How to manage blood glucose levels in diabetes?

From the Guidelines

Managing blood glucose levels in diabetes requires a comprehensive approach including medication, lifestyle changes, and regular monitoring, with a focus on preventing hypoglycemia and hyperglycemia, as well as improving quality of life, as recommended by the most recent guidelines 1. To achieve this, several key strategies can be employed:

• Medication: For type 1 diabetes, insulin therapy is essential, typically involving basal insulin (like Lantus or Levemir) once or twice daily, plus rapid-acting insulin (such as Humalog, NovoLog, or Fiasp) before meals. Type 2 diabetes often starts with metformin (500-2000mg daily in divided doses), with additional medications like SGLT-2 inhibitors (empagliflozin, dapagliflozin), GLP-1 receptor agonists (semaglutide, dulaglutide), or DPP-4 inhibitors (sitagliptin) added if needed, as supported by previous studies 1.
• Lifestyle changes: Dietary changes are crucial, focusing on controlling carbohydrate intake, choosing complex carbohydrates over simple sugars, and maintaining consistent meal timing. Regular physical activity (150 minutes of moderate exercise weekly) helps improve insulin sensitivity, as emphasized in recent guidelines 1. Stress management and adequate sleep also contribute to better glucose control.
• Regular monitoring: Blood glucose should be monitored regularly, aiming for fasting levels of 80-130 mg/dL and post-meal levels below 180 mg/dL. The use of self-monitoring of blood glucose (SMBG) is recommended for all insulin-treated patients with diabetes, and may be desirable in patients treated with sulfonylureas or other insulin secretagogues, as stated in earlier research 1. Some key considerations for specific patient populations include:
• Older adults: The goal is to prevent hypoglycemia and hyperglycemia, with a focus on quality of life, as recommended in recent guidelines 1.
• Patients with advanced disease: Different patient categories have been proposed, including stable patients, patients with organ failure, and dying patients, each with unique management strategies, as outlined in previous studies 1. Overall, a comprehensive approach to managing blood glucose levels in diabetes, incorporating medication, lifestyle changes, and regular monitoring, can help improve outcomes and quality of life for patients with diabetes, as supported by the most recent and highest quality evidence 1.

From the FDA Drug Label

The management of antidiabetic therapy should be individualized. Ideally, the response to therapy should be evaluated using HbA1c which is a better indicator of long-term glycemic control than FPG alone. The main goal of treating diabetes is to lower your blood sugar to a normal level. High blood sugar can be lowered by diet and exercise, and by certain medicines when necessary.

To manage blood glucose levels in diabetes, individualized antidiabetic therapy should be used. The goal is to lower blood sugar to a normal level, which can be achieved through:

• Diet
• Exercise
• Medicines when necessary It is also important to monitor and evaluate the response to therapy using HbA1c as a better indicator of long-term glycemic control. 2 3

From the Research

Managing Blood Glucose Levels in Diabetes

To manage blood glucose levels in diabetes, several strategies can be employed, including medication, lifestyle changes, and monitoring.

• Medication: The use of metformin as a first-line therapy is widely recommended 4. In cases where metformin alone is insufficient, adding a sulfonylurea or pioglitazone can be effective options to improve glycemic control 4, 5.
• Combination Therapy: Research suggests that initial combination therapy with metformin, pioglitazone, and exenatide can be more effective than sequential add-on therapy in achieving better glycemic control with fewer hypoglycemic events and less weight gain 6.
• Monitoring: Traditional monitoring involves laboratory measurement of hemoglobin A1c (HbA1c). However, continuous glucose monitoring (CGM) is emerging as a valuable tool for managing glucose control. The glucose management indicator (GMI), which estimates HbA1c from CGM data, has been proposed but its usefulness is debated, with some arguing that using CGM mean glucose directly is preferable 7.
• Lifestyle Changes: While not directly addressed in the provided studies, lifestyle modifications such as diet and exercise are fundamental components of diabetes management and can significantly impact blood glucose levels.

Considerations for Therapy

When selecting a therapeutic approach, considerations should include the patient's specific needs, potential side effects of medications, and the impact on cardiovascular risk factors. For example, pioglitazone and sulfonylureas have different mechanisms of action and side effect profiles 5, and their choice may depend on the patient's overall health status and the presence of other conditions.

• Side Effects and Risks: The risk of hypoglycemia, weight gain, and other side effects should be carefully weighed when choosing between different therapeutic options 8, 6.
• Cardiovascular Considerations: The impact of diabetes therapies on cardiovascular risk factors is an important consideration. Some therapies may offer benefits beyond glycemic control, such as improvements in lipid profiles and blood pressure 8.