Diabetes mellitus medical therapy

Diabetes mellitus Main page
Patient Information Type 1 Type 2
Overview
Classification Diabetes mellitus type 1 Diabetes mellitus type 2 Gestational diabetes
Differential Diagnosis
Complications
Screening
Diagnosis
Prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3] Karol Gema Hernandez, M.D. [4]

Medical Therapy

For more on the treatment of diabetics with coronary artery disease click here.

Diabetes mellitus is currently a chronic disease, without a cure, and medical emphasis must necessarily be on managing/avoiding possible short-term as well as long-term diabetes-related problems. There is an exceptionally important role for patient education, dietetic support, sensible exercise, self glucose monitoring, with the goal of keeping both short-term blood glucose levels, and long term levels as well, within acceptable bounds. Careful control is needed to reduce the risk of long term complications. This is theoretically achievable with combinations of diet, exercise and weight loss (type 2), various oral diabetic drugs (type 2 only), and insulin use (type 1 and increasingly for type 2 not responding to oral medications). In addition, given the associated higher risks of cardiovascular disease, lifestyle modifications should be undertaken to control blood pressure and cholesterol by exercising more, smoking cessation, consuming an appropriate diet, wearing diabetic socks, and if necessary, taking any of several drugs to reduce pressure. Many Type 1 treatments include the combination use of regular or NPH insulin, and/or synthetic insulin analogs such as Humalog, Novolog or Apidra; the combination of Lantus/Levemir and Humalog, Novolog or Apidra. Another Type 1 treatment option is the use of the insulin pump with the some of most popular pump brands being: Cozmo, Animas, Medtronic Minimed, and Omnipod.

In countries using a general practitioner system, such as the United Kingdom, care may take place mainly outside hospitals, with hospital-based specialist care used only in case of complications, difficult blood sugar control, or research projects. In other circumstances, general practitioners and specialists share care of a patient in a team approach. Optometrists, podiatrists/chiropodists, dietitians, physiotherapists, clinical nurse specialists (eg, Certified Diabetes Educators and DSNs (Diabetic Specialist Nurse)), or nurse practitioners may jointly provide multidisciplinary expertise. In countries where patients must provide their own health care, the impact of out-of-pocket costs of diabetic care can be high. In addition to the medications and supplies needed, patients are often advised to receive regular consultation from a physician (e.g., at least every three to six months).

In hospitalized patients, Clinical practice guidelines are available by the American College of Physicians (ACP) recommends "Best Practice Advice 1: Clinicians should target a blood glucose level of 7.8 to 11.1 mmol/L (140 to 200 mg/dL) if insulin therapy is used in SICU/MICU patients. Best Practice Advice 2: Clinicians should avoid targets less than 7.8 mmol/L (<140mg/dL)"

Contraindicated medications

Diabetes (when coadministrated with ARBs or ACEIs) is considered an absolute contraindication to the use of the following medications:

• Aliskiren
• Amlodipine and Benazepril

Diabetes mellitus with vascular disease is considered an absolute contraindication to the use of the following medications:

• Drospirenone and Ethinyl estradiol
• Norethindrone acetate and Ethinyl estradiol
• Norgestimate and Ethinyl estradiol

2013 American Diabetes Association Standards of Medical Care in Diabetes (DO NOT EDIT)

Insulin Therapy for Type 1 Diabetes

"1. Most people with type 1 diabetes should be treated with multiple dose insulin (MDI) injections (three to four injections per day of basal and prandial insulin) or continuous sub- cutaneous insulin infusion (CSII). (Level of Evidence: A)"

"2. Most people with type 1 diabetes should be educated in how to match prandial insulin dose to carbohydrate intake, premeal blood glucose, and anticipated activity. (Level of Evidence: E)"

"3. Most people with type 1 diabetes should use insulin analogs to reduce hypoglycemia risk. (Level of Evidence: A)"

"4. Consider screening those with type 1 diabetes for other autoimmune dis- eases (thyroid, vitamin B12 deficiency, celiac) as appropriate. (Level of Evidence: B)"

Pharmacological Therapy for Hyperglycemia in Type 2 Diabetes

"1.Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacological agent for type 2 diabetes. (Level of Evidence: A)"

"2. In newly diagnosed type 2 diabetic patients with markedly symptomatic and/or elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents, from the outset. (Level of Evidence: E)"

"3. If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3–6 months, add a second oral agent, a glucagon-like peptide-1 (GLP-1) receptor agonist, or insulin. (Level of Evidence: A)"

"4. A patient-centered approach should be used to guide choice of pharmacological agents. Considerations include efficacy, cost, potential side effects, effects on weight, comorbidities, hypoglycemia risk, and patient preferences. (Level of Evidence: E)"

"5. Due to the progressive nature of type 2 diabetes, insulin therapy is eventually indicated for many patients with type 2 diabetes. (Level of Evidence: B)"

Antiplatelet Agents

"1.Consider aspirin therapy (75–162 mg/day) as a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10-year risk >10%). This includes most men aged >50 years or women aged >60 years who have at least one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). (Level of Evidence: C)"

"2. Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk (10-year CVD risk <5%, such as in men aged <50 years and women aged <60 years with no major additional CVD risk factors), since the potential adverse effects from bleeding likely offset the potential benefits. (Level of Evidence: C)"

"3. In patients in these age-groups with multiple other risk factors (e.g., 10- year risk 5–10%), clinical judgment is required. (Level of Evidence: E)"

"4. Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes with a history of CVD. (Level of Evidence: A)"

"5. For patients with CVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. (Level of Evidence: B)"

"6. Combination therapy with aspirin (75– 162 mg/day) and clopidogrel (75 mg/day) is reasonable for up to a year after an acute coronary syndrome. (Level of Evidence: B)"|-

CHD Treatment

"1. In patients with known CVD, consider ACE inhibitor therapy (Level of Evidence: C) and use aspirin and statin therapy (Level of Evidence: A) (if not contraindicated) to reduce the risk of cardiovascular events. In patients with a prior MI, b-blockers should be continued for at least 2 years after the event. (Level of Evidence: B)"

"2. Avoid thiazolidinedione treatment in patients with symptomatic heart failure. (Level of Evidence: C)"

"3. Metformin may be used in patients with stable CHF if renal function is normal. It should be avoided in unstable or hospitalized patients with CHF. (Level of Evidence: C)"

Management

Diabetes management | Diabetic diet | Anti-diabetic drug | Conventional insulinotherapy | Intensive insulinotherapy