a meal). They can be used on their own or combined with metformin.

I am taking gliclazide but am getting dizziness. Could the tablets be causing this?

Gliclazide could be causing your blood glucose level to be too low so your dizziness could be a mild hypo, particularly if you get this feeling when exercising or before meals. You can easily confirm this by checking your blood glucose at a time when you feel dizzy. If your blood glucose level is above 4 mmol/litre then something apart from the gliclazide must be causing the dizziness. There are of course other causes of dizziness, which have nothing to do with diabetes, and your doctor will check for these.

I find I am dropping off to sleep all the time and never feel refreshed. I take 160 mg of gliclazide twice a day as well as 500 mg metformin. Could I be taking too much?

This is quite a large dose of gliclazide and your sleepiness could be due to a hypo. You should check that your blood glucose is not too low (below 4 mmol/litre). On the other hand, people with high blood glucose often feel drowsy and lacking in energy. So your complaint could be due to either a low or a high blood glucose level, and you can find out by doing a blood glucose test. Take the results to your doctor who will adjust your dose accordingly if necessary.

My doctor is taking me off Diabinese (chlorpropamide). Will I get withdrawal symptoms?

Some medicines, especially certain sleeping tablets and painkillers, become necessary to the body if taken regularly for long periods of time. When these drugs are stopped, the body reacts violently, causing withdrawal symptoms. Tablets for diabetes do not have these effects and can be stopped quite safely - provided, of course, that you no longer need them to keep your blood glucose under control. If your blood glucose begins to rise, the symptoms of thirst, itching, and so on, will return, but these cannot be described as withdrawal symptoms. They are due to the diabetes returning.

Since taking Glucophage (metformin), I have had feelings of nausea and constant diarrhoea and have lost quite a lot of weight. Is this due to the Glucophage?

Nausea and diarrhoea are possible side effects of Glucophage. The loss of weight could be due either to poor food intake because Glucophage has reduced your appetite, or to your diabetes being out of control. Either way you should stop Glucophage or at least reduce the dose and see if the nausea and diarrhoea disappear. If your diabetes is then poorly controlled with high blood glucose levels (more than 10 mmol/litre), you may need a different sort of tablet or perhaps insulin injections in addition to diet, and you should consult your doctor.

My elderly mother has been taking gliclazide to control her diabetes for 5 years. Recently her sugars have been high and her doctor has asked her to take metformin as well with good results. Are there concerns about the long-term safety of metformin?

Metformin is a very good drug and we are not surprised that your mother’s diabetic control has been better since she started taking it in addition to gliclazide. The down side is that metformin frequently causes side effects, mainly affecting the stomach or digestion (diarrhoea, constipation, nausea, loss of appetite). These side effects may develop after metformin has been taken for several years.

What is the cause of a continuous metallic burning taste in the mouth? I am 62 years of age with diabetes, controlled on tablets for the last 4 years.

You are probably taking metformin (Glucophage) tablets as these sometimes do cause a curious taste in the mouth. If the taste is troublesome (and it sounds unpleasant) you should stop taking these tablets. Other tablets for diabetes do not cause this side effect. You should consult your doctor for advice. I have diabetes controlled on tablets.

My dose was halved, and my urine was still negative to glucose. Would it be all right to stop taking my tablets altogether to see what happens? Obviously I would restart the tablets if my urine showed glucose.

Your idea is probably a good one, but you should discuss this with your doctor. You should also check your blood glucose level as urine tests can sometimes be misleading. Provided that your blood glucose remains controlled (less than 8 mmol/litre) you would be better off finding out if you can control your blood glucose without any tablets. If you no longer need tablets, diet becomes even more important for controlling your diabetes and you must avoid putting on weight. Some people think that if they come off tablets, they no longer have diabetes, but this is not so.

There is always the chance that they will need tablets or even insulin at some stage in the future. I have just started taking Glucobay tablets for my diabetes. Could you explain how Glucobay works?

Glucobay, the trade name for acarbose, acts by slowing the digestion of starch and related foodstuffs. Acarbose (Glucobay) slows the breakdown and absorption of many dietary carbohydrates, reducing the high peak of blood glucose which can occur after eating a meal containing carbohydrate. It was launched in the UK in 1993, having been used very extensively in other European countries. It is an addition to diet treatment and has been shown to be effective in many people with diabetes who do not require insulin treatment.

I take Glucobay tablets but always feel very full and bloated afterwards. Would it be better not to take them?

Acarbose (Glucobay) may lead to side effects when you first start taking it. These side effects are related to its action in the body. Because Glucobay slows down the breakdown of carbohydrates, complex sugars may then reach the lower part of the gut where they can cause a bloating sensation giving rise to wind (flatulence) and occasional transient diarrhoea. There are two ways of reducing this problem. Start with a very small dose of one 50 mg tablet of Glucobay a day, taken with the first mouthful of your largest meal. Increase the dose slowly, in consultation with your doctor, until the optimum dose is reached. This may be up to 100 mg three times a day.

Try and exclude sucrose from your diet. Sucrose is the ordinary sugar that we add knowingly to sweeten food. It is also added to many foodstuffs by the manufacturers.

I have heard that there is an anti-obesity pill that works by stopping fat absorption. Would it be suitable for me? I have diabetes and am very overweight.

The tablet you are probably referring to is called Xenical, the brand name for orlistat. It blocks the digestion of fat and is the first anti-obesity pill not to rely on suppressing appetite. Orlistat manipulates the chemical digestion processes, blocking the action of lipases (enzymes that break up fat in the intestine), so that about 30% of fat in any meal goes undigested. However, there can be unpleasant side effects. The dietary fat that is not absorbed can be rapidly excreted, which can lead to stomach cramps, diarrhoea and leakage of faeces. Many nutritionists credit the drug’s success to these side effects as they encourage adherence to a low fat diet. There is no reason why a person with diabetes cannot take orlistat, but you should discuss this with your health professional.

I gather that there is a new ‘type’ of tablet for the treatment of diabetes called ‘rosiglitazone’. What’s different about it?

Rosiglitazone (trade name Avandia, or Avandamet in combination with metformin, from GlaxoSmithKline) is an entirely new form of medication designed for people with Type 2 diabetes. It acts by reducing the body’s resistance to insulin. It has been tested extensively in the UK and elsewhere in clinical trials in people with Type 2 diabetes, and is recommended as an additional therapy in combination with either metformin or a sulphonylurea (e.g. gliclazide or glibenclamide) when metabolic control is not adequate. The NHS National Institute of Clinical Excellence (NICE) has reviewed all the information available on the drug and has recently given it their ‘seal of approval’. Because it is a new drug, certain precautions with its use are advised.

I am a 65-year-old and remain a bit overweight despite my best efforts to reduce my weight through strict dieting and increasing the amount of exercise I take. I know my metabolic control is not good and I am on what my doctor says is a maximum dose of metformin. Today she suggested I add a new tablet called ‘pioglitazone’ to my treatment. She says that it is a new type of tablet and, because of this; I will need to have a blood test to check on my liver. This all sounds a bit formidable – should I go ahead and try these new tablets?

It sounds as if your doctor is giving you sound advice. Pioglitazone is a relatively new drug and trials have shown it to be effective and safe in improving metabolic control in people such as you. However, because it should not be used in people with liver problems, an initial liver blood test is advised, with follow-up blood tests each year.

I am about to go onto a glitazone and would like to know how it works.

You probably have Type 2 diabetes that is not well controlled on your present tablets. Rosiglitazone was introduced in 1999 and relies on the fact that Type 2 diabetes is caused by failure to produce insulin and resistance to the insulin that is available. Glitazones work by making you more sensitive to insulin so that whatever you can produce goes further. Troglitazone was the first of this group of drugs to reach the market but it caused serious liver problems in a few people and had to be withdrawn. Extensive tests have been done on the new glitazones (rosiglitazone and pioglitazone) and they appear to be completely safe. However, most doctors like to arrange liver function tests when they first start people on these drugs.

Glitazones may be used as initial treatment in people who cannot tolerate metformin, or added to metformin, particularly if they are overweight. Rosiglitazone may also be used with metformin and a sulphonylurea.

Unlike other drugs used for diabetes, glitazones work slowly and may take up to 3 months to have their full effect.

I’ve just been put on pioglitazone and my blood glucose readings are no better – should I stop taking it?

Pioglitazone, like rosiglitazone, can be an effective way of controlling Type 2 diabetes. However, it does not usually have a rapid effect and you should wait 3 months before concluding that it is not helping your blood sugars.

I’m on rosiglitazone and gliclazide and my doctor wants to put me on metformin as well. Is this OK?

Yes, rosiglitazone has recently been licensed for use in triple combination treatment with metformin and a sulphonylurea. Presumably your blood sugars are running high on your present tablets and your doctor is adding in metformin as a last ditch attempt to avoid the need for insulin. The chances of success are only around 70% but it is worth giving it a try if there is a very good reason for avoiding insulin (e.g. you may hold an HGV licence).

My doctor has recently started me on Novonorm, which I understand is a new type of tablet for diabetes. How does it differ from metformin, which I also take?

Novonorm is the trade name for repaglinide, which is a prandial glucose regulator. This means that it controls the high glucose levels that can occur when food is consumed. It is a blood glucose-lowering tablet that stimulates the quick release of insulin from your pancreas at mealtimes, and should be taken just before a meal. If a meal is missed, the repaglinide is not taken (unlike metformin).

Nateglinide (trade name Starlix) is another prandial glucose regulator. These tablets are usually used in combination with metformin.

I take a lot of tablets and have been told that I will probably have to change to insulin soon. What is the maximum dose of tablets I could take before insulin is required?

Many people continue to use the maximum dose of tablets for years with rather poor control of their diabetes (blood glucose consistently greater than 10 mmol/litre). Although these people often feel fairly well in themselves, they are usually much better off when they change to insulin. After the change to insulin people notice that they have more energy and can usually manage on a less strict diet. In addition, running high blood sugar levels for years carries an increased risk of heart disease and other diabetic complications, such as eye problems.

What should I do if I am ill while on tablets? Should I take more or perhaps fewer tablets?

During the illness, you may not feel like eating, but you must not stop your tablets as any illness usually causes the blood glucose to rise. If your blood glucose readings become very high, you should contact your doctor.

My doctor has advised me to change from tablets to insulin. Would I be right in thinking that I could avoid doing this if I cut down my intake of carbohydrate?

No, probably not. If you are overweight, you might be able to avoid insulin by dieting strictly and losing weight but only if you are eating more than you need at the moment. If your present food intake is the amount you need, then reducing this will only make you lose weight and in due course become weak – and you may already be suffering from thirst, weight loss and fatigue. So if you are eating too much, eat less and try to improve your control that way. If you are already dieting properly, do not try to starve yourself. Accept insulin and you will probably be grateful, especially if it makes you feel better and more energetic.

My diabetes has been treated with tablets for 2 years and now my doctor has said I need insulin injections. Is my diabetes getting worse?

If your blood glucose can no longer be controlled with tablets, then your pancreas is becoming even less efficient in producing insulin, and in that sense your diabetes is worse. However, it does not mean that you are going to suffer any new problems from the condition, nor does it necessarily mean that you have done anything wrong. Diabetes is a progressive condition and many people will eventually move on to insulin. Once you have got over the initial fear of injecting yourself (and most people manage this very quickly), then going on to insulin should not alter your life – in fact it will probably make you feel much better.

My mother is quite elderly and may have to take insulin. Are there new ways of giving insulin that will make it simpler for her?

We agree that new insulin devices (Innolet) have made it easier for old people to administer insulin. However, it is often difficult to predict whether an older person will be better off on insulin rather than tablets. The factors that her doctor will take into consideration are as follows:

• How unwell or thirsty does she feel while on tablets?

• What side effects are the tablets causing?

• How high are her blood sugars?

• How active and dexterous is she?

• How keen is she to start insulin?

Of all these questions, the last one is the most important and we must not pressurize older people to start a form of treatment, which they may dread. One way round this is to try insulin for a specified period of say 2 months and allow her to decide after Treatment without insulin that time whether or not she wishes to continue with insulin or revert to her previous treatment with tablets.

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