Clinical Data in Diabetes
Clinical data from landmark trials and follow-up studies conducted over the past few decades have demonstrated that lowering blood glucose concentrations toward the normal range can effectively slow or prevent the development of long-term complications such as retinopathy, neuropathy, and nephropathy. In fact, the role of hyperglycemia in diabetic complications was not even established until 1993, when the results of the Diabetes Control and Complications Trial (DCCT) were made public. This major trial, together with two others, established the benefits of long-term blood glucose control in diabetes and is discussed in this module:
• The Kumamoto Study, an eight-year Japanese trial demonstrating that intensive insulin therapy prevents diabetic complications in patients with type 2 diabetes.
• The Diabetes Control and Complications Trial (DCCT), a landmark 10-year trial completed in 1993 in patients with type 1diabetes.
• The United Kingdom Prospective Diabetes Study (UKPDS), the largest and longest trial on the effects of lowering blood glucose in patients with type 2 diabetes.
More recent long-term, large-scale, multi-center studies—some still ongoing, others in follow-up analysis phase—are also discussed here.
Complications of Diabetes
This module describes macrovascular and microvascular long-term complications of diabetes, as well as other medical conditions that commonly impact the cardiovascular health of patients with diabetes, including hypertension and dyslipidemia.
Diabetes and Hypoglycemia (COMING SOON)
The threat and incidence of hypoglycemia is a major concern for both type 1 and type 2 diabetes. Unfortunately, attempts to achieve a normal glucose level, as recommended by current treatment guidelines, increases the incidence of treatment induced hypoglycemia. This module reviews the incidence of hypoglycemia within diabetes, the causes, symptoms, management, treatment, and its effect on quality of life.
Diabetes Landmark Prevention Studies
This module begins with a description of prediabetes. It then describes several diabetes landmark prevention studies.
Diabetes Management Programs
This module begins with a brief discussion of the key elements of a comprehensive diabetes disease management program. It then describes programs that have been implemented, mostly through partnerships involving employers, pharmacy benefit management companies (PBMs),disease management companies, managed care organizations (MCOs) and insurance companies.
Diabetes Treatment Principles
This module presents an overview of the key resources providing such guidelines and principles—in particular, those of the ADA and AACE—and the issues they cover.
Glucose Metabolism and Diabetes
This module will begin with a brief description of normal glucose metabolism and how its activities are regulated, and then discuss the key acute metabolic effects of abnormal glucose metabolism, including hyperglycemia, glucosuria, and ketoacidosis.
Insulin and Insulin-Combination Therapy
This module discusses the goals of insulin therapy and combination therapy for patients with type 1 and type 2 diabetes, and the different types of insulin and insulin regimens employed for achieving those goals.
Lifestyle Management of Diabetes
This module will discuss the importance of coordinated MNT and physical activity plans in managing patients with type 1 and type 2 diabetes.
Monitoring of Diabetes
This module describes diabetes monitoring tests and their appropriate uses for managing diabetes.
New Treatment Options and Future Directions of Diabetes Therapy
This module provides an overview of new treatment options and future directions of diabetes therapy, including:
• New methods of insulin administration
• Pancreas and islet transplantation
• Genetic-based therapeutic approaches, including use of stem cells and cells from the spleen, monoclonal antibodies, and individualized treatments
Noninsulin Injectable Therapy
While insulin and glucagon are the primary regulators of glucose metabolism, there are also important helper regulators, notably:
• Amylin: A hormone secreted along with insulin by pancreatic ß-cells, amylin helps inhibit glucagon secretion, delays gastric emptying and acts as a satiety agent—providing the feeling of fullness that tells you to stop eating.
• Incretin hormones: Gastric inhibitory polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) are secreted from the epithelium of the small intestine after glucose and other nutrients are ingested. Both act to increase insulin secretion; GLP-1 also increases satiety.
• Sodium-glucose linked transporters (SGLT-1 and SGLT-2): These proteins, located in the kidney’s nephron, reabsorb glucose passing through the proximal tubule back into the bloodstream so that, under normal conditions, little or no glucose is excreted in the urine.
Several newer drugs aim to mimic, enhance or inhibit the actions of these helper regulators. These include amylin analogs, SGLT-2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors.
Two of these classes are the focus of this module. Like insulin, they are injectable agents, although in September 2019, the FDA approved the first oral GLP-1 analog, semaglutide, for type 2 diabetes management. They thus form a third therapeutic group besides insulin and oral antidiabetic agents.
• One class, the amylin analogs, such as pramlintide acetate, helps lower blood glucose levels, especially the unhealthy rise in glucose that occurs right after eating. This class is of potential benefit to both type 1 and type 2 diabetes patients.
• The other class, incretin analogs, replicate the antihyperglycemic actions of incretin hormones; they are currently indicated for only type 2 diabetes patients, although their use for treating DM1 is being studied.
Oral Antidiabetic Agents
This module discusses the role and types of oral diabetic agents used in the treatment of type 2 diabetes.
Patient Education and Team Management of Diabetes
This module discusses how patient education and team management of diabetes play a key role in helping delay or prevent these complications.
Screening and Diagnosis of Diabetes
Hyperglycemia and glucosuria—characteristic signs of diabetes—are the basis for tests used to diagnose diabetes. These tests, described in this module, include fasting blood glucose tests and glucose tolerance tests after eating. The same tests can identify patients with prediabetes—whose elevated glucose levels are not as marked as those of diabetes patients and are a risk factor for developing type 2 diabetes.
Determining the exact type of diabetes (eg, DM1 or DM2) requires additional tests, such as those that determine whether the patient is able to produce any insulin. It is also important to consider the patient’s clinical presentation.
Types of Diabetes
This module describes the key characteristics of both type 1 and type 2 diabetes. It also briefly identifies less-common types of diabetes and abnormal glucose metabolism.
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