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Fluid retention and heart failure can occur with concomitant use of thiazolidinediones (TZDs) with insulin.
Apidra® is a rapid-acting insulin analog indicated to improve glycemic control in adults with type 2 diabetes or adults and children (4 years and older) with type 1 diabetes. When used as a mealtime insulin, the dose of Apidra® should be given within 15 minutes before or within 20 minutes after starting a meal. Click the CONTINUE button below to go to the Macromedia Flash Player Download Center, or the CANCEL button to return to the previous page.
DESCRIPTIONGlimepiride Tablets, USP are an oral blood-glucose-lowering drug of the sulfonylurea class. Chemically, glimepiride is identified as 1-[[p-[2-(3-ethyl-4-methyl-2-oxo-3-pyrroline-1-carboxamido)ethyl]phenyl]sulfonyl]-3-(trans-4-methylcyclohexyl)urea. The primary mechanism of action of glimepiride in lowering blood glucose appears to be dependent on stimulating the release of insulin from functioning pancreatic beta cells. In two 14-week, placebo-controlled studies in 720 subjects, the average net reduction in HbA1c for glimepiride tablets patients treated with 8 mg once daily was 2.0% in absolute units compared with placebo-treated patients.
Glimepiride therapy is effective in controlling blood glucose without deleterious changes in the plasma lipoprotein profiles of patients treated for Type 2 diabetes.
PharmacokineticsAbsorptionAfter oral administration, glimepiride is completely (100%) absorbed from the GI tract. Metabolism Glimepiride is completely metabolized by oxidative biotransformation after either an IV or oral dose. ExcretionWhen14 C-glimepiride was given orally, approximately 60% of the total radioactivity was recovered in the urine in 7 days and M1 (predominant) and M2 accounted for 80-90% of that recovered in the urine. These data indicate that glimepiride did not accumulate in serum, and the pharmacokinetics of glimepiride were not different in healthy volunteers and in Type 2 diabetic patients. All MedLibrary.org resources are included in as near-original form as possible, meaning that the information from the original provider has been rendered here with only typographical or stylistic modifications and not with any substantive alterations of content, meaning or intent. This site complies with the HONcode standard for trustworthy health information: verify here. This site is provided for educational and informational purposes only, in accordance with our Terms of Use, and is not intended as a substitute for the advice of a medical doctor, nurse, nurse practitioner or other qualified health professional. Genetic FactorsResearchers have identified at least 18 genetic locations, labeled IDDM1 - IDDM18, which are related to type 1 diabetes.
Hyperglycemic Hyperosmolar Syndrome (HHS)Hyperglycemic hyperosmolar syndrome (HHS) is a serious complication of diabetes that involves a cycle of increasing blood sugar levels and dehydration, usually without increasing blood ketones. Hemoglobin A1c TestThis test examines blood levels of glycosylated hemoglobin, also known as hemoglobin A1c (HbA1c). To achieve good blood sugar control, patients and parents of children must undergo some training. Not recommended as first-line treatment for patients inadequately controlled on diet and exercise. Concomitant insulin (insufficient data); administer as separate injections not adjacent to each other.
Twice-daily dosing: dose titration based on individual glycemic target, 2nd dose with evening meal, at bedtime, or 12 h after morning dose.
Proven, powerful and sustained HbA1c reductions with weight loss.*1–4 An ideal choice for your patients' first injectable. The Apidra® No Co-Pay offer is not valid for patients whose prescriptions are paid in part or full by any state or federally funded programs including but not limited to Medicare, Medicaid, Medigap, VA, DOD or TriCare. Apidra® given by subcutaneous injection should normally be used in regimens that include a longer-acting insulin.
Glimepiride, USP is a white to yellowish-white, crystalline, odorless to practically odorless powder formulated into tablets of 1-mg, 2-mg, and 4-mg strengths for oral administration.
In addition, extrapancreatic effects may also play a role in the activity of sulfonylureas such as glimepiride. In patients where monotherapy with glimepiride or metformin has not produced adequate glycemic control, the combination of glimepiride and metformin may have a synergistic effect, since both agents act to improve glucose tolerance by different primary mechanisms of action. Some patients, particularly those with higher fasting plasma glucose (FPG) levels, may benefit from doses of glimepiride up to 8 mg once daily. Initially, 5-10 units of insulin were administered with the main evening meal and titrated upward weekly to achieve predefined FPG values. Studies with single oral doses in normal subjects and with multiple oral doses in patients with Type 2 diabetes have shown significant absorption of glimepiride within 1 hour after administration and peak drug levels (Cmax ) at 2 to 3 hours. The major metabolites are the cyclohexyl hydroxy methyl derivative (M1) and the carboxyl derivative (M2). Approximately 40% of the total radioactivity was recovered in feces and M1 and M2 (predominant) accounted for about 70% of that recovered in feces.
Oral clearance of glimepiride did not change over the 1-8-mg dose range, indicating linear pharmacokinetics.
Insulin is a hormone that is involved in regulating blood sugar (glucose) by controlling how much glucose you make between meals and how you store glucose that you absorb after a meal. The IDDM1 region contains the HLA genes that encode proteins called major histocompatibility complex. The results are given in percentages and indicate a person's average blood glucose levels over the past 2 to 3 months.
Good blood glucose control is the best way to prevent major complications in type 1 diabetes, including those that affect the kidneys, eyes, nerve pathways, and blood vessels. Changes in insulin strength, manufacturer, type, or method of administration may result in the need for a change in insulin dose or an adjustment in concomitant oral antidiabetic treatment. Glimepiride Tablets, USP contain the active ingredient glimepiride, USP and the following inactive ingredients: lactose monohydrate, magnesium stearate, povidone, and sodium starch glycolate. This is supported by both preclinical and clinical studies demonstrating that glimepiride administration can lead to increased sensitivity of peripheral tissues to insulin.
This complementary effect has been observed with metformin and other sulfonylureas, in multiple studies. In noninsulin-dependent (Type 2) diabetes mellitus (NIDDM) patients, both fasting and 2-hour postprandial glucose levels were significantly lower with glimepiride (1, 2, 4, and 8 mg once daily) than with placebo after 14 days of oral dosing. When glimepiride was given with meals, the mean Tmax (time to reach Cmax ) was slightly increased (12%) and the mean Cmax and AUC (area under the curve) were slightly decreased (8% and 9%, respectively). Cytochrome P450 2C9 has been shown to be involved in the biotransformation of glimepiride to M1. Use associated with disabling and potentially permanent side effects of the tendons, muscles, joints, nerves, and central nervous system that can occur together in the same patient. As with all insulin preparations, the time course of Apidra® action may vary by individual or at different times in the same individual and is dependent on many conditions, including the site of injection, local blood supply, or local temperature. After IV dosing in patients, no significant biliary excretion of glimepiride or its M1 metabolite has been observed.
Type 1 diabetes is considered an autoimmune disorder that involves: The gradual destruction of beta cells in the pancreas. Other chromosomes and genes that affect the risk of developing diabetes continue to be identified. Most people who develop type 1 diabetes do not have a family history of the disease. It is often triggered by a serious infection or another severe illness, or by medications that lower glucose tolerance or increase fluid loss (especially in people who are not drinking enough fluids). Symptoms of HHS include high blood sugar levels, dry mouth, extreme thirst, dry skin, and high fever. They need to match their insulin doses to carbohydrate intake. Healthy eating habits along with good control of blood glucose are the basic goals, and several good dietary methods are available to meet them. It is important to manage heart disease risk factors that might develop as a result of insulin treatment.
This requires an initial learning period, including understanding insulin needs over the course of the day and in different situations (before exercise and driving) and knowledge of carbohydrate counting. Continuous Glucose Monitoring SystemsContinuous glucose monitoring systems (CGMs) use a small plastic sensor inserted under the skin of the abdomen to monitor glucose levels every 5 minutes. However, as with other sulfonylureas, the mechanism by which glimepiride lowers blood glucose during long-term administration has not been clearly established.
HHS can lead to loss of consciousness, seizures, coma, and death. HypoglycemiaTight blood sugar (glucose) control increases the risk of low blood sugar (hypoglycemia).
A diet plan that compensates for insulin administration and supplies healthy foods is extremely important. Frequent blood testing is very important, particularly during the training period. Insulin pumps are more expensive than insulin shots and occasionally have some complications, such as blockage in the device or skin irritation at the infusion site.
Depending on the system, CGMs measure glucose levels for 3 to 7 days and sound an alarm if glucose levels are too high or low. Card carries a maximum offer benefit of $100 per prescription for the duration of the program.
Type 2 DiabetesType 2 diabetes is the most common form of diabetes, accounting for 90 to 95% of cases.
Even in identical twins, one twin has only a 33% chance of having type 1 diabetes if the other twin has it. What is most important is to find a healthy eating plan that works best for you and your lifestyle and food preferences. Despite early concerns, pumps do not appear to increase the risk of ketoacidosis. The main advantages of insulin pump use are the ability to adjust basal rates during the day, the bolus wizard which helps calculate the right dose of insulin to match a meal, not having to carry separate supplies, and the ability to combine the pump with a continuous glucose monitoring sensor that can give warnings and alerts. Patients who are at risk for hypoglycemia should carry some sugar product, or an emergency glucagon injection kit, in case hypoglycemia occurs. In type 2 diabetes, the body does not make enough insulin or does not respond properly to insulin, a condition known as insulin resistance. Children are more likely to inherit the disease from a father with type 1 diabetes than from a mother with the disorder. Genetic factors cannot fully explain the development of diabetes. A1c tests are also used to help patients with diabetes monitor how well they are keeping their blood glucose levels under control. However, for better control of blood glucose in type 1 diabetes, intensive management is usually required.
Despite certain challenges, research continues to progress on a "closed-loop" system that combines an insulin pump with a continuous glucose meter to form an artificial pancreas.
For the past several decades, the number of new cases of type 1 diabetes has been increasing each year worldwide.
For patients with diabetes, A1c is measured periodically every 2 to 3 months, or at least twice a year. While finger prick self-testing provides information on blood glucose for that day, the A1c test shows how well blood sugar has been controlled over the past several months. In general, most adult patients with diabetes should aim for A1c levels below or around 7%. The basal component of the treatment attempts to provide a steady amount of background insulin throughout the day. Pramlintide is injected before meals and can help lower blood sugar levels in the 3 hours after meals. The American Diabetes Association recommends continuous glucose monitoring as a useful tool for patients with type 1 diabetes. Urine TestsUrine tests are useful for detecting the presence of ketones. Patients should also wear a medical alert ID bracelet or necklace that states they have diabetes and take insulin. New Type 1 Diabetes Guidelines In 2014, the American Diabetes Association (ADA) released new guidelines specifically addressing patients with Type 1 diabetes.


Hypoglycemia can sometimes be severe or even life threatening, particularly if the patient fails to recognize the symptoms, especially while continuing to take insulin or other hypoglycemic drugs. Pramlintide is used in addition to insulin for patients who take insulin regularly, but still need better blood sugar control. These tests should always be performed during illness or stressful situations, when diabetes is likely to go out of control. Epidemics of Coxsackie virus, as well as mumps and congenital rubella, have been associated with type 1 diabetes. Risk FactorsType 1 diabetes is much less common than type 2 diabetes, consisting of only 5 to 10% of all cases of diabetes.
Beta-blocking medications, which are often prescribed for high blood pressure and heart disease, can mask symptoms of hypoglycemia. Risk Factors for Severe Hypoglycemia. Pramlintide and insulin 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. The patient should also undergo yearly urine tests for microalbuminuria (small amounts of protein in the urine), a risk factor for future kidney disease.
Nevertheless, like type 2 diabetes, new cases of type 1 diabetes have been rising over the past few decades.
Avoid unhealthy saturated fats (red meat, butter) and trans fats (hydrogenated fat found in snack foods, fried foods, commercially baked goods). Choose protein sources that are low in saturated fat. But other intermediate and long-acting forms may be beneficial when administered twice a day.
Side effects may include nausea, vomiting, abdominal pain, headache, fatigue, and dizziness.
Evidence suggests that both a genetic predisposition and environmental factors, such as a viral infection, are involved. Islets of Langerhans contain beta cells and are located within the pancreas. While type 2 diabetes has been increasing among African-American and Hispanic adolescents, the highest rates of type 1 diabetes are found among Caucasian youth. Type 1 diabetes can occur at any age but usually appears between infancy and the late 30s, most typically in childhood or adolescence.
Hypoglycemia unawareness is a condition in which people become accustomed to hypoglycemic symptoms. Short-acting insulin delivered continuously using a pump is proving to a very good way to provide basal rates of insulin. Meal-time insulin administration.
Patients with type 1 diabetes have an increased risk of severe low blood sugar (hypoglycemia) that may occur within 3 hours following a pramlintide injection. Try to eat fatty fish (salmon, tuna), which are high in omega-3 fatty acids, at least twice a week. Meals require a boost (a bolus) of insulin to regulate the sudden rise in glucose levels after a meal.
This drug should not be used if patients have trouble knowing when their blood sugar is low or have slow stomach emptying (gastroparesis). Metformin (Glucophage, generic) is an oral medication used commonly in patients with type 2 diabetes. It affects about 25% of patients who use insulin, nearly always people with type 1 diabetes. However, some patients with type 1 diabetes may be (or become) overweight or obese and are relatively insulin-resistant. Discuss reducing the dose of basal insulin with your doctor. Children (particularly thin children) may be at higher risk for hypoglycemia because the insulin injection goes into muscle tissue. However, at the point when insulin production bottoms out, type 1 diabetes usually appears suddenly and progresses quickly. In such cases, hypoglycemia appears suddenly, without warning, and can escalate to a severe level.
Pinching the skin so that only fat (and not muscle) tissue is gathered or using shorter needles may help. Monitor blood glucose levels as often as possible, generally four times or more per day.
Snacks may be necessary, but can also mean that basal insulin rates are too high and may contribute to weight gain. Insulin requirements vary depending on many non-nutritional situations during the day, including exercise and sleep. In severe cases, diabetic coma may be the first sign of type 1 diabetes. ComplicationsDiabetes increases the risk for many serious health complications. Even a single recent episode of hypoglycemia may make it more difficult to detect the next episode.
These include weight reduction (when needed), following the Dietary Approaches to Stop Hypertension (DASH) diet, smoking cessation, limiting alcohol intake, and limiting salt intake to no more than 1,500 mg of sodium per day. The kit is available by prescription and contains an injection of glucagon, a hormone that helps to quickly raise blood glucose levels in a patient who cannot eat.
With vigilant monitoring and by rigorously avoiding low blood glucose levels, patients can often regain the ability to sense hypoglycemia symptoms. Reducing sodium can lower blood pressure and decrease the risk of heart disease and heart failure.Healthy Weight ControlWeight gain is a potential side effect of intense diabetic control with insulin. Some patients experience a sudden rise in blood glucose levels in the morning -- the so-called "dawn phenomenon." It is important to maintain a good diet plan and visit your health care team (doctor, nurse, and dietitian) once a month. This approach can help prevent complications due to vascular (blood vessel) abnormalities and nerve damage (neuropathy) that can cause major damage to organs, including the eyes, kidneys, and heart and can result in foot ulcers, infection of bones in the feet, and toe or foot amputation. Managing risk factors for heart disease.
However, sometimes continuous glucose monitoring (CGM) is necessary to identify time periods when patients are hypoglycemic.
In reality, individual patients with identical A1c tests may have very different average glucose levels.
Because of the higher risk for hypoglycemia in children, doctors recommend that intensive insulin treatment be used very cautiously in children under 13 and not at all in very young children. Types of InsulinInsulin cannot be taken orally because the body's digestive juices destroy it.
Within 20 minutes after a meal insulin rises to its peak level. Insulin enables glucose to enter cells in the body, particularly muscle, fat, and liver cells. CGM studies have shown that many people with type 1 diabetes are sometimes unaware that their blood sugars are very low. Symptoms. On the other hand, studies suggest that more than one-third of women with diabetes omit or underuse insulin in order to lose weight. Injections of insulin under the skin ensure that it is absorbed slowly by the body for a long-lasting effect. For some people, especially younger patients, a systolic blood pressure goal of less than 130 mm Hg may be appropriate. Patients with diabetes and high blood pressure need an individualized approach to drug treatment, based on their particular health profile. Patients with type 1 diabetes should always wear a medical alert ID bracelet or necklace that states that they have diabetes and take insulin. Foot CareMeasures to Prevent Foot Ulcers. But it is also very important that people with diabetes control blood pressure, cholesterol levels, and other factors associated with heart disease, including stopping use of all tobacco products. Mild symptoms usually occur at moderately low and easily correctable levels of blood glucose.
These antibodies are referred to as autoantibodies because they recognize the body's own cells, rather than a foreign invader. Eating disorders are especially dangerous in patients with diabetes and can increase the risk for diabetic ketoacidosis.
The timing and frequency of insulin injections depend upon a number of factors: The duration of insulin action.
The blood glucose levels are then referred to as pre-prandial blood glucose concentrations.
Diabetic KetoacidosisDiabetic ketoacidosis (DKA) is a life-threatening complication caused by a complete (or almost complete) lack of insulin. Blood tests for these autoantibodies can help differentiate between type 1 and type 2 diabetes.
Ketoacidosis is a significant complication of insulin depletion and can be life threatening. Exercise and Physical ActivityAerobic activity has significant and particular benefits for people with type 1 diabetes. The most beneficial fall into the following categories Diuretics rid the body of extra sodium (salt) and water. Some tips for preventing problems include: Inspect your feet daily and watch for changes in color or texture, odor, and firm or hardened areas. Many people with diabetes come to recognize their hypoglycemia symptom pattern over time and it is usually consistent. However, many patients with type 2 diabetes also have low levels of one or more autoantibodies and so autoantibodies may simply be the sign of damaged pancreatic islets beta cells. Screening Tests for ComplicationsScreening Tests for Heart Disease.
It increases sensitivity to insulin, lowers blood pressure, improves cholesterol levels, and decreases body fat. These changes may indicate infection and potential ulcers. When washing the feet, the water should be warm (not hot) and the feet and areas between the toes should be thoroughly dried afterward.
Ketones are byproducts of fat breakdown that build up in the blood and appear in the urine. All patients with diabetes should be tested for high blood pressure (hypertension) and unhealthy cholesterol and lipid levels and given an electrocardiogram. Like ACE inhibitors and ARBs, certain calcium channel blockers (diltiazem and verapamil) can reduce urine protein loss caused by diabetic kidneys.
They are produced when the body starts burning much larger amounts of fat than the body needs for energy. Diabetes affects the heart in many ways: Both type 1 and 2 diabetes accelerate the progression of atherosclerosis (hardening of the arteries). Other tests may be needed in patients with signs of heart disease. Click the icon to see an image of an ECG.
Nearly all patients who have diabetes and high blood pressure should take an ACE inhibitor (or ARB) as part of their regimen for treating their hypertension.
These drugs help prevent heart and kidney damage, and are recommended as the best first-line drugs for people with diabetes and hypertension. Extreme stages of diabetic ketoacidosis can lead to coma and death. For some people, DKA may be the first sign that someone has diabetes.
This can lead to coronary artery disease, heart attack, or stroke. In type 1 diabetes, high blood pressure (hypertension) usually develops if the kidneys become damaged.
The earliest manifestation of kidney disease is microalbuminuria, in which tiny amounts of a protein called microalbumin are found in the urine. Insulin lispro (Humalog), insulin glulisine (Apidra) and insulin aspart (Novo Rapid, NovoLog) lower blood sugar very quickly, usually within 5 minutes after injection. In type 1 diabetes, it usually occurs when a patient is not taking insulin as prescribed, runs out of insulin, or cannot afford to buy medication. Microalbuminuria is also a marker for other complications involving blood vessel abnormalities, including heart attack and stroke. The American Diabetes Association recommends that people with diabetes receive an annual urine test for albumin. Insulin peaks 30 to 60 minutes after injection and continues to have some effect for about 4 hours.
An angiotensin-receptor blocker (ARB) is recommended for patients who cannot tolerate ACE inhibitors.
Shoes with a rocker sole may be particularly helpful because they reduce pressure under the heel and in the front of the foot. Children with diabetes are also at risk for hypertension. Impaired nerve function (neuropathy) associated with diabetes also causes heart abnormalities. Because patients with diabetes may have silent heart disease, they should always check with their doctors before undertaking vigorous exercise. Warning on Dietary SupplementsVarious fraudulent products are often sold on the Internet as “cures” or treatments for diabetes. This rapid action reduces the risk for hypoglycemic events after eating (postprandial hypoglycemia). The US Food and Drug Administration (FDA) and Federal Trade Commission (FTC) warn patients with diabetes not to be duped by bogus and unproven remedies. According to the American Diabetes Association, there is no evidence to support herbal remedies or dietary supplements (including fish oil supplements) for the treatment of diabetes.


Other serious complications from DKA include aspiration pneumonia, acute kidney injury, and adult respiratory distress syndrome. A doctor uses the results from a creatinine blood test to calculate the glomerular filtration rate (GFR). There is no evidence that vitamin or mineral supplements can help people with diabetes who do not have underlying nutritional deficiencies.
Transplantation ProceduresIslet-Cell TransplantationResearchers continue to investigate islet-cell transplantation as a way to help patients no longer be dependent on insulin or reduce their use of insulin. Regular insulin begins to act 30 minutes after injection, reaches its peak around 2 hours, and lasts about 6 to 8 hours. The American Diabetes Association considers statin therapy for lowering LDL levels appropriate for patients with type 1 diabetes who are 40 to 75 years old. The American Diabetes Association recommends that patients with type 1 diabetes have an annual comprehensive eye exam, with dilation, to check for signs of retina disease (retinopathy).
Regular insulin may be administered before a meal and may be better for high-fat meals. Intermediate Insulin.
For patients younger than age 40, statin therapy needs to be considered on an individual basis. But it has helped patients with severe type 1 diabetes to become free of insulin injections. However, many of these insulin-independent patients needed to resume insulin injections within a few years.
In addition to a comprehensive eye exam, digital retinal photography may be used as a screening tool.
They include atorvastatin (Lipitor, generic), lovastatin (Mevacor, generic), pravastatin (Pravachol, generic), simvastatin (Zocor, Simcor, Vytorin, and generics), fluvastatin (Lescol, generic), rosuvastatin (Crestor), and pitavastatin (Livalo). Researchers are continuing to work on refining the transplantation protocols so that benefits can be more sustainable and long lasting. A major obstacle for the islet cell transplantation is that every transplantation needs islets from two or more deceased donors to supply sufficient islet cells.
Retinal photography uses a special type of camera to take images of the back of the eye. Screening for Neuropathy. Because the number of donors in many countries remains low, this procedure is only feasible for a very small percentage of patients with type 1 diabetes. Researchers are looking for alternative approaches, including the use of umbilical cord cells, embryonic or adult stem cells, bone marrow transplantation, and other types of cellular therapies.
All patients should be screened for nerve damage (neuropathy), including an annual comprehensive foot exam. Long-acting basal insulins, such as insulin glargine (Lantus), and insulin detemir (Levemir) are released slowly.
However, they may increase blood glucose levels in some patients, especially when taken in high doses. Patients who lose sensation in their feet should have a foot exam every 3 to 6 months to check for ulcers or infections. Patients should also be screened for intermittent claudication and peripheral artery disease (PAD) using the ankle-brachial index for diagnosis.
It starts working in 2 to 4 hours and lasts as long as 24 hours (glargine) or 18 hours (detemir).
If one statin drug does not work or has side effects, the doctor may recommend switching to a different statin. The primary safety concern with statins has involved myopathy, an uncommon condition that can cause muscle damage and, in some cases, muscle and joint pain. Researchers are studying new types of long-acting insulins including one called degludec that requires injections only three times a week. Combinations. Patients should meet with a professional dietitian to plan an individualized diet within the general guidelines that takes into consideration their own health needs. Regimens generally include both rapid-acting and basal insulins to help match the natural insulin secretion. People with diabetes and risk factors for myopathy should be monitored for muscle symptoms. Aspirin for Heart Disease Prevention. Rapid-acting analog insulin is taken before every meal and sometimes with larger snacks. Insulin Pens. For patients with diabetes who have additional heart disease risk factors, taking a daily aspirin can reduce the risk for blood clotting and may help protect against heart attacks. Insulin pens, which contain cartridges of insulin, have been available for some time, although they are still more expensive than vials of insulin. These prefilled disposable pens, are more portable, do not carry the stigma of a syringe, and are easier and more convenient for patients. Inhaled Insulin.
Talk to your doctor, particularly if you are at risk for aspirin side effects such as gastrointestinal bleeding and ulcers. Treatment of RetinopathyPatients with severe diabetic retinopathy or macular edema (swelling of the retina) should see an eye specialist who is experienced in the management and treatment of diabetic retinopathy.
Afrezza is taken before meals and is designed for adult patients who need mealtime insulin to help control hyperglycemia in between meals. Drug therapy with anti-vascular endothelial growth factor (VEGF) is also recommended for treatment of diabetic macular edema. Afrezza should not be used by patients who smoke or those with chronic lung diseases such as asthma or COPD.
A previous inhaled insulin was withdrawn from the market because of changes in lung function and modest patient interest. In some cases, hospitalization and intravenous antibiotics for up to 28 days may be needed for severe foot ulcers and for patients who have peripheral artery disease. In virtually all cases, wound care requires debridement, which is the removal of injured tissue until only healthy tissue remains. The pumps correct for the "dawn phenomenon" (sudden rise of blood glucose in the morning) and allow quick reductions for specific situations, such as exercise. Felted foam uses a multi-layered foam pad over the bottom of the foot with an opening over the ulcer. Many different brands are available. The typical pump is about the size of a pager and has a digital display. Some are worn externally and are programmed to deliver insulin through a catheter under the skin. These include: Administering hyperbaric oxygen (oxygen given at high pressure) is showing promise in promoting healing.
They work by administering a small amount of insulin continuously (the basal rate) and a higher dose (a bolus dose) when food is eaten. Although learning to use the pump can be complicated at first, most patients find over time that the devices are fairly easy to use. It is generally reserved for patients with severe, full thickness diabetic foot ulcers that have not responded to other treatments, particularly when gangrene or an abscess is present. Adults, adolescents, and school children use insulin pumps and even very young children (ages 2 to 7 years) are able to successfully use them. The catheter at the end of the insulin pump is inserted through a needle into the abdominal fat of a person with diabetes. It is not recommended for infection in the bone (osteomyelitis). Total-contact casting (TCC) uses a cast that is designed to match the exact contour of the foot and distribute weight along the entire length of the foot.
Dosage instructions are entered into the pump's small computer, and the appropriate amount of insulin is then injected into the body in a calculated, controlled manner. Treatment of Diabetic NeuropathyThe only FDA-approved drugs for treating neuropathy are pregabalin (Lyrica) and duloxetine (Cymbalta).
Pregabalin (Lyrica) is a first-line treatment and has the strongest evidence for efficacy of all neuropathy treatments. Gabapentin (Neurontin, generic) and valproate (Depacon, generic) may also be considered. Antidepressants. Duloxetine (Cymbalta) and venlafaxine (Effexor) are recommended, as is amitriptyline (Elavil, generic). Tricyclics may cause heart rhythm problems, so patients at risk need to be monitored carefully. Opioids.
Dextromethorphan, morphine, oxycodone, and tramadol (Ultram, generic) may be considered for severe neuropathy pain. These drugs can cause significant side effects (nausea, constipation, and headache) and can be addictive. Topical Medications. PENS uses electrodes attached to precisely placed acupuncture-type needles to deliver electrical current to peripheral sensory nerves. Doctors also recommend lifestyle measures, such as walking and wearing elastic stockings. Treatments for Other Complications of Neuropathy.
Neuropathy also impacts other functions, and treatments are needed to reduce their effects. If diabetes affects the nerves in the autonomic nervous system, then abnormalities of blood pressure control and bowel and bladder function may occur. Erythromycin, domperidone (Motilium), or metoclopramide (Reglan) may be used to relieve delayed stomach emptying caused by neuropathy (diabetic gastroparesis). Patients need to watch their nutrition if the problem is severe. Erectile dysfunction is also associated with neuropathy. Studies indicate that phosphodiesterase type 5 (PDE-5) drugs, such as sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), and avanafil (Stendra) are safe and effective, at least in the short term, for many patients with diabetes. Typical side effects are minimal but may include headache, flushing, and upper respiratory tract and flu-like symptoms. Angiotensin-receptor blockers (ARBs) are also very helpful. For patients with diabetes who have microalbuminuria, the American Diabetes Association strongly recommends ACE inhibitors or ARBs. Microalbuminuria is an accumulation of protein in the urine, which can signal the onset of kidney disease (nephropathy). Nearly all patients who have diabetes and high blood pressure should take an ACE inhibitor (or ARB) as part of their regimen for treating their hypertension. Patients on dialysis usually need injections of erythropoiesis-stimulating drugs to increase red blood cell counts and control anemia.
However, these drugs -- darbepoetin alfa (Aranesp) and epoetin alfa (Epogen and Procrit) -- can increase the risk of blood clots, stroke, heart attack, and heart failure in patients with end-stage kidney disease when they are given at higher than recommended doses. End-stage kidney disease, anemia, and treatment with medications that mimic erythropoietin change the relationship between A1c and blood glucose. Patients with end-stage kidney disease are often at greater risk of hypoglycemia, especially fasting hypoglycemia during the night or early morning. Patients with kidney disease taking insulin to control their blood sugars often need to reduce their insulin doses as their kidney disease progresses.
Treatment of Diabetes During PregnancySome recommendations for preventing pregnancy complications include: Intensive blood sugar control during pregnancy can reduce the risk of health complications for both mothers and babies. Doctors recommend that pregnant women with pre-existing diabetes monitor their blood sugar levels up to 8 times daily. This includes checking your blood glucose before each meal, 1 to 2 hours after a meal, at bedtime, and possibly during the night. Insulin needs increase during the pregnancy, especially during the last 3 months.
This is especially important for women with eye, kidney, or high blood pressure or other heart problems.) To prevent birth defects that affect the heart and nervous system, women with diabetes should take a higher dose of folic acid from the time of conception up to week 12 of pregnancy.
They should also be checked for any heart problems. Women with diabetes should have an eye examination during pregnancy and up to a year afterward. Home ManagementMonitoring Glucose (Blood Sugar) LevelsBoth low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia) are of concern for patients who take insulin. Home monitors are less accurate than laboratory monitors and many do not meet the standards of the American Diabetes Association. However, they are usually accurate enough to indicate when blood sugar is too low. To monitor the amount of glucose within the blood, a person with diabetes should test their blood regularly.



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