Diabetes Care

Insulin is injected under the skin. An injection under the skin is called a subcutaneous injection. Insulin cannot be given in pill form because the acid in the stomach destroys insulin. Insulin may be given continuously by an insulin pump (See section on insulin pumps).

Different types of Insulin

There are many types of insulin. Insulin is divided into types based on how it is made. There is human insulin and analog insulin. Human insulin is the same as the insulin produced in your pancreas. Analog insulins are slightly different than human insulin to allow them to work faster or slower than regular human insulin. Human and analog insulin are divided into types based on how fast it begins to lower blood sugar (onset) and how long it continues to work in the body (duration).

Human insulin

• Short-acting or regular insulin. This type of insulin takes 30 minutes to start working to lower blood sugar and lasts 5 to 8 hours. It is usually taken 30 minutes before meals.
• Intermediate-acting or NPH insulin. This type of insulin takes 1 to 3 hours to start lowering blood sugar and lasts 12 to 16 hours. It is usually taken before breakfast and in the evening.
• Premixed. This type of human insulin is a combination of regular insulin and NPH insulin. It is taken twice daily usually 30 minutes before breakfast and 30 minutes before dinner.

Analog insulin

• Fast-acting. This type of analog insulin starts to work in 15 minutes. It is usually taken right before a meal is eaten.
  Novolog, Humalog, Apidra, Ademelog or Fiasp  
• Long-acting. This insulin works slowly for 24 hours in your body. It is used to control your blood sugar between meals and while you sleep. It should be taken at the same time every day because it works for 24 hours.
  Levemir, Lantus, Toujeo or Tresiba  
• Premixed. This is a combination of fast and intermediate-acting analog insulin. It is taken twice daily usually 30 minutes before breakfast and 30 minutes before dinner.

Insulin Pumps

Insulin pumps are small computerized devices that deliver insulin in two ways:

• In a steady measured and continuous dose (the "basal" insulin)
• As a surge ("bolus") dose, at your direction, around mealtime.

Doses are delivered through a flexible plastic tube called a catheter. With the aid of a small needle, the catheter is inserted through the skin into the fatty tissue and is taped in place. The needle is removed leaving the catheter in place.

The insulin pump is not an artificial pancreas (because you still have to monitor your blood sugar level), but pumps can help some people achieve better control, and many people prefer this continuous system of insulin delivery over injections.

Pumps can be programmed to release small doses of insulin continuously (basal), or a bolus dose close to mealtime to control the rise in blood sugar after a meal. This system most closely mimics the body's normal release of insulin.

Ask your primary care provider if you are interested in an insulin pump. You may need to be seen by an endocrinologist- someone who specializes in diabetes. Check with your insurance carrier to see if insulin pumps are covered under your policy.

All insulin pumps have a toll free number on the back in case you have questions or problems with your pump.

Note: It is a good idea to carry extra insulin pump supplies with you, especially if you will be in the hospital.

In recent years, eight new classes of medicines for people with type 2 diabetes have been approved by the Food and Drug Administration (FDA). Most of these medications are pills. These pills work in different ways to lower blood sugar.

Insulin Secretagogues

Insulin Secretagogues work by stimulating insulin release.

Meglitinides: Take these medications 1-30 minutes before meals to control your blood sugar

Repaglinide (Prandin), Nateglinide (Starlix)

Sulfonylureas: They are taken once or twice daily, 30 minutes before meals. If you are allergic to sulfa, you usually cannot take a sulfonylurea.

Glipizide (Glucotrol, Glucotrol XL), Glyburide (Diabeta, Micronase), Glyburide micronized (Glynase), Glimepiride (Amaryl)

Both meglitinides and sulfonylureas can cause low blood sugar if not balanced with carbohydrate intake and exercise. They may also cause weight gain.

Biguanides

Biguanides works by reducing production of sugar in the liver.

Metformin (Glucophage, Glucophage XR, Glumetza, Fortamet): is often the first medicine given to lower blood sugar in type 2 diabetics. Metformin may help with weight problems because it helps the body use insulin better. It can cause nausea or diarrhea in some people, but the nausea and diarrhea usually go away soon. Taking Metformin with food helps. Take metformin with meals. It is usually given 2 or 3 times daily.

Some people cannot take Metformin because their kidneys do not work well or because they have heart failure. Taking Metformin when you are in heart failure can cause a serious medical problem called lactic acidosis. Lactic acidosis is when lactic acid builds up in the blood faster than it can be removed. Lactic acid is produced when oxygen levels in the body are low.

Thiazolinediones

Thiazolinediones (Glitazones) work by helping your body respond better to insulin.

Periodic liver blood tests are needed. May cause or worsen heart failure- notify your doctor if you gain weight or notice swelling in your legs, ankles feet, arms, hands or belly. Can be taken with or without food. May increase risk for bladder cancer and bone fracture.

Rosglitazone (Avandia), Pioglitazone (Actos)

Alpha-Glucosidase Inhibitors

Alpha-Glucosidase Inhibitors work in your stomach and bowels to slow down the absorption of sugars and carbohydrates.

They can cause abdominal pain, gas and diarrhea. Take with the first bite of food at each meal.

Acarbose (Precose), Miglitol (Glyset)

SGLT-2 Inhibitors

SGLT-2 Inhibitors work by increasing the amount of sugar leaving the body in the urine.

Taken once daily. These medicines may lower your blood pressure. These medicines act as “water pills” (diuretics). If you are on a water pill (diuretic) already, the dose of your water pill may need to be reduced. Have your kidney function tested before starting this medication. These medicines may cause modest weight loss and lower blood pressure. May also cause urinary tract infections or yeast infections.

Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance)

DPP-4 Inhibitors

DPP-4 Inhibitors work by increasing the release of insulin and decreasing the release of sugar from the liver.

Take once daily. Tell your doctor if you have abdominal pain (pain in your belly), nausea and vomiting.

Sitagliptin (Januvia), Saxigliptin (Onglyza), Linagliptin (Tradjenta), Alogliptin (Nesina)

Combinations:

Sometimes two diabetic medications are combined in a single pill. These combination medicines work like both medicines in the pill and reduce the number of pills needed. They can be costly and may not be covered by insurance. If you are prescribed a combination pill, discuss how it works with your doctor or pharmacist.

Synthetic Amylin

Synthetic Amylin works by slowing the rate of movement of food from the stomach to the intestine and tells the liver to decrease glucose output.

Take right before a big meal. Used with insulin for the treatment of type 1 and type 2 diabetes

Pramlintide (Symlin)

Incretin Mimetic

Incretin Mimetic works by causing your pancreas to release insulin when blood sugar is rising.

Incretin is a natural hormone made in your digestive tract. Incretin mimetics act like (mimic) the incretins in your body that lower blood sugar after eating. Cause nausea and vomiting which usually resolves soon after the medication is started. Causes modest weight loss. Tell your doctor if you have abdominal pain (pain in your belly), nausea and vomiting. These medicines are approved for treatment of type 2 diabetes. Should be avoided if personal or family history of pancreatitis or medullary thyroid cancer- notify MD for hoarseness or throat lump.

Twice daily with meal: Exenatide (Byetta)

Once daily: Semaglutide (Rybelsus)- ORAL, Liraglutide (Victoza)

Once Weekly: Exenatide XR (Bydureon), Dulaglutide (Trulicity), Semaglutide (Ozempic)

Medications that affect blood sugar

Some medicines that are used for other conditions such as high blood pressure, COPD, or depression can affect your blood sugar. Some over the counter medicines can affect your blood sugar. Alcohol, caffeine and nicotine all affect your blood sugar.

Below are lists of some of the medicines that might cause your blood sugar to increase or decrease. Do not stop taking prescription medicines or change the dose without talking to your doctor. Always let your doctor know what over the counter medicines, vitamins and supplements you take.

Medicines That Increase Blood Sugar:

• Alcohol (acute use-social drinking)
• Antibiotics (Dapsone, Rifampin)
• Antidepressants (Zyprexa, risperdal, Clozaril, Seroquel, Abilify, Geodon, lithium)
• Beta-2 stimulators (Proventil, Alupent, Serevent, Foradil, Brethine, Theo-Dur)
• Caffeine
• Corticosteroids (Prednisone, Decadron, DepoMedrol)
• Dilantin (phenytoin)
• Nicotine (smoking and patches)
• Estrogens (Premarin, hormone replacement therapy)
• Heart and blood pressure medications (amiodarone, beta blockers, calcium channel blockers, catapress, diuretics)
• Oral contraceptives (Birth control pills)
• Niacin or nicotinic acid
• Protease inhibitors (ritonavir etc-AIDS drugs)
• Thyroid hormones (Synthroid, Levothroid)

Medicines That Decrease Blood Sugar:

• Antibiotics (Bactrim/Septra)
• Alcohol (acute excess amounts)
• Aspirin and other salicylates in larger doses
• Heart and blood pressure medications (ACE inhibitors, beta blockers, Norpace, Quinidine)
• Quinine
• Tylenol (acetaminophen-especially in larger doses)

High Blood Sugar—Hyperglycemia

High blood sugar may occur within hours or may develop over several days. You may have one or all of the following symptoms:

• High blood sugar levels (over 200)
• Extreme thirst
• Fatigue/sleepiness
• Using the bathroom a lot
• Grouchiness
• Pain in stomach with or without nausea and vomiting

Causes of high blood sugar include:

• Too much food or eating the wrong foods
• Not enough diabetes pills or insulin
• Illness or infection
• Not enough exercise (Do not exercise if your sugar is above 240)
• Stress

What to do to prevent hyperglycemia:

• Always take your diabetes medicine unless your doctor tells you not to.
• Test your blood sugar every four to six hours.
• If you usually take insulin, test your urine for ketones. Call your doctor if moderate to large ketones are present.
• If your blood sugar is over 150, drink 8 ounces of sugar-free liquid every one to two hours.
• Call your doctor if you are vomiting and unable to eat or drink liquids.

Remember to call your doctor if your blood sugar stays above the goals you’ve been given for 24 hours.

Low Blood Sugar—Hypoglycemia

Low blood sugar (usually less than 70mg/dL) usually occurs quickly and may require that someone help you get treatment. Symptoms include:

• Sweating
• Shaking
• Fast and/or pounding heartbeat
• Hunger
• Irritability/Confusion
• Fainting

Causes of low blood sugar include:

• Too much insulin or too many diabetes pills
• Not enough food or missing a meal
• Too much exercise, or extra physical activity

What to do to prevent hypoglycemia:

Try to test your blood sugar. If you are too shaky, eat or drink a fast-acting carbohydrate such as:

• 4 ounces juice (orange, apple, cranberry or grape)
• 6 ounces (1/2 can) of a regular soft drink
• 8 ounces skim milk
• 3 glucose tablets
• 8 Sweet Tart candies
• 2 tablespoons raisins

Test blood sugar every 15 to 30 minutes until it is above 100. Eat a second fast-acting carbohydrate if needed. If your next regular meal is more than two hours away, eat a snack such as half a sandwich or three peanut butter or cheese crackers. If you are unconscious, someone should call 911 immediately. You should not be given anything by mouth if you are unconscious.

Be sure to tell your doctor about this episode in case your medication needs to be adjusted.

Medication Used to Correct a Low Blood Sugar

This medicine is available in a kit for a low blood sugar emergency. Symptoms of a low blood sugar emergency are:

• unconsciousness (cannot wake the patient)
• patient is awake but unable to eat
• the patient is having a seizure
• the patient’s blood sugar is still less than 70 even after eating or drinking food containing sugar.

Most often, glucagon is injected into the muscle. This type of glucagon is a powder in a bottle to which sterile water is added from a pre-filled syringe. The same syringe is then used to give the injection. Do not mix the glucagon with water unless you are going to inject the glucagon.

Some glucagon can be given as a puff through the nose. Talk to your healthcare provider about which type may be best for you and your family. A family member or friend should know where you keep your glucagon kit and how to administer the medication. Read the directions that come with the kit with your friend or family member. That way you will be prepared if a low blood sugar emergency happens.

Administering Glucagon in an Emergency

If a diabetic person is unable to be woken up, call 911 immediately.

It is important to act quickly when someone with diabetes becomes unconscious or will not wake up.

1. Turn him/her on his/her side. He/she may vomit when waking up; turning him/her on his/her side will stop him/her from choking on vomit.
2. Administer the glucagon according to the directions that came with the kit.
3. Feed the patient as soon as he/she wakes up. Try small sips of fruit juice or regular pop. If tolerated, follow with a snack of a carbohydrate and a fat, such as peanut butter crackers.

Call 911 even if the patient wakes up.

**Glucagon will not revive someone who is unconscious because of HIGH blood sugar.

Check the expiration date on your glucagon kit and ask your doctor for a new prescription if your kit has expired.

Hypoglycemia or low blood sugar is a concern for people with diabetes. Diabetes medication increases the risk to have low blood sugars and those who take insulin are at the greatest risk for low blood sugars.

Be Prepared

The person having a low blood sugar will notice sudden symptoms such as feeling shaky, light headed, dizzy, sweaty, or unable to focus or concentrate. Since these symptoms occur without warning, everyone should always carry something with them to eat or drink to bring the blood sugar up quickly. 15 grams of carbohydrate is the right amount. The best things to carry are things that are fast-acting like:

• Glucose Tablets 
• Hard candy like Life Savers, peppermints, Skittles, Starbursts
• 4 oz. Juice Boxes
• Tiny boxes or 2 tablespoons of raisins

Activities like driving, operating machinery or caring for small children are dangerous with low blood sugars. It’s always best to be prepared, just in case.