25.6 : Diabetes: Management and Pharmacotherapy

The therapy for diabetes aims to alleviate hyperglycemia-related symptoms, prevent acute metabolic decompensation, and reduce chronic end-organ complications. Glycemic control is evaluated through short-term (self-monitoring, continuous glucose monitoring) and long-term (A1c, fructosamine) metrics, enabling near real-time tracking of blood glucose levels and reflecting glycemic control over specific time frames.

Insulin remains the cornerstone of treatment for most patients with type 1 and many with type 2 diabetes. Subcutaneous insulin administration is pivotal for achieving near-normal glycemia, but differs from physiological insulin secretion in absorption kinetics and circulation dynamics.

Comprehensive diabetes care encompasses more than glucose management, addressing abnormalities in blood pressure, lipids and detecting and managing diabetes-related complications. The treatment goals are individualized to each patient, considering factors such as the risk of hypoglycemia, life expectancy, age, other medical conditions, and advanced complications of diabetes. Patient attitudes, expectations, resources, support systems, and cost considerations are also considered.

Patients are educated about nutrition, exercise, and medications to lower plasma glucose. The dietary approach differs between type 1 and type 2 diabetes. For type 1 diabetes, the focus is on reduced caloric intake, and insulin dosing. For type 2 diabetes, therapies include weight loss, blood pressure reduction, and atherosclerotic risk. Metabolic surgery has shown promising results in preventing or reversing type 2 diabetes, surpassing medical management efficacy in clinical trials.