Diabetes is a complex chronic illness which requires long-term treatment. The management is much more than just glycemic control. It involves screening for diabetes at the appropriate age, education of the patient, lifestyle modification (includes physical activity, nutrition, weight reduction), drug treatment (oral and insulin therapy), prevention and treatment of complications, psychological treatment.
Screening for diabetes :
Screening all adults who are above 45 years of age irrespective of weight.
Screening all overweight or obese adults who have an additional one or more risk factors for diabetes irrespective of their age.
If initial tests are normal then it should be repeated once in 3 years. More frequent checking is advised in adults who have prediabetes.
Risk factors for diabetes:
First degree relative to diabetes
History of gestational diabetes
Lifestyle modifications associated with diabetes:
Carbohydrate from whole wheat, legumes, vegetables, dairy products with an emphasis on food rich in fiber content.
Diet should contain an adequate amount of proteins and fat, micronutrients.
150mts/week of moderate aerobic physical activity is recommended, spread over 3days/week with no more than 2 consecutive days without exercise.
Adults with type 2 diabetes in the absence of contraindications should be encouraged for resistance exercise training at least twice a week.
If the adult has diabetic retinopathy and cardiovascular disease vigorous physical activity is not advisable.
Check HbA1c twice a year who are meeting glycemic targets.
check quarterly who are not meeting glycemic targets
HbA1c should be less than 7%
Oral hypoglycemic agents and insulin
Metformin is the initial drug of choice if there is no contraindication in type 2 diabetes mellitus.
If glycemic goals are not achieved with metformin alone then we can choose a second drug from sulfonylurea, DPP4 inhibitors, thiazolidinedione, SGL2 inhibitors, GLP 1 receptor agonist or basal insulin.
If glycemic goals are not met with 2 drug combination then a third drug can be added from remaining groups.
If glycemic targets are not met with three drug combination then basal insulin + meal time insulin+metformin can be given.
If the sugars are very high at diagnosis then insulin can be used as an initial agent and later oral agents can be added.
Ecosprin and atorvastatin should be included for cardiovascular disease risk prevention strategy.
At least once a year screening for urinary albumin secretion and estimated GFR for all type 2 diabetic patients.
Dilated eye examination for retinopathy at diagnosis and then every year for a patient with type 2 diabetes mellitus should be done.
Comprehensive foot care, evaluation for diabetic neuropathy should be done at diagnosis and then yearly.
Diabetic patients should be evaluated for depression and should be treated if present. Psychosocial support should be provided.