Diabetes Mellitus Management Guidelines, Diabetes Mellitus Treatment, Medicine.

We are going to talk about step-by-step management and treatment of diabetes.

First of all, for the diagnosis of diabetes, you need to do a few tests random blood glucose tests if greater than or equal to 200 milligrams per deciliter in the presence of symptoms of diabetes symptoms like polyuria polydipsia the patient will be labeled as a diabetic patient or if the fasting blood glucose test is greater than or equal to 125 milligrams per deciliter on at least two separate occasions the patient will be labeled as a diabetic patient or glycosylated hemoglobin HBA1c.

If it is greater than or equal to 6.5 percent the patient will be labeled as a diabetic patient. When you have diagnosed a patient with diabetes mellitus.

 Now you have to begin with the treatment, the treatment of diabetes always begins with the first line of therapy,

The first line of therapy is lifestyle modification in lifestyle modification, what you do is you ask the patient to do at least 30-minute exercise every day.

You ask them to change their diet to lower their sugar intake and to lose weight because obesity is related to insulin resistance you ask the patient to come back to your clinic in three months and in follow-up in three months you check their HBA1c level.

If their HBA1c level is elevated you begin your second-line treatment and the target of HBA1c level in a diabetic patient is less than seven percent the target of HBA1c, is slightly lenient we diagnosed a patient with diabetes mellitus if HBA1c was greater than 6.5 but our target is to bring it back at least less than seven percent, this is because that when you start medication or insulin in a patient the risk of hypoglycemia increases and hypoglycemia can kill patients.

More rapidly than hyperglycemia so to prevent the episodes of hypoglycemia with medications insulin, your target is slightly lenient to prevent hypoglycemia if the patient comes back to you after three months and HBA1c is still not under control if it is greater than seven percent now you have to move to your second-line therapy.

Second-line therapy what do is you start a drug metformin, metformin is a hypoglycemic drug metformin acts on the liver and it inhibits hepatic gluconeogenesis it inhibits the synthesis of glucose from the liver, therefore, lowering down the glucose level metformin is an amazing drug but you have to take care that you do not administer it to the impaired patient all those patients who are having renal failure.

You have to avoid this drug because this drug is excreted by kidneys and if there is a renal failure this drug will l accumulate and it will cause lactic acidosis one important side effect of metformin is diarrhea but this diarrhea is self-limiting.

When you start a patient on metformin the patient might come back to you with a complaint of diarrhea but this diarrhea will go away within a few days.

So you start a patient on a lower dose of metformin and then you slightly increase the metformin dose to prevent diarrhea. you put the patient on metformin and ask the patient to come back in three months and you check their HBA1c level. If their HBA1c level is still greater than seven percent and the glucose level is not controlled.

Then you have to move to your third-line therapy and the third line of therapy you add a second drug to metformin and that second drug can be sulfinal urea or it can be any other hypoglycemic drug among the family of hypoglycemic therapies other anti-diabetic drugs are sulfonylurea. Sulfonylurea is a class of drugs that includes glyburide, glyphic and many more the mechanism of action is that they increase insulin secretion from the pancreas and control glucose levels but the side effect is when you are increasing insulin secretion from the pancreas the chances of hypoglycemia are high other than that you can also use glitter zones. Glitter zones are the class of drug that includes Rosy glitter zone, and Pio glitter zone the mechanism of action of glitter zones is that they increase insulin sensitivity in the peripheral tissues.

If you increase the sensitivity of insulin in the peripheral tissues insulin causes lipid synthesis insulin causes fat synthesis so it will cause weight

Gain the other class of drugs that can also be used is SGLT2 inhibitors. That includes glyphosates and glyphlosins act on the kidneys and inhibit glucose absorption from the renal tubules. So all of the excess glucose is lost in urine but if the glucose is high in urine the bacteria that is present in the renal tract will proliferate they will be very happy that so much glucose is coming from the body to the urinary tract.

They will feed on that glucose and cause urinary tract infections the other class of drugs that we are going to talk about is DPP4 inhibitors, dipeptidyl peptidase four inhibitors that include cetagliptin and saxoglyptine the mechanism of action is that they inhibit or block the action of DPP4 enzyme.

That causes the destruction of a hormone in, it is a hormone that potentiates the effect of insulin so if you block the enzyme that is degrading in creatine you increase the level of hormone in creatine, and the increased level of the hormone will potentiate the effects of insulin and insulin will work more causing controlled sugar levels in potentiate insulin effects and we are blocking the enzyme that is destroying in and the good thing is that they are weight neutral they do not cause weight gain now you added a second drug to the patient either it was sulfonylurea or any drug among these you ask the patient to come back in three months and you check their HBA1c level.

If their hba1c level is still not controlled and it is greater than seven percent.

Now you have to move to your fourth line and that is to add a third drug to the regimen is which called triple therapy.

You can pick any of the above drugs according to the patient you pick a drug and you add it to the regimen be it DPP4 inhibitors or be it SGL2 inhibitors.

You put the patient on triple therapy and ask the patient to come back in three months after three months you check their HBA1c level and if their HBA1c level is still not under control then you have to move to your last line of therapy and that is to start insulin one important thing that I want to mention here is that when you are moving ahead in the treatment of diabetes in each and every follow-up visit of the patient.

You must always look into the cause of increased glucose levels you must always search for the cause of poor glucose control for which you have to move to the next line sometimes it happens that the patients are not compliant with the treatment, they are either not following the lifestyle modifications or they are not even taking medications properly.

So you have to search for the cause if the cause is poor compliance you stick to the same line and you ask the patient to be more compliant with the treatment or sometimes it happens that within that same line, you increase the dose and that works and that saves the patient from going to the next line of treatment and then I want to mention that lifestyle changes, can reduce HBA1c level by 1 percent metformin can reduce HBA1c by 3 percent and insulin can reduce HBA1c level by 7 percent so if initially a patient presents to your clinic with HBA1c level of greater than 9 percent that patient sugar cannot be controlled with lifestyle modifications or medication for initial control of that high glucose level you have to start insulin and then you shift the patient to medication.

If a diabetic patient is admitted to the hospital for any active infection and that patient is on oral medications you must shift that patient to insulin till the time that active infection is treated when the active infection is treated you shift the patient back to oral hypoglycemic drugs.

You put the patient on insulin you start insulin by giving a long-acting insulin of 0.1 unit per kg this long-acting insulin is usually taken at bedtime when the patient is going to sleep they take this injection and they check their morning sugar levels.

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If the morning sugars level is elevated you increase the dose of that insulin, Accordingly you check the sugar levels, and the sugar levels are still not controlled then what you do is you add another insulin to it what you do you pick the biggest meal of the day and you add rapid-acting insulin before that meal you ask the patient to take an injection before that big meal of the day and that reproductive insulin will control that glucose spike with that big meal or you can directly shift the patient to an insulin regimen in insulin regimens.

You have an option like basal-bolus which provides the best control or you can start the patient on mixed insulin 70, 30, or insulin sliding scale.

When you have diagnosed a patient with diabetes you start with lifestyle modification if it is not controlled you start metformin. If it is still not controlled you check the HBA1c level it is greater than seven percent you add a second drug to metformin mostly sulfonylurea.

If it is still not controlled you add the third drug to the regimen to keep the patient off the insulin and if the glucose levels are still not under control you have to start insulin. you start insulin by giving a long-acting insulin of 0.1 unit per kg.

If the sugar levels are still not under control you add another insulin or you directly shift to insulin regimens lifestyle changes reduce HBA1c by one percent metformin by three and insulin by seven.

If HBA1c is greater than nine percent immediately start insulin then shift the patient back to oral medication.

 If the patient is having active infection shift the patient from oral medication to insulin and when the infection is treated shift the patient back to oral hypoglycemic drugs.

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