Type 2 diabetes treatment guidelines 2014 georgia,january flower of the month tattoo 3d,meal plan for a type 2 diabetes,type 2 diabetes symptoms upset stomach pain - You Shoud Know


Diet, exercise, and education remain the foundation of any type 2 diabetes treatment program. Ultimately, many patients will require insulin therapy alone or in combination with other agents to maintain glucose control.
The American Diabetes Association and the European Association for the Study of Diabetes have updated guidelines on the management of hyperglycemia in nonpregnant adults with type 2 diabetes.
The novel position statement on the management of hyperglycemia in type 2 diabetes was necessary because since the last similar treatment algorithm, which is more than 3 years old, a lot of new insights have been generated that required an update. According to the ADA, to reduce the incidence of macrovascular disease, HbA1c should be lowered to less than 7% in most patients. For strong recommendations in favour (or against) certain diabetes medications, the evidence is not strong enough; choices and preferences will differ with different patients, their characteristics and attitudes. Several therapeutic options were discussed, including lifestyle interventions to change physical activity levels and food intake; oral agents and noninsulin injectables, as well as insulin. The second step can be a dipeptidyl peptidase-4 inhibitor, it can be a glucagon-like peptide-1 (GLP-1) receptor agonist, it can be a thiazolidinedione, it can be a sulfonylurea agent, or it could be basal insulin. If a patient needs a more intensive insulin regimen, then it is recommended to add 1 or 2 - maybe even 3 - doses of mealtime insulin. The position statement lists all commonly used medications with all their properties (positive and negative), and gives all the information to make good choices based on priorities (ie, avoiding hypoglycemia at all costs) and preferences. Overall, comparative evidence for antihyperglycemic treatment of type 2 diabetes is lacking, and there is a considerable need for high-quality, comparative-effectiveness research on costs and outcomes important to patients, including quality of life and the avoidance of life-limiting complications such as cardiovascular disease. Because of the rapid change in lifestyle in China, there is concern that diabetes may become epidemic. A nationally representative sample of 46,239 adults, 20 years of age or older, from 14 provinces and municipalities participated in the study.
These results indicate that diabetes has become a major public health problem in China and that strategies aimed at the prevention and treatment of diabetes are needed. In an editorial comment in the European Heart Journal, some opinion leaders indicate what might be the reasons for the failure of the dal-HEART programme.Both the on-treatment vascular effects and the underlying molecular mechanism causing increased HDL-c are important in determining the vascular effects of an HDL-c raising therapy. The Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study assessed how to manage diabetes in children and adolescents. The China National Survey of Chronic Kidney disease was a cross-sectional study to evaluate the prevalence of CKD and associated factors in Chinese adults between 2007 and 2010.CKD has become an important public health issue in China, maybe as a consequence of increased diabetes and hypertension.
DPP-4 inhibitors can be used as second line treatment in patients with type 2 diabetes who do not achieve their glycaemic targets with metformin alone. The study was set up to determine all cause mortality and deaths from cardiovascular events related to intensive glucose lowering treatment in people with type 2 diabetes. In GPRD data, current use of sulphonylureas only (with active or inactive metabolites) was associated with an increased risk of hypoglycaemic events, as compared with current use of metformin.
Recent outcome trials of novel antidiabetic drugs shed new light on why diabetes patients develop heart disease. Out of 18 biomarkers, Lp-PLA2 and adiponectin were independently associated with a decreased risk for T2DM. In females with gestational diabetes, the future risk of developing type 2 diabetes depends on certain pregnancy-related and maternal factors that could be used for postnatal counselling. After diagnosis of diabetes, the importance of protecting the body from damage caused by hyperglycemia cannot be overstated.
It is commonly recommended that T2DM patients who use insulin self-monitor their blood glucose levels, but the evidence to support the effectiveness of this practice is inconclusive. It is important to establish individual goals with patients regarding target blood glucose measurements. HbA1c measures nonreversible glycosylation of the hemoglobin molecule, which is directly related to blood glucose concentrations.
Traditionally it has been recommended that therapy be adjusted to maintain HbA1c values near or less than 7% in nonpregnant adults. When considering appropriate pharmacologic therapy, a major factor to consider is whether the patient is insulin deficient, insulin resistant, or both.
Available since the late 1950s, metformin can trace its roots back to medieval Europe, where biguanides in the form of French lilac were used in diabetes treatment.
Metformin is well tolerated, with the most common side effect being gastrointestinal (GI) complaints, such as diarrhea, nausea, abdominal discomfort, and a metallic taste.
The major benefits of metformin are that it usually does not lead to hypoglycemia when used as monotherapy.
Dosing is typically twice daily; however, it can be dosed three times daily or once daily (extended release).
Thiazolidinediones (TZDs) are agonists of peroxisome proliferator-activated receptor gamma (PPARI?) and primarily enhance sensitivity of muscle and fat, and mildly of the liver, to exogenous and endogenous insulin.
Major side effects include weight gain, with an increase in subcutaneous adiposity, and fluid retention which typically manifests as peripheral edema, but heart failure has been shown to occur on occasion. Insulin secretagogues stimulate secretion of insulin from the pancreas, thereby decreasing hepatic glucose production and enhancing glucose uptake by muscles and fat. Glinides work in a manner similar to sulfonylureas; however, they have a more-rapid onset of action and a short duration of action, so they are a good option for patients with erratic timing of meals. Alpha glucosidase inhibitors competitively block the enzyme alpha glucosidase in the brush borders of the small intestine, which delays absorption of carbohydrates (absorbed in the mid and distal portions of the small intestine instead). Incretin-based therapies can be used as injections (GLP-1 analogs) or as pills (DPP-4 inhibitors). These medications should not be given to the individuals who have a history of medullary thyroid carcinomas or have multiple endocrine neoplasia syndrome type 2.
Exenatide is a synthetic form of exendin 4, hormone found in the saliva of the Gila monster, that mimics glucagon-like peptide type 1 (GLP-1). Due to its delaying effects on gastric emptying, the major side effect is GI complaints such as nausea, vomiting, and diarrhea. Exenatide is currently also available as once a week injection, supplied as a kit containing the 2 mg of extended release exenatide.
Dipeptidyl peptidase 4 (DPP 4) is a cell membrane protein that rapidly degrades GLP-1 and glucose-dependent insulinotropic polypeptide. DPP 4 inhibitors act primarily on postprandial blood glucose levels, but reductions in fasting glycemia are also seen.
Pramlintide is a synthetic form of amylin, a hormone secreted by beta-cells that acts to suppress glucagon secretion, slow gastric emptying, and suppress appetite through central pathways.
As with exenatide, the major side effects are GI complaints, especially nausea, and hypoglycemia.
Currently in the United States it is approved only as an adjunctive therapy with insulin, but it can be used both T1DM and T2DM. The SGLT-2 inhibitors are the newest group of medications approved for treatment of diabetes mellitus. At this time canagliflozin and dapagliflozin are only medications in this class approved by the FDA for the treatment of type 2 diabetes. The most common side effects of SGLT-inhibitors are vaginal yeast infections and urinary tract infections. Additional benefits are weight loss (two thirds of weight loss is because of loss of fat tissue and one third is because of loss of water) and drop in the blood pressure. These medications are not indicated in children, in patients with type 1 diabetes, patients with frequent ketones in their blood or urine, severe renal impairment. Reprinted from Endocrine (Robard L, Braithwaite SS, et al; AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. The basal–bolus regimen involves combining a long-acting agent that is used once or twice daily and provides basal insulin needs and a rapid-acting agent for prandial coverage used with meals.
The insulin pump allows use of different basal insulin rates in different periods of the day and administration of the meal bolus as a single discrete bolus or as an extended bolus (square bolus) over a set period of time, which allows a better match between insulin delivery and glucose absorption from the meal in patients with abnormalities of gastric emptying.
In patients with gestational diabetes, insulin therapy is indicated when exercise and nutritional therapy are ineffective in controlling prandial and fasting blood glucose levels.
Insulin sensitizers and incretin-based therapy should be used early in the course of the disease.
Multiple daily doses of insulin providing basal, prandial, and supplemental insulin are a mainstay of insulin treatment. Rodbard HW, Blonde L, Braithwaite SS, et al; AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M; The STOP-NIDDM Trial Research Group. Every patient with documented type 2 diabetes mellitus (T2DM) should have a comprehensive care plan (CCP), which takes into account the patient’s unique medical history, behaviors and risk factors, ethnocultural background, and environment. The multidisciplinary team typically oversees the medical management of T2DM, including the prescription of antihyperglycemic therapy and the delivery of diabetes self-management education (DSME). Either the physician or a registered dietitian (RD) should discuss healthful eating recommendations in plain language at diagnosis of T2DM and then periodically during follow-up office visits (Table 1). MNT involves a more detailed discussion of calories, grams, and other metrics, as well as intensive implementation of dietary recommendations aimed at optimizing glycemic control and reducing the risk for complications.


Patients should be advised that any physical activity is better than none, and that they should make every effort to increase their activity level. An exercise prescription should be developed for each patient according to both goals and limitations. Antidiabetic treatment should be promptly intensified to maintain blood glucose at individual targets.
Selection of agents should be based on individual patient medical history, behaviors, and risk factors, ethnocultural background, and environment. Self-monitoring of blood glucose (SMBG) is a vital tool for day-to-day management of blood sugar in all patients using insulin and many patients not using insulin. Most patients with an initial A1C level greater than 7.5% will require combination therapy using agents with complementary mechanisms of action.
Antihyperglycemic agents may be broadly categorized by whether they predominantly target FPG or PPG levels (see Table 3).
The choice of whether to target FPG or PPG should be based primarily on the individual patient’s glycemic profile obtained by self-monitoring of blood glucose (SMBG). Intensification of pharmacotherapy requires glucose monitoring and medication adjustment at appropriate intervals when treatment goals are not achieved or maintained. Long-acting basal insulin is generally the initial insulin choice, and the insulin analogues glargine and detemir are strongly preferred over human NPH insulin because they have relatively peakless time-action curves and a more consistent effect from day to day, resulting in a lower risk of hypoglycemia. Basal insulin is usually added to existing noninsulin therapy, and many antihyperglycemic agents are approved for use with insulin: DPP-4 inhibitors, glinides, GLP-1 receptor agonists (but not exenatide XR), metformin, pramlintide, sulfonylureas, and TZDs. The risk of hypoglycemia is increased when combining insulin with sulfonylureas, glinides, DPP-4 inhibitors, and GLP-1 receptor analogues. GLP-1 receptor analogues and DPP-4 inhibitors have not been studied with prandial insulin. Using insulin with TZDs may increase the risk of weight gain, edema, and congestive heart failure. Rapid-acting insulin analogues are preferred over regular human insulin because they have a more rapid onset and offset of action and are associated with less hypoglycemia.
Premixed insulin analogue therapy may be considered for patients in whom drug regimen adherence is an issue; however, these preparations lack component dosage flexibility and may increase the risk for hypoglycemia compared with basal insulin or basal-bolus insulin. This approach (ie, transitioning to insulin after noninsulin agents fail to maintain glycemic targets) is supported by the recently published results of the Outcome Reduction with an Initial Glargine Intervention (ORIGIN) trial.
Several new classes of agents are under investigation for the treatment of T2DM, and some new agents within existing classes may represent improvements over currently available options.17 The listing in Table 4 should be considered representative and not necessarily all-inclusive. For complete descriptions of the devices and accompanying technology themselves, click on the links above. CSII is recommended mainly for patients with type 1 diabetes mellitus (T1DM), but patients with advanced T2DM who are absolutely insulin-deficient, take 4 or more insulin injections a day, and assess their blood glucose levels 4 or more times daily are candidates for CSII. Safety—particularly the risk of hypoglycemia—should be the primary concern when choosing an antidiabetic therapy. Table 3 lists the major safety risks associated with currently available antidiabetic agents.
Severe hypoglycemia stimulates sympathetic adrenergic discharge, causing arrhythmias or autonomic dysfunction (or both) and has long been recognized to have potential for causing mortality. In addition to increased mortality, hypoglycemia negatively affects adherence to therapy and quality of life and also contributes to morbidity. Management of hypoglycemia involves appropriate choice of antihyperglycemic therapy, tailoring of insulin treatment to minimize risks, and patient education in the recognition and treatment of acute hypoglycemia (Table 5).40 It is important to remember that the features listed in Table 5 occur along a continuum, and glycemic thresholds and symptom manifestations may vary widely among individuals. For T2DM patients, most of whom are overweight or obese, the risk of additional weight gain must be balanced against the benefits of the agent itself.
Once T1DM and monogenic diabetes have been ruled out and a T2DM diagnosis has been definitively established for a child or adolescent, diet and lifestyle modification are always the first treatment choices.
Children born to women with any form of diabetes are at greater risk of developing T2DM themselves.
Older adults are more likely to have an increased number of comorbid conditions (eg, frailty, dementia, depression, urinary incontinence) that can complicate their diabetes management.
Fasting is a common religious practice that can pose a challenge to diabetes management, particularly if the fast occurs over an extended time, such as Ramadan, a holy month of Islam in which all healthy adults consume no food or fluids between sunrise and sunset. The risk of these outcomes depends on the severity and complications of T2DM according to the categories in Table 7. For the management of glycemia during extended fasts, general principles and recommendations are listed below. Combination therapy with an additional 1–2 oral or injectable agents is reasonable, aiming to minimize side effects where possible. The update is based on new evidence of risks and benefits of glycemic control, evidence on safety and efficacy of new drug classes, the withdrawal and restriction of other drug classes and the increasing need for a more patient-centered approach to care. However, data from type 2 diabetes cardiovascular trials have demonstrated that not all patients benefit from aggressive glucose maintenance, again pointing toward a more individualized approach to treatment. In contrast to previous statements, the present one is based on a patient-centered approach. According to the guidelines, when it comes to prescribing oral agents and noninsulin injectables, agent- and patient-specific properties, such as dosing frequency, side effect profiles, cost and other benefits, are often used to guide drug selection. Anticipated glucose-lowering effects should be balanced with the convenience of the regimen, in the context of an individual’s specific therapy goals.
We conducted a national study from June 2007 through May 2008 to estimate the prevalence of diabetes among Chinese adults. It helps patients and physicians assess the effect of food, medications, stress, and activity on blood glucose levels.
Those who use basal–bolus regimens should self-monitor before each meal and at bedtime (four times daily).
HbA1c is influenced by rapid red blood cell turnover and blood loss; therefore, anemia and hemoglobinopathies can result in inaccurate values. Treatment options can be divided into insulin sensitizers, secretagogues, alpha glucosidase inhibitors, incretins, pramlintide, SGLT-2 inhibitors, insulin and insulin analogs. Its primary mechanism of action is suppression of hepatic glucose output, but it also enhances insulin sensitivity of muscle and fat. It can lead to weight loss, and it has been shown to decrease plasma triglycerides concentration (10%-20%).
Main adverse effects include weight gain (about 2 kg upon initiation) and hypoglycemia. They have a lower risk of hypoglycemia than sulfonylureas; they have a similar to lower risk of weight gain with initiation of therapy. This is because increased incidence of the thyroid C-cell tumors have been observed with these medications in the mice and rats. GLP-1 is produced in the small intestine and stimulates insulin secretion and inhibits glucagon secretion and hepatic glucose production in a glucose-dependent manner. Hypoglycemia does not occur when exenatide is used as monotherapy or with metformin, but it does occur when exenatide is combined with a sulfonylurea.
If a dose is missed, it should be administered as soon as noticed provided that next dose is scheduled 3 or more days later. Suppression of DPP 4 leads to higher levels of insulin secretion and suppression of glucagon secretion in a glucose-dependent manner. Patients can see up to a 50% reduction in their insulin requirements with the addition of pramlintide.
SGLT-2 is a protein acting as sodium-glucose co-transporter in the kidney’s proximal tubules whose main function is reabsorption of the filtered glucose from the urine back into the circulation. Patients should be advised to expect glucose to be in the urine and if they are using urine glucose strips that they will have a positive reading most of the time.
There is no upper limit in dosing for therapeutic effect, so it can be used to bring any HbA1c down to near normal levels. Studies have shown that episodes where the patient required assistance from another due to the hypoglycemia occurred between 1 and 3 per 100,000 patient-years. When initiating therapy with glargine or detemir as the basal insulin, traditionally 50% of the total daily dose is given as basal insulin and the rest as prandial insulin divided equally before meals. Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin: a systematic review. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The role of self-monitoring of blood glucose in the care of people with diabetes: report of a global consensus conference.
Meal-related structured self-monitoring of blood glucose: effect on diabetes control in nona€“insulin-treated type 2 diabetic patients. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomized trial [published online ahead of print June 25, 2007]. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy.
Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial.


The ultimate goal of the CCP is to reduce the risk of diabetes complications without jeopardizing patient safety. DSME is used to educate the patient on the components of therapeutic lifestyle changes, namely medical nutritional therapy (MNT) and physical activity. These recommendations are suitable for the general population, including people without diabetes, and focus on foods that can promote health vs foods that may promote disease or complications from disease. Recommendations should be personalized, and in general, evaluation and teaching should be conducted by an RD or knowledgeable physician.
Overweight individuals with type 2 diabetes should strive for a 5% to 10% reduction in weight and should avoid weight gain.
Unstructured activities include walking up or down stairs instead of using elevators, using parking spaces farther from building entrances, and the like.
Degludec, a new ultra-long–acting basal insulin, is currently undergoing review by the U.S.
This 6-year study, which included over 12,000 patients, compared the use of insulin glargine with standard care in patients with cardiovascular risk factors plus either prediabetes or recent-onset T2DM (mean T2DM duration at baseline: 5 years). These patients must also be motivated to achieve tighter plasma glucose control and be intellectually and physically able to undergo the rigors of insulin pump therapy initiation and maintenance. While individual agents may have contraindications or carry increased risks for specific populations, in general, hypoglycemia and weight gain are the primary limiting factors in diabetes treatment. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan.
Effects of aerobic and resistance training on hemoglobin A1C levels in patients with type 2 diabetes: a randomized controlled trial.
Exercise training improves glycemic control in long-standing insulin-treated type 2 diabetic patients. Continuous low- to moderate-intensity exercise training is as effective as moderate- to high-intensity exercise training at lowering blood HbA(1c) in obese type 2 diabetes patients. Effect of noninsulin antidiabetic drugs added to metformin therapy on glycemic control, weight gain, and hypoglycemia in type 2 diabetes. Lower baseline glycemia reduces apparent oral agent glucose-lowering efficacy: a meta-regression analysis.
Ultra-long-acting insulin degludec has a flat and stable glucose-lowering effect in type 2 diabetes. Insulin degludec, an ultra-longacting basal insulin, versus insulin glargine in basal-bolus treatment with mealtime insulin aspart in type 2 diabetes (BEGIN Basal-Bolus Type 2): a phase 3, randomised, open-label, treat-to-target non-inferiority trial. A new-generation ultra-long-acting basal insulin with a bolus boost compared with insulin glargine in insulin-naive people with type 2 diabetes: a randomized, controlled trial. Renal sodium-glucose transport: role in diabetes mellitus and potential clinical implications.
The effects of salsalate on glycemic control in patients with type 2 diabetes: a randomized trial.
Statement by the American Association of Clinical Endocrinologists Consensus Panel on insulin pump management. Statement by the American Association of Clinical Endocrinologists Consensus Panel on continuous glucose monitoring. Benefits of self-monitoring blood glucose in the management of new-onset type 2 diabetes mellitus: the St Carlos Study, a prospective randomized clinic-based interventional study with parallel groups. Structured self-monitoring of blood glucose significantly reduces A1C levels in poorly controlled, noninsulin-treated type 2 diabetes: results from the Structured Testing Program study. ROSES: role of self-monitoring of blood glucose and intensive education in patients with Type 2 diabetes not receiving insulin.
Restoration of normal glucose tolerance in severely obese patients after bilio-pancreatic diversion: role of insulin sensitivity and beta cell function. The Diabetes Surgery Summit consensus conference: recommendations for the evaluation and use of gastrointestinal surgery to treat type 2 diabetes mellitus. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. The effects of baseline characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of severe hypoglycaemia: post hoc epidemiological analysis of the ACCORD study.
Hypoglycemia in type 2 diabetes: pathophysiology, frequency, and effects of different treatment modalities.
The authors recommend combination therapy with the addition of one to two oral or injectable agents, with the goal of reducing side effects when possible. The prevalence of diabetes was higher among urban residents than among rural residents (11.4% vs.
Initially some patients require more frequent monitoring, including both preprandial and postprandial readings. The frequency of testing depends on the clinical situation and the patient’s treatment regimen.
Physicians should consider these conditions when there is a discrepancy between HbA1c and SMBG values. It affects primarily fasting glycemia; however, some decreases in postprandial glucose concentrations, especially after the midday meal, can also be seen. Metformin causes a small increase in basal and postprandial lactate concentrations in the blood, leading to potential to produce very rare but life-threatening lactic acidosis (<1 in 100,000).
The hypoglycemia episodes can be significant (leading to need for assistance, coma, or seizure) and are seen more often in the elderly.
GI complaints, such as bloating, abdominal cramps, flatulence, and diarrhea are the main side effects. Patients must be warned about this risk and be advised to stop taking these medications and seek medical evaluation if acute abdominal pain develops. So far, there is no increased risk in humans but the above groups of individuals should not use these medications. Other benefits of insulin include its effects on reducing triglycerides levels and increasing HDL.
Meal dose of insulin can be fixed, but it is better to determine the dose based on carbohydrate content of the meal.
Recommendations should be personalized on the basis of a patient’s specific medical conditions, lifestyle, and behavior.
To date, metformin remains the only oral medication approved by the FDA for use in children with T2DM.
Insulin therapy, whether alone or in combination, will ultimately be required to maintain glucose control for many patients. Patients with gestational diabetes who are taking insulin should monitor their blood glucose three or more times daily.
The ADA recommends that patients with stable glycemic control be tested at least twice a year.
The PROactive trial (PROspective pioglitAzone Clinical Trial In macroVascular Events) showed that compared with placebo, pioglitazone does not increase cardiovascular risks. The benefits include a 25% reduction in microvascular complications with or without insulin found by a UKPDS trial. It primarily decreases postprandial blood glucose levels; however, a moderate reduction in fasting blood glucose levels can also be seen. This requires learning carbohydrate counting and knowing the dose of insulin required to cover counted carbohydrates. Patients unable to maintain a healthy weight on their own should be referred to an RD or weight-loss program that has a proven success rate. Insulin use in the prediabetic patients did reduce the incidence of T2DM (see detailed discussion in Prediabetes), but there was no difference in cardiovascular outcomes between treatment groups after 6 years.
The prevalence of isolated impaired glucose tolerance was higher than that of isolated impaired fasting glucose (11.0% vs. Patients should be educated on how to use real-time blood glucose values to adjust their food intake and medical therapy. Table 1, adapted from the ADA’s 2014 Position Statement on diabetes management, demonstrates that correlation between HbA1c and average blood glucose values. TZDs have been shown to have an association with an increased risk of fractures, particularly in women. Its effects and side effects are similar to those of exenatide but it may be slightly more powerful in its actions. Patients with T2DM often require insulin, which can be combined with oral hypoglycemic agents. Median FPG and A1C levels were lower in the glargine group, but the incidence of hypoglycemia and weight gain were modestly increased. Pioglitazone use leads to lowering triglycerides, increasing high-density lipoprotein cholesterol (HDL), and increasing the low-density lipoprotein cholesterol (LDL) particle size.



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