Diabetes Treatment & Care

Treatment & Care

Diabetes is a common disease, yet every individual needs unique care. We encourage people with diabetes and their families to learn as much as possible about the latest medical therapies and approaches, as well as healthy lifestyle choices. Good communication with a team of experts can help you feel in control and respond to changing needs.

Blood Glucose Testing

Blood glucose (blood sugar) is an essential measure of your health. If you're struggling to manage your blood glucose levels, we can help! With the latest tools and strategies, you can take steps today to monitor your condition, prevent serious complications and feel better while living with diabetes.

Medication

Insulin & Other Injectables

Insulin is a naturally occurring hormone secreted by the pancreas. Many people with diabetes are prescribed insulin, either because their bodies do not produce insulin (type 1 diabetes) or do not use insulin properly (type 2 diabetes).

There are more than 20 types of insulin sold in the United States. These insulins differ in how they are made, how they work in the body, and how much they cost. Your doctor will help you find the right type of insulin for your health needs and your lifestyle.

What About Insulin?

Although it is a common practice to try pills before insulin, you may start on insulin based on several factors, including the following:

How long you have had diabetes
How high your blood glucose level is
What other medicines you take
Your overall health
Combination Therapy

Because diabetes pills seem to help the body use insulin better, some people take them along with insulin shots. The idea behind this "combination" therapy is to try to help insulin work better

Insulin Basics

There are different types of insulin depending on how quickly they work, when they peak, and how long they last.
Insulin is available in different strengths; the most common is U-100.
All insulin available in the United States is manufactured in a laboratory, but animal insulin can still be imported for personal use.
Inside the pancreas, beta cells make the hormone insulin. With each meal, beta cells release insulin to help the body use or store the blood glucose it gets from food.

In people with type 1 diabetes, the pancreas no longer makes insulin. The beta cells have been destroyed and they need insulin shots to use glucose from meals.

People with type 2 diabetes make insulin, but their bodies don't respond well to it. Some people with type 2 diabetes need diabetes pills or insulin shots to help their bodies use glucose for energy.

Insulin cannot be taken as a pill because it would be broken down during digestion just like the protein in food. It must be injected into the fat under your skin for it to get into your blood. In some rare cases insulin can lead to an allergic reaction at the injection site. Talk to your doctor if you believe you may be experiencing a reaction.

Types of Insulin

Rapid-acting insulin, begins to work about 15 minutes after injection, peaks in about 1 hour, and continues to work for 2 to 4 hours. Types: Insulin glulisine (Apidra), insulin lispro (Humalog), and insulin aspart (NovoLog)
Regular or Short-acting insulin usually reaches the bloodstream within 30 minutes after injection, peaks anywhere from 2 to 3 hours after injection, and is effective for approximately 3 to 6 hours. Types: Humulin R, Novolin R
Intermediate-acting insulin generally reaches the bloodstream about 2 to 4 hours after injection, peaks 4 to 12 hours later, and is effective for about 12 to 18 hours. Types: NPH (Humulin N, Novolin N)
Long-acting insulin reaches the bloodstream several hours after injection and tends to lower glucose levels fairly evenly over a 24-hour period. Types: Insulin detemir (Levemir) and insulin glargine (Lantus)
Premixed insulin can be helpful for people who have trouble drawing up insulin out of two bottles and reading the correct directions and dosages. It is also useful for those who have poor eyesight or dexterity and is convenient for people whose diabetes has been stabilized on this combination.

Characteristics of Insulin

Insulin has 3 characteristics:

Onset is the length of time before insulin reaches the bloodstream and begins lowering blood glucose.
Peaktime is the time during which insulin is at maximum strength in terms of lowering blood glucose.
Duration is how long insulin continues to lower blood glucose.
Insulin Strength

All insulins come dissolved or suspended in liquids. The standard and most commonly used strength in the United States today is U-100, which means it has 100 units of insulin per milliliter of fluid, though U-500 insulin is available for patients who are extremely insulin resistant.

U-40, which has 40 units of insulin per milliliter of fluid, has generally been phased out around the world, but it is possible that it could still be found in some places (and U-40 insulin is still used in veterinary care).

Insulin Routines

Insulin is required for people with type 1 diabetes and sometimes necessary for people with type 2 diabetes.
Syringe is the most common form of insulin delivery, but there are other options, including insulin pens and pumps.
Insulin should be injected in the same general area of the body for consistency, but not the exact same place.
Insulin delivery should be timed with meals to effectively process the glucose entering your system.
Insulin Therapy

With the help of your health care team, you can find an insulin routine that will keep your blood glucose near normal, help you feel good, and fit your lifestyle.

Type 1

People diagnosed with type 1 diabetes usually start with two injections of insulin per day of two different types of insulin and generally progress to three or four injections per day of insulin of different types. The types of insulin used depend on their blood glucose levels. Studies have shown that three or four injections of insulin a day give the best blood glucose control and can prevent or delay the eye, kidney, and nerve damage caused by diabetes.

Type 2

Most people with type 2 diabetes may need one injection per day without any diabetes pills. Some may need a single injection of insulin in the evening (at supper or bedtime) along with diabetes pills. Sometimes diabetes pills stop working, and people with type 2 diabetes will start with two injections per day of two different types of insulin. They may progress to three or four injections of insulin per day.

Fine-Tuning Your Blood Glucose

Many factors affect your blood glucose levels, including the following:

What you eat
How much and when you exercise
Where you inject your insulin
When you take your insulin injections
Illness
Stress
Self Monitoring

Checking your blood glucose and looking over results can help you understand how exercise, an exciting event, or different foods affect your blood glucose level. You can use it to predict and avoid low or high blood glucose levels. You can also use this information to make decisions about your insulin dose, food, and activity.

Insulin Delivery

Many people who take insulin use a syringe, but there are other options as well.

Insulin Pens

Some insulin pens contain a cartridge of insulin that is inserted into the pen and some are pre-filled with insulin and discarded after all the insulin has been used. The insulin dose is dialed on the pen, and the insulin is injected through a needle, much like using a syringe. Cartridges and pre-filled insulin pens only contain one type of insulin. Two injections must be given with an insulin pen if using two types of insulin.

Pump Therapy

Insulin pumps help you manage diabetes by delivering insulin 24 hours a day through a catheter placed under the skin.

Site Rotation

The place on your body where you inject insulin affects your blood glucose level. Insulin enters the blood at different speeds when injected at different sites. Insulin shots work fastest when given in the abdomen. Insulin arrives in the blood a little more slowly from the upper arms and even more slowly from the thighs and buttocks. Injecting insulin in the same general area (for example, your abdomen) will give you the best results from your insulin. This is because the insulin will reach the blood with about the same speed with each insulin shot.

Don't inject the insulin in exactly the same place each time, but move around the same area. Each mealtime injection of insulin should be given in the same general area for best results. For example, giving your before-breakfast insulin injection in the abdomen and your before-supper insulin injection in the leg each day give more similar blood glucose results. If you inject insulin near the same place each time, hard lumps or extra fatty deposits may develop. Both of these problems are unsightly and make the insulin action less reliable. Ask your health care provider if you aren't sure where to inject your insulin.

Timing

Insulin shots are most effective when you take them so that insulin goes to work when glucose from your food starts to enter your blood. For example, regular insulin works best if you take it 30 minutes before you eat.

Too much insulin or not enough?

High morning blood glucose levels before breakfast can be a puzzle. If you haven't eaten, why did your blood glucose level go up? There are two common reasons for high before-breakfast blood glucose levels. One relates to hormones that are released in the early part of sleep (called the Dawn Phenomenon). The other is from taking too little insulin in the evening. To see which one is the cause, set your alarm to self-monitor around 2 or 3 a.m. for several nights and discuss the results with your health care provider.

Explore: Insulin & Other Injectables

Insulin Storage and Syringe Safety
Follow these tips for storing insulin, using syringes, and keeping the supplies you need to your manage diabetes.

Insulin Pumps

Is an insulin pump right for you? Consider the pros and cons.

Advantages of Using an Insulin Pump

Disadvantages of Using an Insulin Pump

Although there are many good reasons to use an insulin pump, there are some disadvantages.

How Do Insulin Pumps Work?

Insulin pumps deliver rapid- or short-acting insulin 24 hours a day through a catheter placed under the skin.

Getting Started with an Insulin Pump

You don't need to be an expert on insulin pumps overnight. If you are uncertain about anything, you can go to your diabetes care team for help.

Other Injectable Medications

Oral Medication

The first treatment for type 2 diabetes blood glucose (sugar) control is often meal planning, weight loss, and exercising.

Sometimes these measures are not enough to bring blood glucose levels down near the normal range. The next step is taking a medicine that lowers blood glucose levels


Can Diabetes Pills Help Me?

Only people with type 2 diabetes can use pills to manage their diabetes, people with type 1 diabetes must use insulin.

These pills work best when used with meal planning and exercise. This way you have three therapies working together to lower your blood glucose levels.

Diabetes pills don't work for everyone. Although most people find that their blood glucose levels go down when they begin taking pills, their blood glucose levels may not go near the normal range.

Will They Help?

What are the chances that diabetes pills will work for you? Your chances are low if you have had diabetes for more than 10 years or already take more than 20 units of insulin each day. On the other hand, your chances are good if you developed diabetes recently or have needed little or no insulin to keep your blood glucose levels near normal.

Diabetes pills sometimes stop working after a few months or years. The cause is often unknown. This doesn't mean your diabetes is worse. When this happens, oral combination therapy can help.

Even if diabetes pills do bring your blood glucose levels near the normal range, you may still need to take insulin if you have a severe infection or need surgery. Pills may not be able to control blood glucose levels during these stressful times when blood glucose levels shoot up.

Also, if you plan to become pregnant, you will need to control your diabetes with diet and exercise or with insulin. It is not safe for pregnant women to take oral diabetes medications.

There is no "best" pill or treatment for type 2 diabetes. You may need to try more than one type of pill, combination of pills, or pills plus insulin.

My Medicine Tracker

My Medicine Tracker is a free medication monitoring service for patients brought to you by the American Diabetes Association.

It allows you to:

Track and print a list of all your medications, both prescription and over the counter
View safety information regarding side effects and when combining medications may not be advisable
Receive email alerts and updates on important safety information about medications

What Are My Options?

There are different types, or classes, of drugs that work in different ways to lower blood glucose (blood sugar) levels:

Sulfonylureas
Biguanides
Meglitinides
Thiazolidinediones
DPP-4 inhibitors
SGLT2 Inhibitors
Alpha-glucosidase inhibitors
Bile Acid Sequestrants

Sulfonylureas

Sulfonylureas stimulate the beta cells of the pancreas to release more insulin. Sulfonylurea drugs have been in use since the 1950s. Chlorpropamide (Diabinese) is the only first-generation sulfonylurea still in use today. The second generation sulfonylureas are used in smaller doses than the first-generation drugs. There are three second-generation drugs: glipizide (Glucotrol and Glucotrol XL), glyburide (Micronase, Glynase, and Diabeta), and glimepiride (Amaryl). These drugs are generally taken one to two times a day, before meals. All sulfonylurea drugs have similar effects on blood glucose levels, but they differ in side effects, how often they are taken, and interactions with other drugs.

Biguanides

Metformin (Glucophage) is a biguanide. Biguanides lower blood glucose levels primarily by decreasing the amount of glucose produced by the liver. Metformin also helps to lower blood glucose levels by making muscle tissue more sensitive to insulin so glucose can be absorbed. It is usually taken two times a day. A side effect of metformin may be diarrhea, but this is improved when the drug is taken with food.

Meglitinides

Meglitinides are drugs that also stimulate the beta cells to release insulin. Repaglinide (Prandin) and nateglinide (Starlix) are meglitinides. They are taken before each of three meals.

Because sulfonylureas and meglitinides stimulate the release of insulin, it is possible to have hypoglycemia (low blood glucose levels).

You should know that alcohol and some diabetes pills may not mix. Occasionally, chlorpropamide and other sulfonylureas, can interact with alcohol to cause vomiting, flushing or sickness. Ask your doctor if you are concerned about any of these side effects.

Thiazolidinediones

Rosiglitazone (Avandia) and pioglitazone (ACTOS) are in a group of drugs called thiazolidinediones. These drugs help insulin work better in the muscle and fat and also reduce glucose production in the liver. The first drug in this group, troglitazone (Rezulin), was removed from the market because it caused serious liver problems in a small number of people. So far rosiglitazone and pioglitazone have not shown the same problems, but users are still monitored closely for liver problems as a precaution. Both drugs appear to increase the risk for heart failure in some individuals, and there is debate about whether rosiglitazone may contribute to an increased risk for heart attacks. Both drugs are effective at reducing A1C and generally have few side effects.

DPP-4 Inhibitors

A new class of medications called DPP-4 inhibitors help improve A1C without causing hypoglycemia. They work by by preventing the breakdown of a naturally occurring compound in the body, GLP-1. GLP-1 reduces blood glucose levels in the body, but is broken down very quickly so it does not work well when injected as a drug itself. By interfering in the process that breaks down GLP-1, DPP-4 inhibitors allow it to remain active in the body longer, lowering blood glucose levels only when they are elevated. DPP-4 inhibitors do not tend to cause weight gain and tend to have a neutral or positive effect on cholesterol levels. Sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Tradjenta), alogliptin (Nesina) are the DPP-4 inhibitors currently on the market in the US.

SGLT2 Inhibitors

Glucose in the bloodstream passes through the kidneys, where it can either be excreted or reabsorbed.   Sodium-glucose transporter 2 (SGLT2) works in the kidney to reabsorb glucose, and a new class of medication, SGLT2 inhibitors, block this action, causing excess glucose to be eliminated in the urine. Canagliflozin (Invokana) and dapagliflozin (Farxiga) are SGLT2 inhibitors that have recently been approved by the FDA to treat type 2 diabetes.  Because they increase glucose levels in the urine, side effects can include urinary tract and yeast infections.

Alpha-glucosidase inhibitors

Acarbose (Precose) and miglitol (Glyset) are alpha-glucosidase inhibitors. These drugs help the body to lower blood glucose levels by blocking the breakdown of starches, such as bread, potatoes, and pasta in the intestine. They also slow the breakdown of some sugars, such as table sugar. Their action slows the rise in blood glucose levels after a meal. They should be taken with the first bite of a meal. These drugs may have side effects, including gas and diarrhea.

Bile Acid Sequestrants

The bile acid sequestrant (BAS) colesevelam (Welchol) is a cholesterol-lowering medication that also reduces blood glucose levels in patients with diabetes.  BASs help remove cholesterol from the body, particularly LDL cholesterol, which is often elevated in people with diabetes.  The medications reduce LDL cholesterol by binding with bile acids in the digestive system; the body in turn uses cholesterol to replace the bile acids, which lowers cholesterol levels. The mechanism by which colesevelam lowers glucose levels is not well understood. Because BASs are not absorbed into the bloodstream, they are usually safe for use by patients who may not be able to use other medications because of liver problems. Because of the way they work, side effects of BASs can include flatulence and constipation.

Oral combination therapy

Because the drugs listed above act in different ways to lower blood glucose levels, they may be used together. For example, a biguanide and a sulfonylurea may be used together. Many combinations can be used. Though taking more than one drug can be more costly and can increase the risk of side effects, combining oral medications can improve blood glucose control when taking only a single pill does not have the desired effects. Switching from one single pill to another is not as effective as adding another type of diabetes medicine.

My Medicine Tracker

My Medicine Tracker is a free medication monitoring service for patients brought to you by the American Diabetes Association.

It allows you to:

Track and print a list of all your medications, both prescription and over the counter
View safety information regarding side effects and when combining medications may not be advisable
Receive email alerts and updates on important safety information about medications
Interact with others to share experiences with medications

Is There a Danger of Interactions?

In general, diabetes pills are safe and work well. But like any other drug, they must be used with care.

All diabetes pills can interact with other medicines. Because of the chance of medication interactions, you need to tell your doctor about all medicines you are taking. While you're taking diabetes pills, you should check with your doctor before starting anything new — even over-the-counter items.

Any sulfonylurea or meglitinide can cause blood glucose levels to drop too low (hypoglycemia).

Metformin or the glitazones rarely cause hypoglycemia unless taken with insulin stimulators (sulfonylureas or repaglinide) or insulin injections.

Acarbose or miglitol, taken as prescribed, does not cause hypoglycemia. However, hypoglycemia can occur when acarbose or meglitol is taken in combination with other diabetes medications.

My Medicine Tracker

My Medicine Tracker is a free medication monitoring service for patients brought to you by the American Diabetes Association.

It allows you to:

Track and print a list of all your medications, both prescription and over the counter
View safety information regarding side effects and when combining medications may not be advisable
Receive email alerts and updates on important safety information about medications
Interact with others to share experiences with medications

Other Treatments

Aspirin, flu shots, dietary supplments, and more are covered in this section on treatments that people living with diabetes may find beneficial.

Mobile Prescription Therapy

Smartphones and tablet computers are a new way to deliver diabetes therapy. The Food and Drug Administration (FDA) calls this new type of therapy “mobile prescription therapy.”

Mobile prescription therapy (MPT) products tell you what to do to take care of your diabetes. The advice shows up on your smartphone or other device.

Herbs, Supplements and Alternative Medicines

Herbal Supplements

It is best to get vitamins and minerals from the foods you eat. In fact, research has not been able to prove that dietary or herbal supplements (including omega-3 supplements, cinnamon, and other herbs) help to manage diabetes. 

Still, more and more people use dietary supplements. And studies show that people with diabetes are more likely to use supplements than people without diabetes.

The National Health Interview Survey found that 22 percent of people with diabetes used some type of herbal therapy, while another study found that 31 percent used dietary supplements.

Certain ethnic groups, such as Hispanics, Native Americans, Asians, and African Americans are also more likely to use dietary supplements.

Using Supplements Safely

If you’re one of the many people taking dietary supplements, you’re probably concerned about doing the right thing for your body.

However, finding reliable information about the benefits and safety of these products is difficult. There are hundreds of dietary supplements—each purporting their own health benefits.

Unfortunately, the US does not have a system for testing the effectiveness of supplements.

Oral Health and Hygiene

There are more bacteria in your mouth right now than there are people on Earth. If those germs settle into your gums, you've got gum disease. Unfortunately, if you have diabetes, you are at higher risk for gum problems. Poor blood glucose control makes gum problems more likel

Diabetes and Oral Health Problems

The more severe form of gum disease is called periodontitis. When you reach this stage, your gums begin to pull away from your teeth. Pockets form between your teeth and gums. These fill with germs and pus, and deepen. When this happens, you may need gum surgery to save your teeth. If nothing is done, the infection goes on to destroy the bone around your teeth. The teeth may start to move or get loose. Your teeth may fall out or need to be pulled.

Is There an Association Between Gum Disease and Diabetes?

For the nearly 30 million Americans who have diabetes, many may be surprised to learn about an unexpected complication associated with this condition. Research shows that there is an increased prevalence of gum disease among those with diabetes, adding serious gum disease to the list of other complications associated with diabetes, such as heart disease, stroke and kidney disease.

Is There a Two-Way Street?

Emerging research also suggests that the relationship between serious gum disease and diabetes is two-way. Not only are people with diabetes more susceptible to serious gum disease, but serious gum disease may have the potential to affect blood glucose control and contribute to the progression of diabetes. Research suggests that people with diabetes are at higher risk for oral health problems, such as gingivitis (an early stage of gum disease) and periodontitis (serious gum disease). People with diabetes are at an increased risk for serious gum disease because they are generally more susceptible to bacterial infection, and have a decreased ability to fight bacteria that invade the gums.

The Surgeon General's Report on Oral Health states that good oral health is integral to general health. So be sure to brush and floss properly and see your dentist for regular checkups.

If I Have Diabetes, am I at Risk for Dental Problems?

If your blood glucose levels are poorly controlled, you are more likely to develop serious gum disease and lose more teeth than non-diabetics. Like all infections, serious gum disease may be a factor in causing blood sugar to rise and may make diabetes harder to control.

Other oral problems associated to diabetes include: thrush, an infection caused by fungus that grows in the mouth, and dry mouth which can cause soreness, ulcers, infections and cavities.

How Can I Help Prevent Dental Problems Associated with Diabetes?

First and foremost, control your blood glucose level. Then, take good care of your teeth and gums, along with regular checkups every six months. To control thrush, a fungal infection, maintain good diabetic control, avoid smoking and, if you wear them, remove and clean dentures daily. Good blood glucose control can also help prevent or relieve dry mouth caused by diabetes.

What Can I Expect at My Checkup? Should I Tell My Dental Professional About My Diabetes?

People with diabetes have special needs and your dentist and hygienist are equipped to meet those needs—with your help. Keep your dentist and hygienist informed of any changes in your condition and any medication you might be taking. Postpone any non-emergency dental procedures if your blood sugar is not in good control.

Gum Disease and Plaque

When you have gum disease, germs work to destroy your gums (gingiva) and the bone around your teeth. It starts with plaque. Plaque is a sticky film of food, saliva, and germs. Plaque loves to settle at the gum line. There, germs get busy making your gums red, tender, and likely to bleed.

The goal of your daily tooth brushing and flossing is to clean away plaque. When plaque stays put, it hardens into tartar. Tartar builds up under the gum line. More plaque forms over the tartar. Only your dentist or dental hygienist can get tartar off your teeth.

If plaque and tartar are not cleaned away, even gentle brushing can cause your gums to bleed. This is called gingivitis. It is the first stage of gum disease. You can fight gingivitis with:

daily good brushing and flossing habits, and
getting your teeth cleaned at least twice a year at your dentist's office.
If you ignore gingivitis, the gum disease gets worse.

The more severe form of gum disease is called periodontitis. When you reach this stage, your gums begin to pull away from your teeth. Pockets form between your teeth and gums. These fill with germs and pus, and deepen. When this happens, you may need gum surgery to save your teeth. If nothing is done, the infection goes on to destroy the bone around your teeth. The teeth may start to move or get loose. Your teeth may fall out or need to be pulled.

Warning Signs

As if this is not enough, diabetes can make things worse. Plaque is the main bad guy of gum disease. But diabetes can also be a culprit. Diabetes may weaken your mouth's germ-fighting powers. High blood sugar levels can help the gum disease get worse. At the same time, gum disease can make diabetes harder to control.

Often gum disease is painless. You may not even know you have it until you have some serious damage. Regular dentist visits are your best weapon.

While gum disease may not hurt, there are warning signs to watch for.

Bleeding gums when you brush or floss. This bleeding is not normal. Even if your gums don't hurt, get them checked.
Red, swollen, or tender gums.
Gums that have pulled away from teeth. Part of the tooth's root may show, or your teeth may look longer.
Pus between the teeth and gums (when you press on the gums).
Bad breath.
Permanent teeth that are loose or moving away from each other.
Changes in the way your teeth fit when you bite.
Changes in the fit of partial dentures or bridges