In this article, we’ll cover the treatments used in Diabetes Mellitus. We’ll look at key things you need to know about each therapy, when you might start it & common adverse effects. This article isn’t comprehensive or a guideline – you should still look up information & a guideline before starting any treatment.
Type 1 Diabetes (or those with pancreatic diabetes) are usually treated with insulin alone. In contrast, with Type 2 Diabetes there is a range of drugs to choose from. You need to balance the benefits and risks of the drug, aiming to adequately control blood sugars (CBGs) whilst avoiding weight gain. There are many drugs that will control the blood sugars (CBGs) resulting in an excellent reduction in microvascular complications (neuropathy, retinopathy, nephropathy), but many of the older drugs actually increased macrovascular risks (ischaemic heart disease, peripheral arterial disease & cerebrovascular disease) & resulted in weight gain. IHD & Strokes are the biggest killers in T2DM – that’s why any new diabetes medications are now required to show benefits in these outcomes too.
If a patient presents with features of Type 1 Diabetes such as weight loss or ketosis, which suggest insulin deficiency, we will often start these patients on insulin whilst awaiting confirmatory tests of their type of diabetes. This is safer as otherwise, the patient may develop life-threatening DKA. If T2DM is confirmed or suspected, these patients are then started on oral agents as per the algorithm below & the insulin is carefully weaned.
How to choose which treatment to use in T2DM?
We regularly diagnose new diabetes in hospital as every patient who is admitted with have their glucose checked at least once. Our goal in hospital is to not achieve perfect control, but reduce their CBGs to a safe range of around 8-15 mmol/L. This safe range reduces the risk of DKA/dehydration/impairment of the immune system without risking life-threatening hypoglycaemia in hospital or on discharge. We know that when patients are discharged their activity levels may increase and the food they eat will change, hence once discharged the patient may suddenly be at higher risk of hypoglycaemia. If the patient is only on drugs that would not be expected to cause hypoglycaemia (e.g. metformin, “-gliptins”), we may aim for lower targets closer to the ideal range. Upon discharge, the patient can monitor their CBGs and receive follow up via their GP.
Unfortunately, the NICE guidelines are out of date, but the American Diabetes Association has published a great algorithm:
What are the medications available, their risks & how do I start them?
References & Further Reading
- Diabetes Bible: an awesome guide to everything about diabetes for medical professionals
- NICE Guidelines
- ADA Guidelines
Written by Dr Akash Doshi (ST4 Endocrinology & Diabetes)
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