The goals management of Diabetes
mellitus are to 1) stop symptoms related to hyperglycemia (increase glucose) 2)
reduce the long term microvascular and macrovascular complication of diabetes
mellitus, and 3) normalized lifestyle as possible. The patient with diabetes
mellitus needs education and medicines to keep a normal level of glucose, and
management of diabetes related complications. Symptoms of diabetes mellitus are
resolved when it normalized glucose levels. The management of diabetes mellitus
patients need a multidisciplinary team. Patient’s input associated with primary
care providers and need subspecialists to treat complications and management of
diabetes mellitus are necessary.
The
ongoing aspect of comprehensive diabetes care
We will discuss different
terminology such as intensive insulin therapy, intensive glycemic control, and
comprehensive diabetes care, to focus on optimal diabetic care. The morbidity
and mortality can be prevented by getting over the diabetic complications. Many
diabetic patients did not receive adequate comprehensive diabetes care. Many
aspects should need to address as social, cultural, job, finance in
comprehensive care. The international diabetes federation
(IDF) has issued guidelines for comprehensive care on medical management of
diabetes mellitus.
Lifestyle
management in diabetes care
The
American diabetes association
suggests lifestyle modification by 1. Diabetes self-management education and
diabetes self-management support 2.nutritional therapy 3.psycosocial care
Diabetes
self-management education and support
The diabetes educator should be a
health care professional. Gives patient-centered education including self-monitoring
blood glucose, urine ketone monitoring insulin administration, prevention of
hypoglycemia foot, and skincare
Nutrition
therapy
Medical nutrition therapy consists
of caloric intake with other aspects of diabetes therapy such as insulin, exercise,
weight loss, and nursing management of diabetes mellitus. Current practice has
much changed MND. Now, includes little bit sucrose and fruits to modify the
risk factors such as hyperlipidemia and hypertension. Glycemic index term used
for postprandial glucose rise after eating food to improve glycemic control.
The ADA suggests MND and SMBG should be integrated to give insulin therapy. And
should be flexible for other aspects of therapy. In type 2 diabetes aim of MND
is to reduce weight because most people with Diabetes mellitus type 2 have
obesity so reduce caloric intake. Fasting for religious purposes should take
advice from health professionals before going on.
Physical
activity
Exercise has many benefits such as
reduces heart disease, weight loss, blood pressure, maintain muscle mass. ADA
recommends exercise 150 minutes per week. Although its fruitful, exercise may
produce hyperglycemia or hypoglycemia. To avoid these complications a person
should monitor his blood glucose before, during, and after exercise.
Psychological
care
Diabetes mellitus patients should be
an essential part of the diabetes care team. Emotional stress may stimulate
change in behavior, so adherence to diet exercise, or therapeutic regimen.
Monitor
glycemic control
Glycemic control involves HBA1c
which reflects average blood glucose of the previous 2-3 months.
Self-monitoring
of blood glucose
SMBG is standard care in the
management of diabetes mellitus with insulin and allows him /her to measure
blood glucose at any time. Capillary blood glucose combined with diet and
exercise help physician to select medication. Type 1 diabetes mellitus needs to
measure 10 times in a day. Type 2 diabetes mellitus require less frequent
monitoring. Devices for continuous glucose monitoring measure interstitial
fluid which is close to plasma glucose. In type 1 diabetes mellitus it’s used
is quickly rising because it alerts on hypo or hyperglycemia. Open-loop devices
that are adjusted dosage by the patient and closed-loop devices which is
automatic is approved by US food and drug administration.
Assessment
of long glycemic control
HBA1c is a standard method to
measure of prior 2-3 months of blood glucose. In other methods like SMBG and
CGM have up and downs in blood glucose so it correct lacunae. Clinical
condition who has abnormal RBC such as hemoglobinopathies, anemia,
reticulocytosis, transfusions, uremia may alter HBA1c. American diabetes association (ADA)
recommends measure HBA1c every 3 months to prevent complications of diabetes
mellitus.1,5-anhydroglycitol and fructosamine ( glycated albumin) reflect
glycemic control before 2 weeks.
Pharmacological
treatment of diabetes
Type 1 and 2 diabetes mellitus
patients should require on nutrition, exercise, and monitoring of glycemic
control.
Establishment of the target level of glycemic control.
The target level of glycemic control should be individualized depending upon
occupation, social, lifestyle, family support. Improvement in glycemic control
will lower diabetes mellitus complications, mostly microvascular. Our target
HBA1c should be <6.5 but those who prone to hypoglycemia target <7.5.
Type
1 diabetes mellitus
General
aspects
The insulin regime should mimic
physiological secretion. management of type 1 diabetes mellitus insulin
partially or completely deficiency so needs bolas administration of insulin.
Which is essential for glucose utilization of fat break-down, prevent
ketogenesis.
also see my blog on diabetes mellitus insulin vs glucose
Intensive
management
The intensive management goal is to
reach normal or near-normal glycemia. It is achieved by educating patients,
diet, exercise, and insulin regime. The insulin regime includes multiple daily
injections (MDIs), continuous subcutaneous infusion (CSII). It will reduce
acute and chronic microvascular complications of diabetes Mellitus, fetal
malformation, prolong c-peptide level, however it comes with a significant
personal and financial cost.
Insulin
preparations
Currently, the management of
diabetes mellitus with insulin prepared from recombinant DNA technology and
consists of an amino acid sequence of human insulin. Short-acting U-200(200
units per/ml) and long-acting U-300(300 units/ml) to limit volumes. Regular
insulin U-500 used for severe resistance to insulin. Short-acting insulin
lispro is an analogue in which 28 and 29th amino acid (lysine and proline) on B
chain reverse by DNA technology. Insulin Aspart and glulisine are modified
analogue. All three full biological active and less tendency to self
-aggregation, resulting in more rapid absorption. glargine insulin is a
long-acting aspargine is replaced by glycine at 21 amino acid, two arginine
residue are added to c terminal B chain. Its duration is 24 hours and less
peak. Detemir insulin has a fatty acid side chain bind to albumin and duration
12-20 hr.
Degludec insulin has a prolonged
duration of up to 42 hours. Short and long insulin can be prescribed to mimic
physiological insulin release.e.g. 70% NPH and 30% regular (70/30) or equal NPH
and regular(50/50). Although two times injection in a day is more convenient.
Besides, pen availability may help. Now newer inhalation insulin available can
be used in the patient where not contra-indicated like lung disease and smoker.
Long-acting insulin and glucagon-like peptide 1 (GLP-1) receptor agonist
combination (degludec + liraglutide ) or ( glargine+ lixisenatide)recently
available are effective.
Insulin
regime
Long-acting insulin( NPH, glargine
degludec, detemir) supply basal insulin, where regular, insulin aspart,
glulisine,lispro provide prandial insulin.short-acting should be injected just
before 10 minutes and regular insulin 30-45 minutes prior to a meal. No insulin
is a physiological cycle mimic however, short-acting insulin provides more
reliance. Type 1 diabetes mellitus requires 0.4-1 units/kg per day of insulin
divided into multiple dosages, with 50% of insulin given as basal insulin. MDI
regimes consist of basal and bolas insulin and the dose should be calculated by
anticipated food intake and exercise. Type 1 Diabetes mellitus dose calculated
by insulin to carbohydrate ratio 1 unit/ 10-15 g of carbohydrate, and it must
be an individual basis. Another formula is 1 unit of insulin for every 50 g
glucose and (body weight in kg) *[blood glucose-desired glucose in mg/dl]/1500.
Dosage should depend on insulin sensitivity.
NPH
mixed-used twice daily basis in
which 2/3 dosage given in morning time and 1/3 given in evening time. However,
the biggest problem is the rigid pattern of this regime, no flexibility, if a
person eats more carbohydrate then this regime will be failed.
management of diabetes mellitus guidelines, CSII very effective regime in which
short-acting insulin is infuses at various rates. Many advantages like
providing normal glucose levels throughout the day,
can adjust the dosage if SMBG is high or low. Disadvantages are blockage occurs
due to shorter duration of insulin it may develop diabetic ketoacidosis(DKA).
Currently sensor-based pump available in the USA so if the patient had
hypoglycemia then it automatically stopped the pump. A partially closed-loop
recently available however clinical experience is limited but the use is increasing.
Another
agent that improves glucose control
Amylin, a37 amino acid compound
which is co secreted by the pancreas . It blocks the action of glucagon and
delayed gastric emptying 1 diabetes mellitus 15 microgram injection before each
meal, and in type 2 diabetes mellitus 60 microgram injection and may titrate up
to 120. The major side effect is nausea vomiting.
see also my blog on managemet of COVID 19
Type
2 diabetes mellitus
Overview
Individuals with type 2 diabetes
need special attention to obesity, hypertension, dyslipidemia, and CVD. It
needs multiple approaches in management of diabetes mellitus type 2 such as
multiple drugs and lifestyle modification.
Medication
Medications have a different
mechanism of action, the category is increasing insulin secretion, reduce
glucose production, increase insulin sensitivity, enhance GLP-1 action, or
promote urinary excretion.
Biguanides
Metformin reduces hepatic glucose
production and increases peripheral glucose utilization. It activates
AMP-dependent protein kinase and decreases hepatic glucose production. Fasting
plasma glucose, improve lipid profile, and modest weight loss by metformin.
Fewer GI side effects (diarrhea, nausea vomiting) with sustained release. Watch
for vitamin b12 level and renal function test (GFR) maximum dosage is
2000mg/day and reduced dose if GFR <30.
Insulin
secretagogues-ATP K+ channel
It stimulates ATP sensitive
potassium channels and effective in < 5 years of diabetes mellitus type 2.
First-generation not used now. The second generation is rapid onset better
coverage but shorter half-life.
Glimepiride and glipizide can give a single dose. The main concern is
hypoglycemia and weight gain, so better to look in the elderly patient.
Insulin
secretagogues- GLP-1
GLP-1 receptor analog stimulates
glucose-dependent insulin secretion, so hypoglycemia less likely to occur.side
effects are weight loss and appetite suppression. Short actin is exanatide, lixisenatide.
Long-acting such as liraglutide, albiglutide, dulaglutide. Liraglutide is an FDA approved drug for obesity. It also
reduces CVD cardio-vascular disease and diabetic kidney disease. side effects
are GI intolerance and should not be used in the thyroid cancer patient. DPP-4
inhibitors inhibit the degradation of GLP-1 analogs.
Alpha-glucosidase
inhibitors
Alpha-glucosidase inhibitors
(voglibose) reduces postprandial glucose. It delaying glucose absorption and no
effect on insulin. Major side effects are diarrhea flatulence so not used in
gastroparesis or inflammatory bowel disease.
Thiazolidinediones
Reduce insulin resistance by
peroxisome proliferator-activated receptor y (PPAR-y). which is express in
adipocytes and regulates many genes, reduces hepatic fat accumulation, and
promotes fatty acid storage. In addition, it redistributes fat central to
peripheral. The main side effect is hepatic toxicity so do LFT before starting.
Although, rosiglitazone and pioglitazone do not appear liver abnormality.
Rosiglitazone raises LDL, HDL, and triglyceride. Is also develop weight gain,
edema, fracture, induce ovulation so contraindicate in CHF, liver disease,
PCOD, and not safe in pregnancy.
Sodium-glucose
cotransporter 2 inhibitor(SGLT-2)
These agents inhibit SGLT -2 and act
on proximal convoluted tubules. Reduced renal threshold and increase urinary
glucose secretion. Major side effects are urinary tract infection specifically
mycotic. reduction of volume leads to a decrease in systolic blood pressure.
Empaglifazone and canagliflozin reduce cardiac events but the risk for
nephropathy and CHF hospitalization.
Bile
acid-binding resins
Bile acid resins signaling through
nuclear receptors (colesevelam). It also used for hypercholesterolemia. The
most common side effect is GI and increases triglycerides.
Bromocriptine
This agent binds with dopamine
receptor agonist however role uncertain.
Insulin
therapy
Insulin should start early in lean, hospitalized, liver disease patients with
type 2 diabetes mellitus.
Longer-acting insulin 0.2-0.4/kg per day should start and 10% increment as
dictated by SMBG.
see my blog on obesity
Thank you for reading
Dr Manish khokhar
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