Type 2 diabetes: treatment guidelines (part 2)

In a previous article, we started talking about the principles of treatment for type 2 diabetes. In this article, we continue to talk about the treatment of this disease. Non-drug treatments   

The main lifestyle recommendations for patients with type 2 diabetes are quitting smoking and following an appropriate diet. Patient education  

  • When determining the training needs of patients, consider their beliefs, life values ​​and cultural characteristics.
  • If the patient has a biased attitude or anxiety, listen carefully to him and provide the necessary explanations.
  • Explain patient learning goals and the relationship between blood glucose control, diet, and exercise. 
  • Explain the consequences of ineffective blood glucose control and its effect on the development of complications.
  • Explain the importance of screening for complications. 
  • Explain the importance of a healthy lifestyle, especially physical activity and smoking cessation.
  • Explain the role and importance of self-monitoring (for example, self-monitoring of blood glucose).
  • Explain the need for regular foot care.

Nutrition recommendations

  • Eat regularly so that starchy foods such as bread, potatoes, rice, and pasta are the mainstay of food . 
  • It is necessary to reduce the consumption of fried and fatty foods.
  • Skimmed or semi-skimmed milk is recommended . 
  • You need to include at least 5 servings of fruits, vegetables or legumes in your daily menu.
  • Avoid eating chocolate and other sweets.  
  • It is necessary to reduce salt intake . 
  • It is recommended to drink alcohol in moderation.

Other lifestyle recommendations

  • It is necessary to reduce weight to a really achievable level – a body mass index of 25 (80-90% of patients with type 2 diabetes are overweight).
  • You must try to take at least 30 minutes a day for moderate-intensity sports or normal physical activity for at least 5 days a week.  

Drug treatment

The principles of treatment of type 2 diabetes are as follows : 1.14-16 :

  • In most cases, first-line drugs in the treatment of type 2 diabetes are agents containing metformin. According to the recommendations of the European Association for the Study of Diabetes and the American Diabetes Association, from the moment of confirming the diagnosis of type 2 diabetes mellitus, it is necessary to combine lifestyle recommendations with the appointment of a drug containing metformin. According to the latest data, it is not recommended to set aside a “trial period” during which the patient is recommended to change his lifestyle, but the drug containing metformin is not prescribed. 
  • With insufficient control of blood glucose levels, in addition to a drug containing metformin, one of the sulfonylureas should be prescribed.

In certain clinical situations, you can also prescribe the following drugs:

  • thiazolidinediones;
  • dipeptidyl peptidase-4 inhibitors (dpp-4);
  • glucagon-like peptide-1 analogues (hpp-1);
  • postprandial glucose regulators;
  • funds containing acarbose;
  • insulin.

Standard medication

Preparations containing metformin

Metformin-containing drugs inhibit the production of glucose by the liver. They also stimulate the absorption and use of glucose by muscle cells. 

Benefits Metformin reduces the risk of developing micro- and macro-vascular complications of diabetes.

Side effects metformin can cause anorexia, nausea, and diarrhea. In rare cases, it can lead to lactic acidosis – an increased content of lactic acid in the blood (in extremely rare cases, this is observed against a background of impaired renal function).  

Metformin is contraindicated in patients in the following cases:

  • renal failure;
  • liver failure;
  • alcoholism;
  • diabetic ketoacidosis;
  • volumetric surgery;
  • sepsis.

Patients who have an intravascular contrast X-ray examination should stop taking the drug containing metformin before the procedure and resume taking it only after 48 hours, provided that kidney function is restored to its original level.  

Research results

Taking drugs containing metformin reduces the risk of micro- and macrovascular complications. As part of a UK diabetes prospective study (UKPDS), an additional study was conducted to evaluate the use of metformin for the intensive care of overweight patients and type 2 diabetes. Hypoglycemia attacks were less likely to occur with the use of metformin; there was less weight gain compared with other drugs 16 .  

Possible benefits for patients

It is necessary to offer patients drugs containing metformin as a first-line therapy from the moment of confirmation of the diagnosis of type 2 diabetes mellitus. This drug has special advantages for patients with overweight.

Treatment with a drug containing metformin can be used as monotherapy (only one medicine is prescribed) or in combination with sulfonylurea preparations.

Sulfonylurea preparations

Sulfonylurea preparations stimulate the production of insulin by the pancreas.  

Advantages sulfonylurea preparations control the level of glucose in the blood and reduce the incidence of distant microvascular complications.

Side effects taking sulfonylurea drugs can cause weight gain of up to 4 kg. Hypoglycemia can be a serious problem, especially in the following cases:

  • in the elderly;
  • in people with impaired liver or kidney function;
  • with irregular nutrition. 

Alcohol can also be a factor causing the development of hypoglycemia. Long-acting sulfonylureas can cause delayed hypoglycemia, including prolonged hypoglycemia.

Research results

Compared to placebo , sulfonylureas on average lower HbA 1c hemoglobin levels by about 1-2% 17 .   

Therapy with sulfonylureas reduces the incidence of distant microvascular complications 18 .

Possible benefits for patients

If glycemic control worsens, sulfonylurea preparations must be prescribed in combination with drugs containing metformin. Sulfonylurea preparations should be considered as one of the first-line treatment options for metformin intolerance, contraindications or for patients without excess weight.

It is also possible to prescribe sulfonylurea preparations in combination with preparations containing acarbose, thiazolidinediones, GLP-1 analogs, DPP-4 inhibitors and insulin.

Postprandial Glucose Regulators

Taking postprandial glucose regulators causes a rapid but short-term increase in pancreatic insulin secretion . This helps restore a normal insulin response to food intake.  

Advantages postprandial glucose regulators control blood glucose and lower HbA 1c hemoglobin .

Side effects to the side effects of postprandial glucose regulators include weight gain and gipoglikemiya.Eti drugs should be used with caution in patients with impaired renal and hepatic function 17 . 

Research results

Postprandial glucose regulators effectively control the level of glucose in the blood and reduce the level of hemoglobin HbA 1c (maximum 2%). 17.18  

Possible benefits for patients

Postprandial glucose regulators are especially effective under the following conditions:

  • unorganized lifestyle of the patient;
  • recurring episodes of hypoglycemia during treatment with sulfonylurea;
  • the development of hypoglycemia after eating. 

Acarbose-containing preparations

Acarbose reduces the absorption of carbohydrates in the intestines. 

Advantages compared with placebo, acarbose reduces the level of glycated hemoglobin HbA 1c by about 0.5%. 

Side effects Acarbose intake often causes side effects from the gastrointestinal tract (e.g., flatulence). These drugs should not be prescribed to patients with the following diseases: 

  • non-specific inflammatory bowel diseases;
  • malabsorption syndrome;
  • other similar gastrointestinal disturbances.

Research results

Acarbose is less effective in lowering HbA 1c hemoglobin levels than metformin or sulfonylureas. The average decrease in HbA 1c hemoglobin levels with alpha-glucosidase inhibitors is approximately 0.5-1% compared with placebo 17 . 

Possible benefits for patients

Drugs containing acarbose can be considered as alternative drugs to reduce blood glucose in those patients who are contraindicated in any other oral drugs.

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