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Diagnosis and Management of Type 2 Diabetes, 10th Edition, Ch 12-Pt 1

Treatment Algorithm

Diagnosis_and_Management_of_Type_2_Diabetes

Steve V. Edelman, MD

Robert R. Henry, MD

The primary treatment goals of managing Type 2 diabetes are to:

• Eliminate symptoms of hyperglycemia

• Recognize the symptoms of hypoglycemia….

• Achieve and maintain normal or near-normal metabolic and biochemical parameters (both fasting and postprandial blood glucose levels, A1C [Table 12.1], LDL and HDL cholesterol, and fasting triglycerides)

• Achieve normal blood pressure and address procoagulant state

• Reduce insulin resistance and its adverse metabolic consequences

• Assist the patient in achieving and maintaining a reasonable body weight

• Prevent or delay the development and progression of microvascular and macrovascular complications

Therapeutic efforts to achieve these goals involve using a variety of treatment modalities:

• Dietary modifications

• Regular physical activity

• Aspirin therapy

• Antidiabetic agents

• Insulin injections.

An individualized approach is recommended based on:

• Patient age

• The presence of coexisting illnesses and/or diabetes-related complications

• Lifestyle, including:

– Attitude
– Habits
– Cultural/ethnic status

• Financial considerations

• Ability to learn and follow self-management skills

• Level of patient motivation.

The cornerstone of effective diabetes management is maintaining good glycemic control. Compelling evidence indicates that long-term glycemic control can prevent or delay the microvascular complications of diabetes.

The DCCT and the UKPDS demonstrated definitively the value of improved glycemic therapy in patients with Type 1 and Type 2 diabetes in delaying the onset and slowing the progression of retinopathy, nephropathy, and neuropathy.

The benefits of reducing glycemia are seen in both Type 1 and Type 2 diabetes. The ADA now recommends establishing a management goal of achieving the best possible blood glucose control in patients with Type 2 diabetes. Treatment methods for managing Type 2 diabetes should focus on:

• Dietary modifications

• Exercise

• Weight control

• Supplemental oral hypoglycemic agents and/or insulin as needed.

The following algorithm (Figure 12.1) provides a general guideline for making decisions regarding the various types of pharmacologic therapy. It should be noted that several consensus algorithms proposed by various organizations such as the ADA, the EASD, the AACE, and the Texas Diabetes Council differ somewhat in their details including glycemic targets and the sequential use of specific medications. For example, the target glycemic goal proposed by the AACE is an A1C of 6.5% whereas a goal of A1C

Edelman_Table12-1
Edelman_Fig12-1
 
Edelman_Fig-1a

Next Week, Assessment of the Treatment Regimen

You can purchase this text at Amazon.com, just click on this link: Diagnosis and Management of Type 2 Diabetes 10E

 SUGGESTED READING

American Diabetes Association. Standards of medical care in diabetes–2010. Diabetes Care. 2010;33(suppl 1):S11-S61.

American Diabetes Association. Medical Management of Non–insulindependent (Type II) Diabetes. 3rd ed. Alexandria, VA: American Diabetes Association; 1994:22-39.

Davidson JA, Blonde L, Jellinger PS, et al. Road map for the prevention and treatment of type 2 diabetes. http://www.aace.com/meetings/consensus/odimplementation/roadmap.pdf. Accessed July 2, 2010.

Mudaliar S, Henry RR. Combination therapy for type 2 diabetes. Endocrinol Pract. 1999;5:208-219.

Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia. 2006;49:1711-1721.

Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non–insulin-dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract. 1995;28:103-117.

United Kingdom Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837-853.

Texas Diabetes Council. Insulin Algorithm for Type 2 Diabetes Mellitus in Children and Adults. October 20, 2005. http://www.tdctoolkit.org/algorithms_and_guidelines.asp. Accessed July 2, 2010.

 

© Copyright 2010. Steven V. Edelman, MD, Robert R. Henry, MD, Professional Communications, Inc. All rights reserved.