Management of Diabetes Mellitus
In any illness, management and treatment is based on risk vs. benefit and consideration of the least invasive means. Since lowering blood sugar is done by methods ranging from lifestyle alterations to injecting insulin, a personalized regimen is necessary for each diabetic patient. Within this range, from least invasive to most invasive, are the oral hypoglycemics, such as metformin.
Type 2 DM
The treatment goal in Type 2 DM is a drop in glycated hemoglobin A1c to ≤7%. Every 1% drop lowers the complication rate due to vascular injury.
- Education and life-style alterations: Patients who are knowledgeable of their condition are more compliant with treatment and do better. Counseling on nutrition and weight reduction through caloric restriction, physical exercise, and preventing complications go hand-in-hand with pharmacologic therapy.
- Medication should begin at the time of diagnosis: Metformin is an oral hypoglycemic that is the recommended initial medication. It decreases liver production and intestinal absorption of glucose and improves insulin sensitivity. There are other oral hypoglycemics, but metformin has been associated with fewer episodes of hypoglycemia–a risk of any sugar-lowering strategy. Persistent hyperglycemia in spite of lifestyle alterations and oral hypoglycemics indicates the need for insulin administration.
Type 1 DM
Type 1 DM requires insulin, which is injected. The treatment goal in Type 1 DM is a glycated hemoglobin A1c of 7%. Insulin is given daily for a baseline level and supplemented when necessary by pre-meal boluses of shorter-acting insulin. Other methods, such as continuous infusion by a pump, add to the treatment choices.
For Type 2 DM, biannual A1c levels are obtained in patients with a history of good glycemic control. This is prescribed more frequently in those adjusting to new medications or doses or those who have not met their therapeutic goals. With good glycemic control, the lifestyle changes and metformin monotherapy protocol can continue indefinitely. For those who fail to reach goals, a combination with insulin is required.
For Type 1 DM, self-monitoring of blood glucose is an important part of diabetes therapy, and a combination of glucose measurements by physician and self-testing by patient has been proven to be the best surveillance method.