As with all chronic diseases, the management of diabetes involves far more than just prescribing medication to treat hyperglycaemia or to combat one of diabetes’ many complications. Good diabetes management requires an integrated effort of both patient and care-giver to handle the disease in such a way that the impact of the disease on patient’s well-being is minimised.

Education and lifestyle

Given the important role of the patient in his/her own treatment, it is imperative that the patient is well educated about the disease. The patient should be well aware of the various factors contributing to the disease and the possible complications that may result. More importantly, however, the patient should be helped in making informed choices about treatment modalities, some of which may sometimes affect his daily life more than the disease itself.

The global diabetes epidemic is largely the result of three factors:

  1. the aging population worldwide, specifically in newly developing countries, such as China and India;
  2. the abundance of food in the developed countries; and
  3. the reduction in energy expenditure through physical activity as a result of automatisation and urbanisation.

For aging there is no cure, but since diet and lifestyle have a profound influence in type 2 diabetes, education about these factors is the cornerstone of treatment.

Oral glucose lowering drugs and incretins

Galega OfficinalisMetformin is the current first-line treatment of type 2 diabetes, and has been used as a drug since 1957. It belongs to the class of drugs called the biguanides. Even though the details of the mechanism of action of metformin are still being researched today, the flower Galega officinalis (the French Lily) from which these were derived was already known to have antidiuretic properties in the Middle Ages.

The sulfonylurea derivatives (SUs) are also a relatively old class of drugs. They were developed after some sulfonamide antibiotics were shown to have glucose-lowering side effects. They act by stimulating the secretion of insulin from the beta cells of the pancreas.

The alpha-glucosidase inhibitors exert their effects in the intestine, by slowing the degradation of carbohydrates from food and thus delaying the absorption of glucose from meals.

More recently, growing knowledge of metabolic pathways has led to targeted development of drugs such as the thiazolidinediones, the incretins (glucagon-like peptide-1 (GLP-1) analogues and dipeptidyl peptidase-4 (DPP-4) inhibitors) and sodium/glucose co-transporter 2 (SGLT2) inhibitors.

Insulin therapy

Before 1922, dietary intervention was the only treatment option for diabetes mellitus and patients with type 1 diabetes were doomed to die within a few months. The development of insulin in 1922 was a medical revolution. Insulin is still the most effective glucose-lowering agent and is essential for all patients who lack insulin secretion. Various types of insulin and various treatment modes have emerged over the years in attempts to mimic normal physiological insulin secretion but this goal remains elusive.

Bariatric surgery

Bariatric surgery aiming to reduce the intake and uptake of nutrients had been shown to be a remarkably efficacious way of treating obesity and diabetes. It is therefore no surprise that the number of surgical operations performed has boomed in the last few years. While it seems a rather mutilating way to combat the adverse consequences of overeating and physical inactivity, until society comes up with better ways to prevent or treat these twin epidemics, bariatric surgery will remain an important treatment option for those with severe obesity and diabetes.

Pancreas and islet transplantation

It seems reasonable to consider pancreas transplantation or transplanted islets the optimal replacement of a patient’s own pancreas. However, the procedures involved are laborious and difficult, and a patient still needs to take daily immunosuppressive drugs. For these and other reasons, transplantation is still not availabele for widespread use, although significant progress has been made over the last few years.

Immune intervention and gene therapy

Despite much (animal) research into the immunopathogenesis of type 1 diabetes, the treatment of type 1 diabetes through immunomodulatory interventions is still in its infancy. Although some success has been booked in recent years, one of the main problems remains the fact that there is only a short window of opportunity to treat before all islet cells are destructed by the autoimmune process.

Controversial therapies

When doctors fail to completely understand, explain or cure a disease, patients are likely to go looking for alternative remedies. Many of these have been shown to be inefficacious while some of these are still untested. Still, many patients will resort to therapies such as cinnamon or chromium. Therefore the merits (or lack thereof) of these therapies is also discussed within Diapedia.

Cardiovascular risk management

While diabetes patients suffer excessively from cardiovascular morbidity and mortality, good glycemic control plays a relatively minor role in reducing this risk. More important are appropriate control of blood pressure and dyslipidaemia. These important management issues are discussed in the sections Hypertension and Lipid disorders in diabetes elsewhere in Diapedia.

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