Diabetes Self-Management Articles

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The Right Drug at the Right Dose
How Doctors Decide What to Prescribe

by Mark T. Marino, MD

Following up
After a diagnosis is made and a course of therapy is decided upon, the next step is to see if it is effective. Depending on the condition and the therapy, a person might follow up with his doctor the next day, within several days, within a week or two, or after a month or more. When the diagnosis is diabetes, follow-up appointments are a time to see how well a person’s blood glucose is controlled and make changes to the diabetes drug regimen, if necessary.

Once an effective drug and lifestyle regimen has been established, the HbA1c test is used periodically to see whether the regimen continues to be effective. In addition, tests and examinations for long-term diabetes complications such as kidney disease, retinopathy, neuropathy, and cardiovascular disease should be done periodically.

People with diabetes also do their own follow-up in the form of blood glucose self-monitoring. The recommended frequency for monitoring depends on the treatment: People who take insulin are usually advised to monitor more frequently than those who use diet and exercise to lower their blood glucose and those who take pills. Common times to monitor are before meals, two hours after meals, at bedtime, and any time a person has symptoms of hypoglycemia. More frequent monitoring may be necessary during an illness, during pregnancy, or in other special situations.

The advent of continuous glucose monitors has allowed some people to keep even closer tabs on their glucose levels. Continuous glucose monitors measure the glucose level of interstitial fluid — the fluid found between cells — in the fatty layer of tissue just below the skin. They give glucose values every five minutes throughout the day and are particularly useful for showing whether the glucose level is rising or falling. This allows a person to take action before hypoglycemia or very high glucose occurs. Studies with continuous monitors have shown that their use can result in improved diabetes control and a lower HbA1c.

What lies ahead
In the future, doctors may have other ways of determining what treatment will be most effective for the individual.

Genetics. Some day, genetic tests may be used routinely to determine the best drug treatment for the individual. Already, studies have shown that individuals may react differently to certain drugs based on genetic variations, and for some drugs, genetic tests are already available to help physicians determine what dose should be administered or if the drug is safe for the patient.

There’s a long way to go, however. At this point, scientists do not understand many of the functions that genes perform. In addition, medical science still does not know how many drugs cause their therapeutic effects. Much research in both of these areas is needed before DNA analysis can be used on a routine basis to tailor drug therapy.

Therapeutic drug monitoring. Tests to determine the level of drug in the blood and tests to determine if the drug is having its intended action are currently available for some drugs, but they will most likely be used more often in the future. One of the most common of these tests in use today is the INR (which stands for international normalized ratio), which shows how quickly a person’s blood clots. It is used when a person is prescribed the drug warfarin (Coumadin), which is taken to prevent blood clots. At too low a dose, a person’s blood may continue to form unwanted clots, and at too high a dose, the person can bleed to death. The test is done frequently at first, to establish an effective dose, and then less frequently, to make sure the dose is still effective.

An evolving picture
In diabetes care, as in life, change is inevitable. Bodies change over time, and lifestyles generally do, too, meaning that diabetes regimens need to change along with them. Having to do things differently can be frustrating when you feel that things were just fine the way they were. But change can also come as a relief, when new opportunities or options arise, or when you feel better as a result of it.

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