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Medical Treatment of Diabetes Mellitus

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In the United States, 57.9% of patients with diabetes mellitus (DM) have at least 1 diabetes-related complication and 14.3% of patients with diabetes have 3 or more diabetes-related complications.1 Achieving glycemic control in patients with DM reduces the development and progression of retinopathy, nephropathy, and neuropathy. Aggressive treatment of dyslipidemia and hypertension decreases macrovascular complications.2–4 The techniques for monitoring blood glucose and the various treatment options available to manage glycemic control in patients with diabetes are reviewed below.

Measuring Glycemic Control

The primary techniques available to assess the quality of a patient’s glycemic control are self-monitoring of blood glucose and interval measurement of hemoglobin A1c (HbA1c). Continuous glucose monitoring is also available and may be appropriate for select patients, such as patients with brittle diabetes and those using insulin pumps.

Self-monitoring of blood glucose

For patients with type 1 DM and patients with insulin-dependent type 2 DM, self-monitoring of blood glucose allows patients to adjust insulin dosing to prevent hypoglycemia and hyperglycemia.2,5–7 The American Diabetes Association (ADA) guidelines recommend that patients with type 1 DM self-monitor their glucose:

  • Before eating
  • At bedtime
  • Before exercise
  • If hypoglycemia is suspected
  • Until hypoglycemia is corrected
  • Postprandially upon occasion
  • And before critical tasks (ie, driving).8

Patients should be educated about how to use real-time blood glucose values to adjust their food intake and medical therapy.

It is commonly recommended that patients with type 2 DM self-monitor their blood glucose levels, but the evidence to support the effectiveness of this practice is inconclusive. Initial studies showed reductions in HbA1c with self-monitoring; however, the inclusion of beneficial health behaviors such as diet and exercise in the analyses makes it difficult to assess the effectiveness of self-monitor blood glucose alone.2,9

The ADA recommends that nonpregnant adults maintain blood glucose levels of 80 mg/dL to 130 mg/dL preprandial and less than 180 mg/dL postprandial.8 The blood glucose goals for patients with gestational diabetes are 95 mg/dL or less preprandial and either 140 mg/dL or less 1-hour postprandial or 120 mg/dL or less 2-hours postprandial.

HbA1c

HbA1c tests reflect the mean blood glucose values over a 3-month period and can predict patients’ risk of microvascular complications.10,11 The ADA recommends that patients with stable glycemic control have an HbA1c test at least twice a year. Quarterly HbA1c testing is suggested for patients with a recent change in therapy or for patients not meeting their glycemic goals.8

Measurement of HbA1c is influenced by the red blood cell turnover rate; therefore, anemia, transfusions, and hemoglobinopathies can cause inaccurate test values. The ADA recommends that nonpregnant adults maintain HbA1c levels near 7%. For patients with diabetes who become pregnant, the goal is HbA1c levels less than 6.0%.8 The ADA also recommends that select patients, especially those with a long life expectancy and little comorbidity, adopt glycemic targets near normal levels (HbA1c < 6.5%), providing the target can be achieved without significant hypoglycemia.8

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