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
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.
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.
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
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
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
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.
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.
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.
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
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.
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.
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 (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.
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.
This agent binds with dopamine receptor agonist however role uncertain.
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