Type 2 Diabetes
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Type 2 Diabetes

Chinese medicine has a great deal to offer those with Type 2 Diabetes (DMII). Much can be done with simple food-as-medicine for obesity, dyslipidemia, hypertension, and insulin resistance/ elevated blood sugar levels. This combination is called Metabolic Syndrome- which is often comorbid with DMII.  

Chinese herbs can lessen the risk for or reverse complications associated with the disease [e.g. peripheral neuropathy and nephropathy]. Herbs can decrease medication dose [and side effects] and/or the need for more than one drug to manage the disease and/or insulin-dependance. The goal of herbal therapy can be to ameliorate the overall morbidity associated with the disease. For information on know how Chinese herbal medicine ameliorates type 2 diabetes see EVENTS.

Risk factors for getting DMII are obesity, inactivity & poor diet, race & familial history. Certain drugs/medications, as well as common and rare diseases also predispose people to DMII. Infections and inflammations are notorious for causing uncontrolled blood sugars in those at risk for DMII. 

DMII is a progressive disorder of glucose metabolism, primarily characterized by insulin resistance [IR]. IR is when cell membranes refuse to recognize the insulin that wants to carry sugar into cells- sugar remains in the blood stream as the cells are sending a message that they desperately need sugar inside. In response to them, the pancreas pumps out even more insulin - hyperinsulinemia despite hyperglycemia. The liver starts creating glucose [gluconeogenesis] and releasing stored glucose [glucagon]. The pancreas eventually gets tired leading to decreased insulin production. At this stage one oral drug looses its effectiveness- other drugs must be added. As the problem progresses, oral drugs alone are ineffective - insulin must be added. 

HbgA1c is the main lab test to determine if blood glucose levels (BGL) have been normal during the previous 3 months. The complete diagnostic criteria for DMII includes a fasting blood glucose level (FBGL) >125 mg/dL; HbgA1c >6.5%; an abnormal glucose tolerance test (GTT), or a random blood glucose level (RBGL) ≥200 mg/dL plus signs and symptoms. The 3 Ps, polyuria, polydipsia, and polyphagia are the classic symptoms. 

The metabolic derangements of DMII may begin many years before symptoms appear. The goal is to nip pre-diabetes in the bud to prevent progression of MACROvascular damage [coronary, cerebral & peripheral vascular disease], and MICROvascular damage [retinopathy, nephropathy, and neuropathy]. The metabolic derangements seen with DMII are often part of what is called "Metabolic Syndrome", which includes diabetes, hypertension, dyslipidemia, and abdominal obesity.

People with diabetes have greater chance of dying from heart attack or stroke due to micro/macro vascular damage. Standard of care to lower CVD risk include tight blood sugar control, blood pressure control, lipid control with Statin drugs, anti-platelet therapy with aspirin [for certain risk groups], and drugs to prevent renal damage.

Weight-Management & Diet
Therapeutic lifestyle changes are 1st line therapy for pre-diabetes and DMII to include diet, and exercise. For those with a BMI >30 plus metabolic syndrome, stress is placed on losing 5-10% of body weight. And increasing physical activity to 150 minutes per week of interval training (combined cardio-aerobic and weight resistance) 3 times per week. Also reinforced is carbohydrate counting, carbohydrate exchange diet, and nutritional counseling.

Medically prescribed diet, such as the Very Low Carbohydrate Diet (VLCD) are for rapid weight loss in patients with BMI >30 (>27 if obesity presents serious health risks). There is research that it also improves insulin sensitivity, but there is risk of deadly metabolic acidosis for those on Metformin. The Mediterranean Diet is good maintenance. Pre/Probiotics are receiving attention for their role in weight management, and ameliorating non alcoholic fatty liver disease [comorbid with insulin resistance]. Branched chain amino acids (BCAA) may also improve insulin sensitivity in obese individuals.

Glycemic Control Drugs
Drugs are prescribed if blood glucose levels (BGLs) are not controlled with lifestyle & diet modifications. Metformin (a biguanide) may be prescribed first, up to 2000mg daily. If BGL does not reach goal, a sulfonylurea (e.g. Glimepiride, Glipizide), or a meglitinide (e.g. Prandin, Starlix) may be added. If BGLs are still not at goal with a 2-drug combination, then basal insulin or a 2nd/ 3rd line drug is added. Januvia, a DPP4 alpha glucosidase inhibitor and Byetta, a glucagon-like peptide agonist/GLP-1, are 2nd line drugs. Actos (Poglitazone), a thiazolidinedione, is a 3rd line drug. Many of these oral diabetic medications have GI, CV, renal and liver side-effects or cause weight gain.

Elevated BGLs may stabilize once an infection or chronic inflammation is addressed (e.g. UTIs, periodontal disease). Insulin resistance can also be an adverse reaction associated with estrogen-progestin oral contraceptive such as Ortho tri-cyclen-28. 

Antihypertensive Drugs
The American Diabetes Association recommends an ACE inhibitor drugs or angiotenin-II receptor blockers [ARBS] for those with DM and hypertension. The ACE-inhibitor called Lisinopril has the added benefit of being protective against diabetic nephropathy. ACE-inhibitors may increase the risk for hypoglycemia when used in conjunction with a sulfonylurea drug (e.g. Glimepiride) or a meglitinide (e.g. Prandin, Starlix). Beta-blockers are avoided because they can mask symptoms of hypoglycemia in those with diabetes.

Antiplatelet Drugs
The American Diabetes Association recommends aspirin therapy for primary care and prevention in adult males over 50 years of age with DMII, or for those with CVD risk factors plus a high Framingham score. The Framingham score is based on HDL, age, sex, height & weight, and smoking status plus at least 2 other CV risk factors. It measures the likelihood of having a cardiovascular event within the next ten years.

Anti-hyperlipidemic Drugs
Statins are 2nd line therapy (behind lifestyle modifications) for dyslipidemia. If cholesterol is not managed on a statin drugs, then niacin or a bile acid sequesterant is added as 3rd line therapy. Cycloset is a bile acid sequesterant used specifically for diabetics (Edmunds, Winterton & Maren, 2013, p. 590). Fibric acid derivatives are adjunctive 3rd line therapy, and ezetimibe (Byetta) is 4th line therapy (Epocrates Online).

Screens & Labs
All patients with a BMI > 25 who have more than one risk factor, should be regularly screened and followed-up for DMII. In the absence of risk factors, screening should begin at 45 years of age with repeated testing every 3 years. If a person has been on target with continuity of care, success of the treatment plan ultimately depends on their compliance with weight loss, lifestyle modifications, and medications.

Self-monitoring fasting and post-prandial BGLs helps determine the effectiveness of a treatment plan. This monitoring also helps determine which medication(s) and dose is best.  For example, a meglitinide (e.g. Prandin) is indicated for elevated post-prandial BGL with low FBGL. There are many screens and labs, but the HbgA1c is measured at regular intervals until BGL is regulated. The HOMA score screens for the effectiveness of interventions to improve insulin resistance and/or to determine insulin regimens.

Edmunds, M., Winterton, M. & Maren, S. (2013). Pharmacology for the primary care
       provider (4th ed.). St. Louis, MO: Elsevier Mosby.
Epocrates Online.(2014). Adult type II diabetes: Treatment details.
Mayo Clinic. Cholesterol levels: What numbers should you aim for. In Diseases and
       Conditions. Retrieved from http://www.mayoclinic.org/diseases-conditions/high
National Institute of health, National Lung, Heart and Blood Institute. Risk assessment
     tool for estimating your 10-year risk of having a heart attack. Retrieved from
Nursing Drug Handbook. Ortho tri-cyclen-28: Adverse reactions. Digital Android

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