DOCTOR'S VIEW ARCHIVE
Diabetes Update -- Brunilda Nazario, MD -- 06/17/03
WebMD Live Events Transcript
What is the latest news about diabetes prevention and treatment? We asked our own specialist, endocrinologist Brunilda Nazario, MD, when she joined us on WebMD Live.
The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Member: I have pre-diabetic tendencies and suffer from peripheral neuropathy, which is very painful. I recently read about the use of an antiepileptic drug, Topamax, being used in trials to treat both of these conditions. How soon do you think this treatment will be offered at large? And how can I find out if can participate in any of the trials going on for this drug?
Nazario: I hope that you got the information from our site, that's actually a paper that I reviewed yesterday. The primary researcher who did that study, Dr. Vinik, is probably the premier physician in the field of research and working with diabetic neuropathy.
The use of antiepileptics for the treatment of painful peripheral neuropathy is not new. What is new here is that unlike previous treatments, this is not covering painful neuropathy sensation, but also leading to regrowth of nerves that have been killed from diabetes or prediabetes. The drug itself is also not a new drug. This drug is not indicated for this use, as most antiepileptics are not.
The study that you may have read about is, unfortunately, a small study. There were only 11 or so patients that were studied, but all 11 patients did improve. There are continued clinical trials on various drugs for neuropathy, not only antiepileptics.
Member: How does alcohol consumption affect diabetes?
Nazario: There are a lot of effects that alcohol can have on diabetes, both short and long term. Typically what we hear about is the effects of alcohol resulting in low sugars. This usually happens a few hours to at most two days after the ingestion of modest amount of alcohol. What the substance does is it stops the liver from producing sugars. When we eat, the sugars that we do not use at that moment get stored within the liver. The storage of that sugar is for use when we are in a state of relative fasting or when we're not eating. If one consumes alcohol, alcohol blocks the use of that stored sugar when we need it.
There are also some effects of alcohol on cholesterol abnormalities known to be an associated risk factor for cardiovascular disease. Long-term modest ingestion of alcohol can increase good HDL cholesterol and can give a modest reduction in bad LDL cholesterol. There are also some effects of alcohol on the veins and arteries, causing them to be somewhat more relaxed, rather than stiff. Both the improvement in cholesterol profile and the relaxation of vessels are beneficial to cardiovascular health.
Member: What is the new drug for diabetes?
Nazario: I'm assuming the new drug is not Topamax that we spoke about earlier. The new drug for diabetes, called Exantide, is not on the market yet; it is still in experimental stages, but you've probably heard about it from all the major headlines.
It's a derivative of a substance from the gila monster lizard. It is similar to a hormone that we produce in our stomachs called glucagon-like peptide (GLP). What it does, is that it helps stimulate insulin from our pancreas so it's indicated only in type 2 diabetics. It's released only when sugars are high, like after we eat. When your sugars are low it has no action, so a person taking a drug like this would not suffer from hypoglycemia.
The second important effect of the drug is that it tends to suppress appetite and therefore can result in weight loss, which is really a benefit in the type 2 diabetic, because of risks associated with cardiovascular disease, like obesity.
The third important thing that it does is that it stops the intestines from slowing, so it helps food move along the intestinal tract. In essence, food is not sitting in your intestines continuing to be absorbed. This particular defect, where the stomach is slowed and you continue to increase the absorption of sugars can lead to high sugars after a meal. Presumably this drug, by increasing transit time of food in the intestines, can smooth out sugars after meals.
One last thing this drug does which I think is really critical is the following: There are two basic problems in diabetes.
- Abnormality in insulin
- Abnormalities in glucagons
Insulin decreases sugars, while glucagon increases sugars. Type 2 diabetics have an increased release of sugars because of glucagon. This drug stops glucagon from being released. Therefore, with stopping the glucagon from being released, in essence you're not releasing excess amounts of sugar. Overall, patients that have been on this drug have not only improved their HgIAC, but also have had improvement in weight loss.
Member: I have diabetes type 2 for the last five years. I would like to know where I could find information about proper eating.
Nazario: The issues of nutrition or understanding nutrition in diabetes are of utmost importance in maintaining good glycemic control. Because people are very different and diseases are very different and body sizes are very different and activities are very different, an individualized approached is always recommended. I feel the best way to attain the goals of medical nutritional therapy for diabetes is through a certified diabetic educator. This will give you a one to one approach to deal with diabetes and the other complex issues that come into play when dealing with the diabetic patient.
In other words, there are patients that need weight loss management and some that don't. There are patients that need management of blood pressure control, control of cholesterol, there are a subset of patients that have pregnancy and diabetes, and there are those patients that have kidney disease, so all of these subsets of diabetes could never be approached by one program.
Member: How do you feel about chromium and Tegreen (green tea but think there is a supplement called Tegreen made from green tea leaves) and diabetes?
Nazario: I would say what you're talking about are both dietary supplements, both the green tea and the chromium. There have been a ton of studies looking at the benefits of green tea, anywhere from boosting your immune system to fighting bacteria that cause cavities to lowering the risks of multiple types of cancer. Unfortunately, the substances are not regulated substances, so when you look at the studies out there on dietary supplements you will find many studies that show positive benefits and many studies that have negligible benefits. The real pivotal factor here is that there is no way to regulate the quality or the quantity of the substances being taken and studies, so in general, as a medical professional, I do not recommend these unproven therapies that have been studied well in case controlled clinical trials.
Member: I have been diagnosed recently and I have lost weight (went to diabetic class at Virginia Mason in Seattle). I am on metformin 1,000 mg a day. Will I be able to take less as I get it under control better with exercise and diet? I am a male and eat three carbs a meal, four at dinner.
Nazario: Yes. The more of a healthy lifestyle, including exercise, appropriate nutrition, the less dependent on medications you will be. The natural history of type 2 diabetes is that there is progressive beta cell failure. So you still may be on some type of "diabetic medication" but the healthy lifestyle might prevent you from being on things such as medications to lower your triglycerides or medications to control your blood pressure, etc. So the better your glycemic control, the better the end result.
Member: I have to test my blood twice a day and I am having so many problems doing this. Is there another way to test your blood? We can send men and women to the moon, there must be a better way to test your blood.
Nazario: At this point in time there are the home glucose monitoring tests that do check fingersticks. With time, patients become less sensitive to the finger pricking. Now there is the gluco watch that is also available, but that is not indicated to replace fingersticks or home glucose checks through fingersticks. The future also holds a few gadgets that will be less invasive in checking sugars at home.
Member: I'm female, 54, type 2 diabetic, having great blood sugar control all day long. But overnight I usually spike from 80 or so at bedtime to 135 or so in the a.m. My doctor says we have to get these morning numbers down but offers no suggestion as to how to do it. I've been taking my second dose of glucophage at bedtime instead of with dinner, plus walking on the treadmill after I eat, and I've reduced it to 112 or so. Better, but a far cry from the 80 that he thinks it ought to be. I'm sure this is throwing off my averages, which are perfect all day long except for this glitch. I'm frustrated by this and would appreciate any suggestions. I'm doing Atkins, have lost 15 pounds, and very comfortable with all aspects of blood sugar control except for this.
Nazario: That's a good. I'm sure that a lot of members on the board would probably say this is a dawn phenomenon. Going back a couple of questions, I had mentioned there are two major abnormalities in diabetes. What you're classically seeing is the second abnormality. Diabetic patients like everybody else, produce glucose at night. That comes from what we have stored in the liver during the day. The defect in type 2 diabetics is that the release of sugar is in an amount that is in excess.
Metformin is the one drug that is currently available that stops the liver from releasing excess sugars at night. So you're on the right track. The medication that I talked about earlier will also be able reduce that amount of glucose released from the liver and have the same effect. Exantide, or the classic gut hormone, as they're going to be termed, is the medication that I talked about earlier.
Now that we know the problem, how do you deal with it? The first thing is to make sure this is a dawn phenomenon, and not another more complicated phenomenon, known as a Somoygi effect. I would start by checking the middle of the morning sugar about 3 or 4 a.m. If it's high, then we're probably looking at a dawn phenomenon, which is a problem that is very common in type 2 diabetics. So to deal with the problem, continue to do exactly what you're doing now: exercise, weight loss, and a well balanced, calorically restricted diet. These things will help sensitize you to insulin and normalize the metabolic abnormalities that produce this rise in sugar in the morning.
The second thing you need to be aware of is how accurate your meter is. Because your meter is checking whole blood, it's typically much higher than what a lab test would show, which checks plasma sugar. That difference could be about 10% higher than what it should be. So if your sugar readings are averaging 112 in the morning by your meter, in general, your lab results will be 10% less than that. So they're averaging about 100.
Overall control is ultimately what's important. So my to you is, where is the hemoglobin AIC at? Is it at the goal set by the ADA or AACE?
Member: What if the reading is low at 3 a.m.?
Nazario: If the reading is low, then the increase in sugar that you see the first thing in the morning is a natural response to low sugars that are happening in the middle of the night. In other words, you bottom out at night and your body reacts by pushing out sugars and you have a high sugar in the morning. Here, to prevent the high sugars, you would have to prevent the bottoming out. We typically tell patients who have the Somoygi effect to have a more extended, more complex protein or carbohydrate before bedtime. That would eliminate the bottoming out and therefore the high sugars in the morning.
Member: My soon to be 13-year-old daughter wants to start pumping; the rep from MiniMed has been to our home and the demonstration has really made us excited about the pump. Our endocrinologist has told us we must go to the hospital to get started. I would like to see my daughter start at home under the supervision of the RN. We live less than a half mile to the local hospital and I feel that if we have an emergency we have the support here. The hospital the endocrinologist wants us to go to is 15 miles away. My question is what risks would we be taking if we were to start at home? I must add that emergencies may happen in the future and we must be prepared at all times so is the hospital a must in your opinion?
Nazario: I agree with you. There really is no contraindication to starting the pump at home, especially if you have an RN who is knowledgeable of diabetes, hypoglycemia, and the use of the pump. Years and years ago to start an insulin pump on patients we would hospitalize them. That was a total waste of time, basically. Many endocrinologists can start with the certified diabetic educator, the patient, the doctor, and the nutritionist as a team approach on an outpatient basis. Many times they can start the pump with sterile normal saline, so that the patient has experience dealing technically with the machine.
So I'm on your side. I don't see why you can't start an insulin pump therapy in a step-wise fashion at home. One day here's the pump, explain the pump; the following day explain insulin to carb ratios, explain basal rates and boluses; the following day maybe start with hooking up the pump with sterile saline, and dealing with different possible scenarios that might occur. Then choose a startup day and start the pump.
That means that somebody needs to be on call to receive phone calls for questions or emergencies -- the doctor or the certified diabetic educator, but other than that, there's really no reason a pump could not be done on an outpatient basis. It's actually done all the time.
Member: My mother was just recently place on Humulin 70/30 and injects approximately 40u in the morning and 40u in the evening. I am very concerned because her blood sugar levels are not stabilizing. The doctor is suspecting her kidneys of not functioning properly. I am so scared, my mom is young (47 years old) and all I can think about is all the scary complications that can occur (renal failure, dialysis, death). Is it OK to be so scared, is it normal, is there anything I can do to make her feel better?
Nazario: I think that it's OK to be scared. It's a complicated disease and all we hear about are all the bad complications that occur to patients that have diabetes. What you and your mother can do is to become more knowledgeable about the disease, and with that knowledge you'll feel a lot more comfortable with her having diabetes.
I agree with you that the dose of 70/30 seems a little unusual; in essence, they're giving her 80 units of insulin, half in the morning and half in the evening. The recommendations are usually two-thirds in the morning and one-third in the evening. I'm not sure what your mother's weight is, but there is a certain amount of insulin per weight that is used to figure out how much insulin a person needs. It doesn't seem that that was done.
You also said that she had kidney problems and with kidney problems, insulin tends to hang around a lot longer. She needs to have her insulin dose given to her a little bit more the way experienced diabetic specialists dictate, with more in the morning and less in the evening; and
she needs a dose based on what her weight is and the fact that she has kidney problems. If she's not with an endocrinologist/diabatologist, I would probably get her there.
Moderator: Our thanks to Brunilda Nazario, MD, for sharing her expertise with us today.
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