General strategy and non-pharmacological approach
The basis of successful patient management is a comprehensive approach implemented across three key areas simultaneously. First, strict glycemic control is required, achieved through a combination of diet, lifestyle modification, medications, and physical activity (which must be adequate but not excessive). Second, mandatory risk factor correction is performed, including treatment of arterial hypertension, hyperlipidemia, and obesity. Third, complication management is carried out: patients are indicated for regular screening to detect and treat retinopathy, nephropathy, neuropathy, and heart failure.
A regimen focusing on high physical activity is extremely important. Its physiological rationale is that it effectively promotes the reduction of excess body weight.
Diet therapy is based on the principles of fractional nutrition (four meals a day are recommended) and strict selection of consumed carbohydrates:
- Fast carbohydrates are excluded: any sugar and products containing it, flour products (including pasta), sweet fruits (such as grapes and dates), and alcohol (especially sweet wines and strong alcoholic beverages).
- Slow carbohydrates and fiber are included: black bread, various porridges, potatoes, bran, and vegetables with a high dietary fiber content are permitted.
Oral hypoglycemic therapy
Tableted medications are indicated primarily for type 2 diabetes mellitus, especially if the disease occurs against the background of excess body weight. Long-term compensation of hyperglycemia using these agents, if accompanied by normalization of blood pressure and lipid profile, has important prognostic significance: it allows delaying the progression of both macrovascular and microvascular complications.
Three main groups of drugs are distinguished:
- Biguanides: drugs of first choice, among which metformin is most frequently used.
- Sulfonylureas.
- Thiazolidinediones: an additional group of medications whose specificity lies in reducing insulin resistance, the main pathogenetic link of type 2 diabetes.
Absolute contraindications to the prescription of oral forms must be strictly taken into account: these include any manifestations of ketoacidosis and the presence of renal failure.
Basics of insulin therapy
According to epidemiological data, insulin is used in approximately 1/3 of all diabetes patients. Drugs are classified into three categories by duration of action:
- Regular insulin: characterized by a rapid and relatively short-lived effect.
- Intermediate-acting insulin (NPH/intermediate): prolonged (intermediate) action drugs.
- Long-acting insulin: agents with an even more delayed and prolonged effect.
The mechanism of prolongation of these drugs is based on their slow absorption from the injection site, which ensures a prolonged hypoglycemic effect.
Dosage calculation and administration regimen: The basic calculation principle relies on the fact that 1 U of insulin promotes the utilization of 3–5 g of glucose. There is also an approximate calculation method based on glucosuria levels: for every 100 g of glucose lost by the patient in urine per day, approximately 20 U of insulin must be administered. The calculated daily dose must be divided into 2–3 injections.
The modern treatment regimen implies a combination of drugs of varying duration of action (up to 24–36 hours), which allows individualizing the dose as much as possible for each patient. Transition to insulin therapy makes it possible to somewhat expand the diet, but strict restriction or complete exclusion of sweets remains an absolute mandatory condition.
Briefly: answers to topical questions
What specific international nonproprietary names belong to sulfonylureas?
Sulfonylureas comprise a broad group of hypoglycemic drugs that stimulate insulin secretion by acting on ATP-dependent potassium channels. This group is classified into two generations and includes the following international nonproprietary names:
- First-generation drugs include carbutamide, tolazamide, tolbutamide, and chlorpropamide.
- Second-generation drugs include glibenclamide, gliclazide, glipizide, and gliquidone.
Which receptors do thiazolidinediones act on to reduce insulin resistance?
To reduce insulin resistance, thiazolidinediones act as agonists of PPAR-$\gamma_2$ receptors. This mechanism promotes an increase in the population of small adipocytes, which have a higher sensitivity to insulin. In addition, the drugs lead to an increase in the number of insulin-dependent glucose transporters (GLUT-4) and a decrease in the concentration of free fatty acids, which normally inhibit glucose uptake by tissues.
To memorize prohibited foods, use the mnemonic "SAMS": Sugar, Alcohol, Flour products, Sweet fruits are the main sources of fast carbohydrates that must be excluded.
Class and exam questions
What is the main goal of diabetes mellitus treatment?
The main goal is to maintain normoglycemia throughout all 24 hours of the day, with the mandatory condition of completely excluding hypoglycemic states.
Can oral medications be used in complicated cases of diabetes?
No, the development of ketoacidosis, as well as the onset of renal failure, are absolute contraindications to taking oral hypoglycemic forms.
How to calculate insulin requirements based on urinalysis?
An approximate calculation based on glucosuria is used: for every 100 grams of glucose lost in the urine per day, approximately 20 U of insulin is administered to the patient.
How is the long-term effect of long-acting insulins achieved?
The mechanism of their prolongation consists in the very slow absorption of the drug directly from the injection site, which allows maintaining the hypoglycemic effect for a long time.
What else to study on this topic
- Pathogenetic significance of insulin resistance
- Screening and treatment of diabetic retinopathy
- Screening and treatment of diabetic nephropathy
- Mechanisms of action of biguanides (metformin)
- Effect of hyperlipidemia on the progression of macrovascular complications
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