Therapy of diabetes mellitus type 2 diabetes news diabetes news

The focus of type 2 diabetes therapy has changed in recent years. The focus is no longer on achieving the best possible blood glucose levels. In the earlier guidelines, the HbA1c as a representative for good blood glucose values was the target parameter on which the therapy was based. Today the goals of therapy are redefined. The two main therapeutic goals are:

Prevention of complications

Optimization of the quality of life

Since each patient is individually different, it is necessary to consider and determine which therapy goals make sense for that patient before any therapy begins. This is a joint task of the patient and his physician. Any therapy that is applied to the patient without taking into account his personal problems, wishes and characteristics is doomed to failure.

On 25. March 2021, the 2. Aufl. of the national care guideline type 2 diabetes published. It differs from the recommendations of the American Diabetes Association (ADA) in one important point: the use of metformin in therapy is not recommended at diagnosis, but only after the exhaustion of basic non-drug therapy. We deliberately use the American guidelines here. The revised version of the American guideline is published every year in January. Is adapted to the latest scientific knowledge. The German national care guideline, on the other hand, is valid until 2026 and will not be updated until then. With the rapid progress in medical research, it can be expected to be outdated as early as next year.

The American Diabetes Association (ADA) recommendations describe the approach in a decision cycle.

(Click on the graphic to enlarge the image) Modified from: Standards of Medical Care in Diabetes-2021, Diabetes Care 2021; 44, Supp1, p41

The focus is on the patient. The goals of therapy are to avoid complications. The improvement of quality of life.

To achieve this, the patient's characteristics must first be evaluated. Treatment goals and treatment plans must be developed with the patient. For this purpose, the individual wishes. taking into account one's personal goals.

When treating type 2 diabetes, do not just look at blood glucose levels

Before starting therapy, one must be clear about what is achievable with the therapy. Therapy does not only consist of trying to adjust blood glucose levels as well as possible. A patient with diabetes mellitus type 2 is usually overweight, has high blood prere, a lipid metabolism disorder and a disorder of the sugar metabolism. This is common to almost all patients. It does not make sense to treat only one of these components. All must be treated to reduce the risk of heart attack and stroke. To prevent stroke or myocardial infarction, optimal blood prere control is essential. Cholesterol levels much more important than blood glucose levels. Nevertheless, blood glucose should not be neglected. Small vessel disease, which can lead to blindness, kidney failure, and leg amputation, is efficiently prevented by good blood glucose control or. delayed.

Avoiding weight gain and hypoglycemia

Good blood glucose control does not mean that the lowest possible blood glucose values should be achieved at all costs. Sulfonylureas, glitazones and insulin lead to weight gain. Especially under insulin therapy, weight gain can be very severe. Sulfonylureas and insulin may also cause hypoglycemia (low blood sugar). However, these negative effects do not mean that one should not try to achieve good blood glucose control. However, good glycemic control should not be achieved at the expense of severe weight gain. Not be associated with an increased risk of hypoglycemia.

An individual HbA1c target should therefore be set for each patient. When choosing treatment, consider the effect on weight, hypoglycemia, and the side effects of medication. Overly complex regimens are not suitable for every patient.

The patient should be involved in decisions regarding his or her treatment plan. The prerequisite for this is an informed and educated patient.

The goals of the treatment plan, the SMART goals, should be agreed upon with the patient. SMART means the goals must be specific to the patient (Specific), measurable (Measurable), achievable (Achievable), realistic (Realistic) and be achievable within a reasonable time frame (Time limited).

To implement the action plan, doctor's visits are recommended at least every three months. In these presentations, the well-being should be. The tolerability of the medication should be checked. The check-ups include a discussion of blood glucose control, clinical parameters including SMBG (self-measured blood glucose values), weight, exercise (steps taken), long-term blood glucose value HbA1c, blood prere and blood lipids. The individual decision cycle. Action plan should be reviewed at least once a year.

Start type 2 diabetes therapy immediately

Treatment should be started as soon as type 2 diabetes mellitus is diagnosed. Treatment initially consists of "lifestyle" change. Essential measure is the initiation of an exercise program. Dietary changes for weight reduction. These two points are discussed in the chapters "Therapy Pillars: Diet and exercise" and "Weight loss helps type 2 diabetes".

Treatment options also include tablets (metformin, Arcabose, sulfonylureas, glitazones) and newer treatment options (DPP4 inhibitors and incretin mimetics, SGLT-2 inhibitors) and insulin – sometimes in combination. Read more about these treatment options in the individual articles by clicking on their respective links.

Pharmacological stepwise therapy in type 2 diabetes mellitus

In contrast to earlier guidelines, the recommendations of the American Diabetes Association (ADA) on the approach to drug therapy for type 2 diabetes mellitus are no longer based on blood glucose alone, but on the patient and his or her concomitant diseases.

(Click on the graphic to enlarge the image) ASCVD, atheroskeloritic cardiovascular disease; CKD, chronic kidney disease; CV, cardiovascular; CVOT, cardiovascular endpoint studies; DPP-4i, dipeptidyl peptidase-4 inhibitor; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide-1 receptor agonist; HI, heart failure; SGLT-2i, sodium-glucose transporter-2 inhibitor; SH, sulfonylurea; TZD, thiazolidinedione, HFrEF ejection fraction in heart failure; LVH hypertrophy of left ventricle.

Modified from: Standards of Medical Care in Diabetes-2021, Diabetes Care 2021; 44, Supp1, p116

Initially, diabetes therapy begins with dietary changes including regular weight control, increased exercise, and starting treatment with metformin. Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes. Metformin treatment should be continued as long as it is tolerated and not contraindicated. Other agents, including insulin, should be added to metformin. Early combination therapy may be considered in some patients. Completely independent of the present HbA1c or the individual HbA1c target or the use of metformin, the use of GLP-1 receptor agonists or SGLT 2 inhibitor should be considered.

Which drug treatment is given depends on whether the patient is at high risk for or already has known atherosclerotic cardiovascular disease, chronic kidney disease, or heart failure.

If there is evidence of arteriosclerotic cardiovascular disease (CHD) or a high risk for such disease, treatment should be started with a GLP-1 receptor agonist with proven cardiovascular benefit or an SGLT-2 inhibitor with proven cardiovascular benefit. If the HbA1c target is not achieved, drugs from both substance classes can be combined. If GLP-1 receptor agonists are not tolerated, DPP-4 inhibitors can be used instead, or a basal insulin or a sulfonylurea. Thiazolidinediones are not reimbursable in Germany for the treatment of patients with statutory health insurance. Enter your postal code or your place of residence. Set a perimeter for the search. Alternatively, you can search for a specific name. Multiple choices possible.

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