From the Guidelines
Uncontrolled diabetes requires immediate medical attention and a comprehensive management approach, prioritizing medication therapy, lifestyle modifications, and regular blood glucose monitoring to prevent serious complications and improve quality of life. The management of uncontrolled diabetes should be guided by the most recent and highest quality evidence, which emphasizes the importance of individualized treatment plans and regular follow-up appointments with healthcare providers.
Key Components of Management
- Medication therapy: typically starting with metformin (500-2000mg daily) for type 2 diabetes, or insulin therapy for type 1 diabetes (with individualized dosing based on weight and blood glucose levels) 1
- Lifestyle modifications: including a balanced diet low in refined carbohydrates, regular physical activity (aim for 150 minutes weekly), weight management, and stress reduction 2
- Regular blood glucose monitoring: with target fasting levels of 80-130 mg/dL and post-meal levels below 180 mg/dL
Complications of Uncontrolled Diabetes
- Cardiovascular disease
- Kidney damage
- Nerve damage
- Vision problems These complications can be prevented or delayed with proper management, as evidenced by studies such as the Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study 3
Importance of Recent Evidence
The most recent study on glycemic monitoring and management in advanced chronic kidney disease, published in 2020, highlights the need for better strategies to improve glycemic outcomes in high-risk populations 3. Another study published in 2020, the 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases, emphasizes the importance of lifestyle changes, including reduced calorie intake and moderate-to-vigorous physical activity, in preventing diabetes and its cardiovascular complications 2
Individualized Treatment Plans
Regular follow-up appointments with healthcare providers are necessary to monitor the condition and adjust treatment as needed, taking into account the individual's response to therapy, comorbidities, and other factors that may influence treatment outcomes 4, 1, 3, 2
From the Research
Uncontrolled Diabetes Management
- Uncontrolled diabetes can be managed with various medications, including GLP-1 receptor agonists, SGLT-2 inhibitors, and DPP-4 inhibitors, which can be used as add-on therapies to insulin and oral hypoglycemic drugs 5.
- The combination of GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT-2 inhibitors can effectively lower HbA1c and fasting plasma glucose levels in patients with type 2 diabetes who have poor therapeutic effects on basic insulin combined with metformin/sulfonylureas 5.
- GLP-1 receptor agonists can also significantly reduce body weight and basic insulin dosage, while DPP-4 inhibitors and SGLT-2 inhibitors have a lower risk of hypoglycemia 5.
Comparison of Medications
- A study compared the efficacy and safety of sitagliptin, a DPP-4 inhibitor, with glipizide, a sulfonylurea, in patients with type 2 diabetes inadequately controlled on metformin alone, and found that sitagliptin was non-inferior to glipizide in terms of HbA1c reduction 6.
- Another study found that the addition of sitagliptin to ongoing metformin therapy provided similar HbA1c-lowering efficacy to glipizide, with a lower risk of hypoglycemia and weight loss compared to weight gain with glipizide 6.
- A systematic review compared the safety and efficacy of sulfonylureas and DPP-4 inhibitors as second-line therapies in type 2 diabetes mellitus, and found that DPP-4 inhibitors may be considered a clinically stable choice for second-line therapy due to their lower risk of hypoglycemia, despite being less efficacious than sulfonylureas in lowering HbA1c 7.
Treatment Approach
- The STEPS approach (safety, tolerability, efficacy, price, and simplicity) can be used to evaluate pharmacotherapy options for type 2 diabetes mellitus, and metformin is generally considered the first-line treatment option 8.
- The choice of subsequent medications depends on multiple patient-specific factors, including cardiovascular risks, risk of hypoglycemia, metabolic changes, and cost 8.
- A randomized controlled trial found that the addition of sitagliptin to pre-existing therapy with liraglutide, a GLP-1 receptor agonist, increased intact GLP-1 and GIP concentrations, but had marginal, non-significant effects on glycaemic control 9.