Treatment of Type 2 Diabetes Mellitus

A multi-disciplinary approach is usually use in the management of patient with diabetes. Diabetic patients are likely to have vascular complications of diabetes such as coronary heart diseases, stroke, nephropathy and peripheral vascular complications. Therefore, the aim of treatment is to reduce their risks of such complications as well as to minimize symptoms while allowing a normal life.

This can be done through 2 main modalities: lifestyle modifications and pharmological interventions.

1) Lifestyle Modifications:

- Diet:

Control of caloric intake can be done through modifying the diet such that 30 calories is given per kilograms of ideal body wt: can be increased to 40 calories per kilograms for an active person and 50 calories per kilograms if the patient does heavy physical labour. Therefore, Mr Tan ideal calories intake should be 30 x 69 = 2070 calories per day. The calories should be distributed as 55% to 60% carbohydrates, 25% to 35% fat, and 15% to 20% protein.

Emphasis should be placed on complex carbohydrates rather than simple and refined starch as well as polyunsaturated fats instead of saturated fats in a ratio of 2:1. Therefore, Mr Tan should be advised to eat wholemeal bread, brown rice, margarine, vegetable oil instead of rice, fried food, and fatty meat.

He should also be educated on the glycemic index of various foods. A lower rise in blood sugar occurs after the ingestion of simple sugars compared to complex carbohydrates which is seen after the absorption of glucose.

Fiber (soluble and insoluble) intake should also be encouraged as it delays glucose absorption and have also been shown to lower elevated triglyceride level.

- Exercise:

He should be advised to exercise at least 3 times a day for at least 30 minutes each time.
And if possible, he should take the stairs instead of the lift. Working as a taxi driver requires him to sit for long hours, increases his risk of having deep vein thrombosis. Therefore, he should be advised to do some light exercises every few hours to improve blood circulation.

2) Pharmological intervention: Oral Hypoglycemic Agents

- Biguanides (insulin sensitizers)
Metformin is the commonly used drug in this group.
They work by increasing the density of insulin receptors; directly stimulate glycolysis in peripheral tissues; reduce hepatic gluconeogenesis; decrease glucose absorption from the gastrointestinal tract and reduce plasma glucagon level.

- Sulphonylureas (Insulin secretagogues)
Glibenclamide/ daonil is used in this patient as it produces a synergistic effect with metformin in the control of diabetes.
They work by closing ATP sensitive potassium channels, causing depolarisation of islet cells and influx of calcium ions which stimulates the release of insulin.

Other classes of drugs such as thiazolinediones, meglitinide, alpha-glucosidase inhibitors have also been prove their worth in diabetic control. Hence, they can be used as additions or subsitiutions to Mr Tan’s current regimen if glycemic control is inadequate seen in the subsequent follow-ups.

In all, Mr diabetic patients should be educated on the importance of good glycemic and blood pressure (preferably less than 130/80 mmHg) control to prevent the complications of diabetes mellitus. Good compliance with diet and medication as well as support from family and healthcare personnel will help to reduce the morbidity and mortality of the disease.

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Dr Greeve, MD
Where can you get Senior Doctor’s Professional Advice for free
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