Treatment of Diabetes Mellitus - General Approach to Treatment ; Appropriate care requires goal setting for glycemia, blood pressure, and lipid levels, regular monitoring for complications, dietary and exercise modifications, medications, appropriate self-monitored blood glucose (SMBG), and laboratory assessment of the aforementioned parameters. Glucose control alone does not sufficiently reduce the risk of macrovascular complications in persons with DM.
Glycemic Goal Setting and The Hemoglobin A1c
Controlled clinical trials provide ample evidence that glycemic control is paramount in reducing microvascular complications in both type 1 DM and type 2 DM. HbA1c measurements are the gold standard for following long-term glycemic control for the previous 2 to 3 months. Hemoglobinopathies, anemia, and red cell membrane defects can affect HbA1c measurements. Other strategies such as measurement of fructosamine, which measures glycated plasma proteins and correlates to glucose control over the last 2 to 3 weeks, can be necessary to assess diabetes control in these patients.
Unless the risk outweighs the benefit (as in elderly patients, patients with advanced complications, and patients with other advanced disease), a HbA1c target of <7% is appropriate (Table bellow), and lower values should be targeted if significant hypoglycemia and/or weight gain can be avoided.
Glycemic Goals of Therapy
Biochemical Index ADA ACE and AACE
Hemoglobin A1c <7%a ≤6.5%
Preprandial plasma glucose 90–130 mg/dL <110 mg/dL
(5.0–7.2 mmol/L)
Postprandial plasma glucose <180 mg/dLb <140 mg/dL
(<10 mmol/L)
Hemoglobin A1c <7%a ≤6.5%
Preprandial plasma glucose 90–130 mg/dL <110 mg/dL
(5.0–7.2 mmol/L)
Postprandial plasma glucose <180 mg/dLb <140 mg/dL
(<10 mmol/L)
Monitoring Complications
The ADA recommends initiation of complications monitoring at the time of diagnosis of DM. Current recommendations continue to advocate yearly dilated eye examinations in type 2 DM, and an initial eye examination in the first 3 to 5 years in type 1 DM, then yearly thereafter. Less frequent testing (every 2 to 3 years) can be implemented on the advice of an eye care specialist. The feet should be examined and the blood pressure assessed at each visit. A urine test for microalbumin once yearly is appropriate. Yearly testing for lipid abnormalities, and more frequently if needed to achieve lipid goals, is recommended.
Self-Monitoring of Blood Glucose
The advent of SMBG in the early 1980s revolutionized the treatment of DM, enabling patients to know their blood glucose concentration at any moment easily and relatively inexpensively. Frequent SMBG is necessary to achieve near-normal blood glucose concentrations and to assess for hypoglycemia, particularly in patients with type 1 DM.62 The more intense the pharmacologic regimen is, the more intense the SMBG needs to be (four or more times daily in patients on multiple insulin injections or pump therapy). The optimal frequency of SMBG for patients with type 2 DM is unresolved.
Frequency of monitoring in type 2 DM should be sufficient to facilitate reaching glucose goals. The role of SMBG in improving glycemic control in type 2 DM patients is controversial but has shown to reduce the HbA1c ~0.4%.63 What is clear is that patients must be empowered to change their therapeutic regimen (lifestyle and medications) in response to test results, or no meaningful glycemic improvement is likely to be effected.
Nonpharmacologic Therapy
Diet
Medical nutrition therapy is recommended for all persons with DM. Paramount for all medical nutrition therapy is the attainment of optimal metabolic outcomes and the prevention and treatment of complications. For individuals with type 1 DM, the focus is on regulating insulin administration with a balanced diet to achieve and maintain a healthy body weight. A meal plan that is moderate in carbohydrates and low in saturated fat (<7% of total calories), with a focus on balanced meals is recommended. The amount (grams) and type (via the glycemic index, although controversial) of carbohydrates, whether accounted for by exchanges or carbohydrate counting, should be considered. It is imperative that patients understand the connection between carbohydrate intake and glucose control.
In addition, patients with type 2 DM often require caloric restriction to promote weight loss. Rather than a set diabetic diet, advocate a diet using foods that are within the financial reach and cultural milieu of the patient. As most patients with type 2 DM are overweight or obese, bedtime and between-meal snacks are not needed if pharmacologic management is appropriate.
Clinical Controversy
The recommended daily carbohydrate intake for type 2 DM, and even type 1 DM, has become controversial since low-carbohydrate diets such as the Atkins, South Beach, and Carbohydrate Addict’s Diets have become exceptionally popular. Currently, the ADA recommends that approximately 45% to 65% of daily caloric intake should come from carbohydrates and does not recommend restricting diets to <130 grams of carbohydrate a day.
Many clinicians are trying to increase the monounsaturated fat percentage and decrease the carbohydrate percentage in a patient’s diet to accomplish improved glycemic control. Recent studies have documented short-term success for weight loss on low-carbohydrate diets (~6 months), without deleterious effects on the lipid panel. Weight loss can reduce cardiovascular risk factors in type 2 DM.
Activity
In general, most patients with DM can benefit from increased activity. Aerobic exercise improves insulin resistance and glycemic control in the majority of individuals, and reduces cardiovascular risk factors, contributes to weight loss or maintenance, and improves well-being. The patient should choose an activity that she or he is likely to continue. Start exercise slowly in previously sedentary patients. Older patients, patients with long-standing disease (age >35 years, or >25 years with DM ≥10 years), patients with multiple cardiovascular risk factors, presence of microvascular disease, and patients with previous evidence of atherosclerotic disease should have a cardiovascular evaluation, probably including an electrocardiogram and graded exercise test with imaging, prior to beginning a moderate to intense exercise regimen. In addition, several complications (autonomic neuropathy, insensate feet, and retinopathy) can require restrictions on the activities recommended.
Physical activity goals include at least 150 minutes/week of moderate (50%–70% maximal hear rate) intensity exercise. In addition, resistance training, in patients without retinal contraindications, is recommended for 30 minutes three times per week.
Salam
by Umaee
Source: pharmacotherapy 7th
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