Diabetes Treatment: Managing Type 1 & Type 2 Diabetes
Diabetes treatment
Diabetes is a group of conditions that are characterised by high blood glucose (also known as ‘glycaemia’), which is caused by problems with insulin — a hormone produced by the pancreas in order to regulate blood glucose [1, 2] — and/or the receptors targeted by insulin. If someone has diabetes, their body cannot produce any or enough of the hormone insulin, or use insulin effectively [3].
Type 1 diabetes, which makes up 5–10% of cases, is caused by the immune system attacking the insulin-producing cells of the pancreas [1]. Type 2 diabetes, which is about 90–95% of diagnoses, is due to a combination of resistance to the effects of insulin with some level of insulin secretion problems [1].
There are a number of treatments available that can help manage diabetes.
Type 1 diabetes treatment
People with type 1 diabetes need to take insulin in order to maintain blood glucose levels in the proper range [3]. Without insulin, they would not be able to survive [3].
Although this might sound scary, with the right daily insulin treatment, regular blood glucose monitoring and maintenance of a healthy lifestyle, people with type 1 diabetes can live a healthy life [3]. Careful management and treatment of diabetes can help to delay and reduce the risk of complications associated with diabetes [3].
Most people with type 1 take insulin either as multiple-dose insulin (MDI) injections using a pen or syringe, or by using insulin pump therapy (which delivers insulin as a drip under the skin — known as ‘subcutaneous infusion’) [4].
Insulin syringes
Millions of people around the world inject themselves with insulin every day [5]. In many regions, syringes are used extensively for insulin injection [6].
The syringes that were initially used for insulin injection were large, bulky and had to be reused multiple times [7]. Thankfully technology has come a long way since then. Modern syringes are disposable [7] and have scale markings on the side specifically to help with accurate insulin dosing [8].
Modern needles have also improved significantly [7]. Older variants were long and large-bore — these days, they have been replaced by smaller, shorter needles [7].
Insulin pens
They allow a dose to be selected using a dial, rather than drawing up from a vial with a syringe and needle [8].Insulin pens consist of three components — a cartridge that contains the insulin, a disposable needle, and a one-click-per-unit dosing dial [7].The insulin pen itself can either be disposable or reusable, where the insulin cartridge is replaced when empty [7].
A modern update is the ‘smart pen’ [7]. This device has memory functions for things like dose and timing, and can use USB or Blue Tooth to integrate with digital platforms, such as a smartphone app [7]. This allows for much more efficient ways to monitor diabetes [7].
Insulin pens became available in the 1980s
Insulin pump therapy
Insulin pumps are different from injections, as they deliver a continuous ‘basal’ flow of rapid-acting insulin [8].
The pump typically consists of an insulin reservoir that sits inside the pump and an infusion set with tubing [7]. The reservoir and infusion set are connected to a catheter in the skin to continuously deliver insulin to meet daily needs [7]. A different variety is the ‘patch pump’ [7]. These devices are small, lightweight and attached directly to the skin (without an infusion set) [7].
Much has changed since pumps were originally designed. The first pump prototype had to be worn as a backpack, but modern pumps are much smaller [7].
Modern ‘smart’ pumps have many features, including built-in calculators for bolus doses (additional one-off doses of insulin), computer interfaces and alarms [7]. Rapid changes to the rate can be set by the user to respond to food intake, and insulin delivery can also be suspended to respond to hypoglycaemia [8].
Some pumps can also work with glucose sensors to automate the delivery of basal insulin (called ‘hybrid closed loop systems’) [8].
Type 2 diabetes treatment
Unlike type 1 diabetes, where the main treatment is insulin [4], there are a number of different treatments for type 2 diabetes [3]. Some of these therapies are taken as tablets, some by injection, while some aren’t medications at all.
Physical activity and Nutitrition
The cornerstone of type 2 diabetes treatment is a healthy lifestyle, which includes adopting a balanced diet, regular physical activity, smoking cessation and maintaining a healthy body weight [3].
There is strong evidence that nutrition therapy is an effective part of diabetes care [9]. Nutrition therapy aims to [9]:
- Promote healthy eating patterns
- Improve markers of good blood glucose management such as HbA1c
- Help meet blood pressure and cholesterol targets
- Achieve and maintain weight goals
- Delay or prevent the complications of diabetes
- Address individual nutrition needs and maintain the pleasure of eating
- Provide tools for day-to-day meal planning
In addition to diet changes, it is recommended that alcohol is only drunk in moderation [9].
Exercise also forms an important part of diabetes management. For adults, it is recommended that 150 minutes of moderate-intensity or 75 minutes of high-intensity aerobic exercise be performed every week [3]. However, if you have heart disease, it is best to speak to your diabetes care team about what you can and can not do when it comes to exercise. If you want to take part in sports, your diabetes care team may suggest a screening for heart disease first.
Oral antidiabetic drugs
There are a number of tablets that can be taken for type 2 diabetes [4].
The preferred medication to start on first, if the person with diabetes is not allergic to it, is metformin (at a lower dosage) [4]. Metformin lowers blood glucose levels by reducing the rate at which glucose is produced by the liver [4].
If the dose of metformin has been increased to its maximum and blood glucose targets (measured by HbA1c) are still not met, either a second tablet or insulin injections could be started [4].
There are several other tablets that could be prescribed, either instead of, or in addition to, metformin [4]. These include [10]:
- Biguanides
- Sulfonylureas
- Sulfonamides (heterocyclic)
- Thiazolidinedione (TZDs)
- Alpha-glucosidase inhibitors
- Dipeptidyl peptidase 4 (DPP-4) inhibitors
- Sodium-glucose co-transporter 2 (SGLT2) inhibitors
Your healthcare team will help you decide what treatment is best for you, taking into account your preferences as well as the characteristics of the treatments available [4]. The aim will be to meet your blood glucose goals while avoiding or minimizing side effects [4].
Injectable medications for type 2 diabetes
While tablets are the preferred first medication for type 2 diabetes, for some patients, other treatments may be needed [4].
One type of injectable medication for type 2 diabetes is GLP-1 inhibitors [4]. These increase insulin secretion but do not increase the risk of low blood glucose (hypoglycaemia) [4].
In newly diagnosed type 2 diabetes, if the blood glucose is very high or the person has symptoms of high blood glucose, the healthcare team may decide to start insulin treatment [4].
People with type 2 diabetes may be put onto a basal-bolus regimen. This involves taking a longer-acting form of insulin (which keeps blood glucose levels stable through periods of fasting) as well as separate doses of shorter-acting insulin (which prevent rises in blood glucose levels resulting from meals). If they experience significantly high blood glucose levels after meals and need to have a flexible insulin regimen to fit in with their lifestyle.
Type 2 diabetes can be a progressive condition, so many patients will eventually end up on insulin therapy [4].
References
1.American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2004; 27(S1): S5-S10
2.Wilcox, G. Insulin and insulin resistance. Clin Biochem Rev. 2005; 26:19-39
3.International Diabetes Federation, IDF Diabetes Atlas 8th edition, 2017
4.American Diabetes Association. Standards of medical care in diabetes- 2015. Diabetes Care 2015;38(Suppl. 1): S1-S93
5.Dolinar, R. The Importance of Good Insulin Injection Practices in Diabetes Management. Endocrinology. 2009;5(1):49-52
6.Frid, AH, et al. New insulin delivery recommendations. Mayo Clin Proc. 2016; 91(9):1231-1255
7.Kesavadev, J., Saboo, B., Krishna, M.B. et al. Evolution of Insulin Delivery Devices: From Syringes, Pens, and Pumps to DIY Artificial Pancreas. Diabetes Ther 2020; 11: 1251–1269
8.Buse, JB et al. 100 years on: the impact of the discovery of insulin on clinical outcomes. BMJ Open Diab Res Care. 2021; 9:e002373
9.Evert AB, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care. 2019; 42:731-754
10.WHO Collaborating Centre for Drug Statistics Methodology, ATC/DDD Index. Accessed 07/2022. Available at: https://www.whocc.no/atc_ddd_index/?code=A10B&showdescription=yes