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Diet, exercise, and education remain the foundation of all type 2 diabetes treatment programmes. After metformin, it is reasonable to consider combination therapy with an additional 1-2 oral or injectable agents with the objective of minimising side-effects where possible. For many patients insulin therapy alone or in combination with other agents will ultimately be required to maintain glucose control.
All treatment decisions, where possible, should take into account the patient’s preferences, needs and values.
Diabetes may be diagnosed based on HbA1c criteria or plasma glucose criteria, either the fasting plasma glucose (FPG) or the 2-h plasma glucose (2-h PG) value after a 75-g oral glucose tolerance test (OGTT). For all patients, particularly those who are overweight or obese, testing should begin at age 45 years. Two primary techniques are available to assess the effectiveness of glycaemic control: Patient self-monitoring of blood glucose (SMBG) or interstitial glucose and A1C. Patients on multiple-dose insulin or insulin pump therapy should perform SMBG prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycaemic, and prior to critical tasks such as driving.
Initial therapy: Most patients should begin with lifestyle changes – healthy eating, weight control, increased physical activity, and diabetes education. Advancing to dual combination therapy: If the HbA1c target is not achieved after ~3 months with metformin, there are six drug choices including a second oral agent (sulfonylurea, TZD, DPP-4 inhibitor, or SGLT2 inhibitor), a GLP-1 receptor agonist, or basal insulin.


Advancing to triple combination therapy: Evidence suggests that there is some advantage in adding a third noninsulin agent to a two-drug combination not achieving the glycaemic target. Do you agree that private hospitals should be paid via the NTPF to cut public hospital waiting lists? For decades, the diagnosis of diabetes was based on plasma glucose criteria — either the fasting plasma glucose (FPG) or the two-hour value in the 75g oral glucose tolerance test (OGTT).
Since last year, the American Diabetes Association has recommended using the A1C test to diagnose diabetes, with a threshold of ?6.5 per cent. NICE recommends metformin as an option for first-line glucose-lowering therapy where blood glucose is inadequately controlled using lifestyle interventions alone. Metformin and the thiazolidinediones (TZDs such as pioglitazone) act on the liver to reduce hepatic glucose production.
The glucagon-like peptide-1 (GLP-1) analogues, the inhibitors of dipeptidyl peptidase 4, (DPP-4 inhibitors) and the sulphonylureas are effective in the area of insulin secretion. There are two incretins, known as glucose-dependent insulinotropic peptide (GIP) and glucagon-like peptide-1 (GLP-1).
Incretins are going to dominate the field of diabetes over the next five years, Prof O’Shea said. The active compound GLP-1 (7-36) is very quickly broken down by DPP-4 into the inactive compound GLP-1 (9-36). Lowering A1C to below or around 7 per cent has been shown to reduce microvascular and neuropathic complications of diabetes and, if implemented soon after the diagnosis of diabetes, is associated with long-term reduction in macrovascular disease. The landmark UKPDS trial of type II diabetes observed a 16 per cent reduction in cardiovascular complications (combined fatal or nonfatal myocardial infarction [MI] and sudden death) in the intensive glycaemic control arm. Aspirin therapy may be considered as a primary prevention strategy in those with type II diabetes who are at increased cardiovascular risk. Hypertension is a common comorbidity of diabetes, affecting the majority of patients, with prevalence depending on type of diabetes, age, obesity, and ethnicity. Patients with more severe hypertension (systolic blood pressure ?140 or diastolic blood pressure ?90mmHg) at diagnosis or follow-up should receive pharmacologic therapy in addition to lifestyle therapy.
The American Diabetes Association says that treatment should include an angiotensin converting enzyme (ACE) or an angiotensin II receptor blocker (ARB). Gastric reduction surgery, either gastric banding or procedures that involve bypassing, transposing or resecting sections of the small intestine — when part of a comprehensive team approach — can be an effective weight-loss treatment for severe obesity. Bariatric surgery has been shown to lead to near or complete normalisation of glycaemia in between 55-95 per cent of patients with type II diabetes, depending on the surgical procedure.
Patients with type II diabetes who have undergone bariatric surgery need life-long lifestyle support and medical monitoring. Dr Velma Harkins of the Irish College of General Practitioners, the National Clinical Lead for Diabetes Prof Richard Firth and Dr John Devlin of the Department of Health published guidelines in regard to diagnosis, targets for clinical care and the interventions that are appropriate at each stage of the disease. Metformin is contraindicated in those with renal impairment, those at risk of sudden deterioration of renal function and end-stage cardiac and hepatic failure. DPP-4 inhibitors such as sitagliptin and vildagliptin are approved as add-on therapy to metformin. Identify your HbA1c test score, mean blood and glucose level to know if your blood glucose is in the optimum level. Diabetes may be identified in seemingly low risk individuals who happen to have glucose testing, in symptomatic patients, and in higher-risk individuals who are tested because of a suspicion of diabetes. When lifestyle efforts alone have not achieved or maintained glycemic goals, metformin monotherapy should be added at, or soon after, diagnosis (in patients intolerant, or with contraindications for, metformin, select initial drug from other treatment options). However, self blood-glucose monitoring (SBGM) is the single most expensive aspect of diabetes care to the State.
It is no longer necessary to measure glucose to make a diagnosis of diabetes, Prof O’Shea said. Incretins, such as exenatide (Byetta) and liraglutide (Victoza) may be given in type II diabetes. After 10 years of follow-up, the UKPDS showed that for participants originally randomised to intensive glycaemic control — compared with those randomised to conventional glycaemic control — there were long-term reductions in MI (15 per cent with sulfonylurea or insulin as initial pharmacotherapy and 33 per cent with metformin as initial pharmacotherapy). There is an argument in diabetes about whether blood pressure management, rather than glycaemic management, should be pre-eminent. Multiple drug therapy (two or more agents at maximal doses) is generally required to achieve blood-pressure targets.
In this trial, 73 per cent of surgically-treated patients achieved ‘remission’ of their diabetes, compared with 13 per cent of those treated medically.


Long-acting, once-daily sulphonylureas may be useful where concordance with therapy is a suspected problem.
Shared decision making with the patient is important to help in the selection of therapeutic option. Since diabetes is associated with progressive beta-cell loss, many patients, especially those with long-standing disease, will ultimately need to be transitioned to insulin. All of these agents are used and they all confer a benefit to the A1c — and to cardiovascular and microvascular profiles. There were also reductions in all-cause mortality (13 per cent and 27 per cent respectively). In type II diabetes, hypertension usually coexists with other cardiometabolic risk factors.
The UKPDS study proved that if blood pressure could be controlled, patients did much better. This is especially the case if the diabetes or associated co-morbidities are difficult to control with lifestyle and pharmacologic therapy. Am J Med 2009) of studies of bariatric surgery involving 3,188 patients with diabetes reported that 78 per cent had remission of diabetes (normalisation of blood glucose levels in the absence of medications) and that the remission rates were sustained in studies that had follow-up exceeding two years. The Expert Advisory Group in Diabetes in its 2007 report recognised the need for a new model of care for people with type II diabetes.
The choice is based on patient and drug characteristics, with the over-riding goal of improving glycaemic control while minimising side-effects.
Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Doctors encourage this and need to steer away from it, said Prof Donal O’Shea, Consultant Endocrinologist at St Vincent’s Hospital. The DPP-IV inhibitors include Januvia (sitagliptin), Onglyza (saxagliptin) and Eucreas — a combination of vildagliptin and metformin. As is the case with microvascular complications, it may be that glycaemic control plays a greater role before macrovascular disease is well developed. Remission rates tend to be lower with procedures that only constrict the stomach, and higher with those that bypass portions of the small intestine. This integration across primary, secondary and tertiary care requires agreed clinical guidelines. Dexcom (G4 Platinum Continuous Glucose Monitor) and Asante (Snap insulin pump) have announced a partnership on their future products that will allow the controlling and viewing of data on smartphones. However, compounds have been developed that activate the GLP-1 receptor with a view to improving insulin secretion. Additionally, there is a suggestion that intestinal bypass procedures may have glycaemic effects that are independent of their effects on weight, perhaps involving incretins. In using triple combinations the essential consideration is obviously to use agents with complementary mechanisms of action. In certain settings (like a business meeting or patient visit), even pulling out a smartphone can be an untimely distraction.
With glanceable glucose data accessible on your watch, checking your sugar would take just a few seconds.Furthermore, the Apple Watch introduces a new Taptic engine that provides a gentle sensation as if someone is tapping your wrist.
Apple CEO Tim Cook specifically mentioned there would be no audible buzz that would alert others around you.The Taptic engine’s tactile feedback on your wrist can have different patterns. He satisfies his passion for diabetes technology by working on Sugar Streak, an iPhone and Apple Watch app for Diabetes, and blogging at diabe.tech. Log in to Reply savvy venkat January 19, 2015 at 12:06 pm # How does the Apple Watch for Diabetes work? Our physician editors lead a team of physicians, allied health professionals, medical trainees, and mHealth analysts in providing reviews, research, and commentary of mobile medical technology. Our publication is heavily based on our own experiences in the hospital and clinic setting.



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