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Diabetes therapy: The way to normoglycemiaTip: No desire to read? Then just start our online endocrinology course for free.

Figure: "Fluctuations in blood glucose (red) and the blood glucose-controlling hormone insulin (blue) in a healthy person over the course of the day with three meals. Also shown is the effect of a sugary (dashed) versus a starchy (solid line) meal." by Jakob Suckale, Michele Solimena resp. Shaddim. License: CC BY-SA 3.0

Patients who develop diabetes mellitus need comprehensive education from their treating physician. Because it is only when the extent of the disease has been assessed that late complications can be avoided, which are usually responsible for death from diabetes mellitus. The therapy of diabetes mellitus requires good compliance in order to be successful.

Treatment of diabetes mellitus type 1

Since there is little or no insulin left in diabetes mellitus type 1, the body must be supplied with insulin from the outside. Healthy eating and exercise can make a small contribution, but cannot avoid the injection of insulin.

In the Insulin therapy the need for insulin depends on the patient's daily routine, because food, illness and exercise have an influence on the insulin level and must be taken into account in the dosage so that neither hypo- nor hyperglycemia occurs. Training the patient is therefore very important, because he or she injects the insulin independently using a pen s.c. The greatest danger with insulin therapy is that the Hypoglycemia, but also insulin edema can occur. Rarely, patients form allergies or antibodies to the insulin.

Various human insulins with concentrations of U40 (40 IU/ml) and U100 (100 IU/ml) are available for therapy:

Normal insulin: inject 10-30 min before meal, works ca. 5 hours, corresponds to the body's own insulin. Insulin analogues: inject 0-10 min before meal, works ca. 3 hours, genetically modified. – Insulin analogues with 24 hours effect – insulin for insulin pumps Delayed-release insulin: acts ca. 10-12 hours due to supplements such as zinc or protamine. Mixed insulin: Combination of normal and long-acting insulin, works quickly and for a long time.

Figure: "Effectiveness profile of different insulin preparations or. Insulin analogues after subcutaneous injection." from Chris828. License: CC BY-SA 3.0

Intensified insulin therapy

Which insulins are used depends on the patient. As a rule, for type 1 diabetics intensified insulin therapy Aimed at. This involves both normal insulin as well as delayed-release insulin injected to mimic natural insulin levels. Delayed-release insulin accounts for 40-50% of the total daily requirement and provides a constant-low level during the day and at night; an appropriate injection in the evening is usually sufficient; in rare cases, injections are given in the morning and evening.

Normal insulin, on the other hand, which accounts for the remaining 50-60% of the total daily requirement, is injected before meals to meet the corresponding insulin requirement. The Bolus of normal insulin is determined beforehand by the blood glucose value and depends on the carbohydrate content of the meal and the subsequent activities. How patients can manage their insulin injections individual adapt them to their daily routine. However, this requires extensive training, as blood sugar must often be measured and insulin injected. Intensified insulin therapy is therefore only suitable for mentally fit type 1 diabetics.

Conventional insulin therapy

Since elderly patients often have a regular daily routine and find it more difficult to handle the insulin pen, a conventional insulin therapy advisable. Only in the morning and evening must mixed insulin injected before meals, injecting 2/3 of the total daily requirement in the morning and the remaining 1/3 in the evening. The evening injection can also be replaced by a delayed-release insulin if fasting blood glucose is too high. In conventional insulin therapy, it is important that insulin injections are always given at the same time to avoid hypoglycemia.

Insulin pump therapy

Another alternative is Insulin pump therapy. It allows an even more individualized daily routine. Better blood glucose control than intensified insulin therapy. The insulin pump is attached directly to the body and continuously injects normal insulin via catheter under the skin (continuous subcutaneous insulin infusion = CSII). Before meals, a button is pressed to activate a extra bolus injected, which can be adjusted to the carbohydrate content of the diet. The insulin pump must be worn all day and must not be used more than once a day. be taken off for 2 hours at a time.

Insulin pump therapy is particularly suitable for patients with an irregular daily rhythm or who suffer from the Dawn phenomenon suffer. In the latter case, hypoglycemia often occurs in the morning, which can be remedied by pump programming, as this increases the insulin injection already during sleep. A disadvantage of the insulin pump is that the catheter can slip out of the subcutaneous fatty tie unnoticed, leading to a rapid rise in blood glucose levels. Insulin pump therapy is therefore only suitable for experienced type 1 diabetics.

Transplants

Instead of injecting insulin several times a day, there is the possibility of a pancreas or islet cell transplantation. However, both surgical interventions are only performed in rare cases. Pancreas transplantation is usually considered when young diabetics are already suffering from progressive renal insufficiency. The kidney is also replaced during this surgery. The patient must take immunosuppressants for the rest of his life in both pancreas transplantation and islet cell transplantation.

Dietary therapy

Type 1 diabetics cannot influence the body's insulin production through diet, but they can influence the blood glucose level. Patients should therefore be given comprehensive information about healthy nutrition, as they need to coordinate food intake and insulin dose. It should also be noted that physical activity lowers blood glucose levels and must be taken into account in insulin dosing.

In the case of therapy with normal insulin, six meals, divided into three main meals and three snacks, are recommended. In contrast, three meals a day are sufficient for treatment with insulin analogues. This prevents severe fluctuations in blood glucose and keeps blood glucose relatively constant.

Treatment of type 2 diabetes mellitus

Since in type 2 diabetics a Relative insulin deficiency If the patient is diabetic, the first therapeutic goal is to stimulate insulin production with diet and exercise to stabilize the metabolism. 40-50 % of type 2 diabetics are obese at the same time and reduce their diabetes risk many times over if they aim for a BMI of 19-25. Nevertheless, it may become necessary to prescribe oral antidiabetic drugs in the course of the disease. If drug therapy is unsuccessful, type 2 diabetics must also resort to insulin injections, which are only the last resort for this type of diabetes.

Dietary therapy

Diabetes-adapted nutrition plays a greater role in type 2 than in type 1, as normoglycemia is achievable. To achieve this, it is necessary to observe the following basic rules of healthy nutrition:

– The daily energy requirement should not be exceeded. (For light physical work: weight in kg x 32 = kcal) – Distribute food intake over several small meals. 50-60 % carbohydrates (1 BE (bread unit) = 12 g carbohydrate equivalent), low in sugar and white flour (monosaccharides), high in fiber 30 % fat (1/3 saturated fatty acids, 1/3 unsaturated fatty acids, 1/3 polyunsaturated fatty acids), low cholesterol 15 % protein (in case of renal insufficiency correspondingly less) – renunciation of sugary soft drinks and juices (cyclamate, aspartame, saccharin are allowed) – abstaining from alcohol (inhibits gluconeogenesis in the liver and thus leads to hypoglycemia)

Oral drug therapy

If dietary therapy and plenty of exercise are not sufficient to lower blood glucose levels and stimulate insulin production, oral antidiabetic drugs are prescribed. There are currently seven substance groups available for this purpose:

Alpha-glucosidase inhibitor such as acarbose and miglitol (inhibit the sugar-splitting enzymes in the small intestine mucosa.) Biguanide such as metformin (delay carbohydrate absorption from the intestine, inhibit gluconeogenesis in the liver, promote glucose uptake into the muscles and suppress appetite.) Glitazones such as pioglitazone may now only be prescribed in exceptional cases (increase sensitivity of peripheral cells to insulin, only in combination with biguanides or sulfonylurea). Glinides such as repaglinide (short-term increase in insulin secretion by beta cells) Incretin analogues such as exenatide (mimic action of natural incretins, regulate insulin secretion) Incretin enhancer such as linagliptin (prevent degradation of incretins by the enzyme DPP-4, thus increase incretin concentration) Sulfonylureas like glibenclamide (stimulate insulin secretion of the pancreas, can be combined with insulin)

Insulin therapy

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Picture: "Blood glucose meter Accu-Chek Aviva With test strips, lancet drum and lancing device from Roche Diagnostics" from Animagus. License: CC BY-SA 3.0

Oral drug therapy is often combined with insulin in type 2 diabetics. The most suitable drugs are biguanides and sulfonylureas. For this purpose, a single injection of insulin a day is sufficient. Either mixed insulin injected in the morning or delayed-release insulin in the evening.

Is the Combination therapy If insulin therapy is unsuccessful, conventional insulin therapy can be effective. If this treatment is also unsuccessful, intensified insulin therapy is the next step to lower blood sugar.

Treatment of gestational diabetes

Women who develop diabetes during pregnancy are first recommended to lower blood glucose with the help of appropriate diet, exercise and weight reduction. Oral antidiabetics are contraindicated in gestational diabetes. Insulin therapy is the last choice.

Popular exam questions on diabetes therapy

The solutions can be found under the questions.

1. After nightly unnoticed hypoglycemia, a type 1 diabetic always measures hyperglycemic values in the morning. What is this phenomenon called?

1. Rebound hypoglycemia 2. Somogyi effect 3. Dawn phenomenon 4. Post-hyperglycemic hypoglycemia 5. Glucagon effect

2. What is not suitable for the therapy of gestational diabetes?

1. Short-term insulin 2. Normal insulin 3. Dietary adjustment 4. Metformin 5. Light sports

3. You are the primary care physician of a 56-year-old type 2 diabetic who you had to switch to insulin a few months ago. The HbA1c value you have now checked is 12.3%. You suspect that the patient does not always inject themselves.

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