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Management of Type 2 Diabetes

Management of type 2 diabetes goals of care are to prevent complications and optimize quality of life. Type 2 diabetes is a metabolic disorder that causes sugar, in the form of glucose to accumulate in the blood rather than being used as fuel by the cells in our body. The goal of type 2 diabetes management is to safely keep blood glucose in the normal range.

Normal Ranges:

  • 90 – 130 mg/dl fasting blood glucose
  • HbA1c of 6.5 – 7%
  • 2 hours post meal <180 mg/dl

Improving diet and exercising regularly are important aspects of type 2 diabetes management and treatment. In over-weight or obese persons, weight loss can often return blood glucose levels to normal, if it occurs early.

Exercise decreases the resistance of the cells to the action of insulin making it easier for the glucose to enter the cells from the blood stream. This benefit of exercise occurs even if there is no associated weight loss. If weight loss, improved diet and exercise do not reduce blood glucose levels adequately, then medication is the next step.

There are a variety of oral and injectable medications used to manage type 2 diabetes. Most persons with diabetes are initially prescribed metformin (an oral antidiabetic agent). Metformin blocks the production of glucose by the liver. Metformin also decreases the resistance of cells to insulin, making it easier for the cells to take up glucose from the blood stream. 

After metformin, doctors often prescribe sulfonyureas or DPP-IV inhibitors. Like metformin, sulfonyureas are inexpensive and effective. They work by increasing insulin release from the pancreas; however, they may cause hypoglycaemia.

Hypoglycaemia occurs when the blood glucose level drops too low. It is important for patients to recognise the symptoms of hypoglycaemia, such as – shakiness, sweating, palpitations and weakness before it leads to more severe effects such as confusion, fainting or loss of consciousness.

Incretins are essential chemicals secreted by the gut in response to meals and have important antidiabetic effects. They work by slowing the emptying of the stomach so you feel full longer – increasing insulin secretion, improving insulin sensitivity and decreasing glucose production.

In diabetes, incretin levels are reduced. There are two types of medications that works to improve the levels of incretins in the body – the oral DPP-IV inhibitors and the injectable GLP-1 analogues.

 The DPP-IV inhibitors prevent the breakdown of incretin hormones and increase their antidiabetic effects. These newer medicines work by increasing insulin production, they have little risk of hypoglycaemia. They also make cells more sensitive to the action of insulin. The injectable GLP-1 analogs replace the incretins directly. They also slow the movement of food through the digestive tract so you feel fuller for longer. They improve insulin secretion and may promote weight loss. They also have a low risk of hypoglycaemia.

Thiazolidinediones is another class of oral antidiabetic agents. They work by making the cells more sensitive to insulin and decreasing glucose production. They do not cause hypoglycaemia but they may cause weight gain. Other types of pills for diabetes include SGLT-2 inhibitors (blocks glucose reabsorption in kidneys), alpha-glucosidase inhibitors (slow release of sugar into blood stream), bromocriptine and colesevelam.

Over time, medications often become less effective. Rather than switching your medication, your doctor may combine two different medications which have been shown to work well together. If your blood glucose cannot be controlled by pills alone, your doctor may put you on insulin.

Insulin is the most common injectable medication used to manage diabetes. There are two types of insulin – long-acting or basal insulin and short-acting or meal-time insulin. An insulin pump can be used in type 2 diabetes to deliver insulin just like the pancreas.

Healthy diet, exercise and maintaining a healthy body weight are important aspects of diabetes management, even if you are on medications. You should develop a self-management plan with your doctor and other professionals, such as a dietician and certified fitness professional.

Your plan should include eating healthy foods and incorporating regular moderate intensity exercise into your lifestyle. Important dietary interventions specific to diabetes include reducing sugars, starches and fatty foods.

Strategies to reduce stress at home and at work, ensuring adequate sleep and managing depression, if present, are also important.

In summary, type 2 diabetes is treated by a combination of diet, exercise and medication. A variety of drugs are available to treat diabetes. However, self-management through lifestyle plays a very important role.

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