Type 2 DM is treated in stages, based on individual circumstances and changes in the body. Initially, in type 2 DM, there is always enough insulin in the body, but it has a weaker effect. The sensitivity of the target cells to insulin decreases more and more. Experts speak of insulin resistance in the cells and a "relative" lack of insulin. As long as the pancreas is making insulin, lifestyle changes and medications that either increase insulin production or increase the effects of the hormone can help. Only when the pancreas can no longer produce insulin does it become necessary to replace the insulin - i.e. to inject insulin preparations.
Before the therapy, the disease must be reliably diagnosed as usual. In DM type 2, this can be impossible based on the symptoms, because in most cases they are initially absent or very weak. However, blood sugar tests show early on whether there are indications of a preliminary stage (prediabetes) of DM type 2 or whether the disease is fully developed. Especially from the age of 45 (or earlier if other risk factors are present), it is advisable to have your blood sugar tested regularly. Early diagnosis and appropriate treatment can prevent permanent consequential damage. In later stages, some typical symptoms of DM type 2 and some complaints from secondary diseases lead to the trace of the metabolic disorder. Blood sugar values then turn a suspicion into a certainty. Experts advise to always repeat the measurements if the results are not clear. If possible, the same test as the first time should be carried out. If the blood sugar is well above the limit value, one measurement can be sufficient for diagnosis. This is especially true if there are additional symptoms typical of DM.
Various measurements of blood sugar
Four different blood sugar values appear in connection with diabetes mellitus, three of which are mainly used for diagnosis. Fasting blood glucose, casual blood glucose, and two-hour blood glucose provide snapshots of blood glucose levels. Various units of measurement can be specified here (mmol/l or mg/dl). The level of the limit values can also differ, depending on whether the blood sample comes from a fingertip (capillary blood) or a vein (venous blood). The fourth value, the HbA1c value, shows an average for the blood sugar over the past few weeks.
- The fasting blood sugar (fasting glucose, fasting plasma glucose) is measured after a fasting phase of at least eight hours. During this time, test subjects are not allowed to consume any calories – i.e. neither food nor sweet or nutritious drinks. Therefore, the measurement almost always takes place in the morning before breakfast.
- The occasional blood sugar (blood glucose, occasional plasma glucose) can be determined at any time during the day.
- For the two-hour blood sugar value (two-hour glucose, two-hour plasma glucose), a measurement takes place two hours after the intake of a precisely defined amount of glucose. It is an oral glucose tolerance test (OGTT) in which the test person drinks a solution containing 75 grams of glucose. After that, usually several blood sugar measurements are taken over a period of two hours at specific time intervals. Test subjects must be sober at the beginning of the test, i.e. they must not have eaten any calories for eight to twelve hours beforehand.
- Doctors refer to the HbA1c value as average blood sugar (blood sugar memory, long-term blood sugar, saccharified hemoglobin). This is a form of the red blood pigment hemoglobin (Hb) to which a sugar has attached itself. The higher the blood sugar level, the more hemoglobin is saccharified - the more red blood cells contain saccharified Hb, i.e. HbA1c. Since this connection is stable and red blood cells live for an average of eight weeks, doctors can use the HbA1c value to see how much sugar was in the blood over the past few weeks: The HbA1c value corresponds to the average blood sugar level over the past eight to twelve weeks. It is mostly used in treatment to adjust blood sugar, the measurement can take place regardless of the time of day. Incorrect results can be caused by certain blood diseases, heavy blood loss, blood transfusions, liver diseases (e.g. cirrhosis, insufficiency), kidney weakness, iron deficiency and pregnancy. Most often, HbA1c values are expressed as a percentage, although the official unit is millimoles per mole (mmol/mol).
Normal and elevated values
Prediabetes is characterized by blood glucose levels that are higher than normal but lower than in full-blown type 2 DM. However, prediabetes often progresses to full-blown type 2 DM. The risk of secondary diseases (e.g. heart attack, stroke) is already increased. Experts therefore advise those affected to take countermeasures in the sense of changing their lifestyle. A healthy diet, regular exercise and reducing excess weight can normalize sugar levels. The risk of diabetes mellitus (and the risk of possible side effects) decreases significantly.Normal readings:
- Fasting blood sugar: < 5.6 mmol/l (100 mg/dl)
- Two-hour blood glucose, capillary: < 7.8 mmol/L (140 mg/dL)
- Average blood sugar: < 5.7% (39 mmol/mol)
- Fasting blood sugar: 5.6–6.9 mmol/l (100–125 mg/dl)
- Two-hour blood glucose, capillary: 7.8–11.0 mmol/L (140–199 mg/dL)
- Average blood sugar: 5.7–6.4% (39–47 mmol/mol)
Measurements in diabetes:
- Fasting blood glucose: ≥ 7.0 mmol/L (126 mg/dL)
- Two-hour blood glucose, capillary: ≥ 11.1 mmol/L (200 mg/dL)
- Average blood sugar: ≥ 6.5% (48 mmol/mol)
Some texts on DM type 2 still give a blood sugar value (occasional blood sugar) of 11.1 mmol/l (200 mg/dl) measured at any time as proof of diabetes, especially if typical symptoms are present at the same time (frequent urination, severe thirst , unexplained weight loss).
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| type 2 diabetes treatment |
Diabetes therapy - goals and drugs
The goals of the therapy are determined individually and jointly by the doctor and patient. On the one hand, the treatment must lower the elevated blood sugar to such an extent that symptoms subside, the patient's quality of life improves, there are no complications and the risk of secondary diseases is reduced to a minimum. At the same time, it is important to prevent blood sugar from falling too low and dangerous hypoglycaemia from occurring. The therapy must therefore avoid values that are too high or too low: The blood sugar may only fluctuate within a certain range. Therefore, the medication must be individually tailored to the amount of carbohydrate intake and consumption.
Experts strongly recommend education for all patients with type 2 DM. It provides comprehensive information on what negatively influences the disease, what needs to be considered during therapy, what mistakes many patients make and how everyday life with diabetes can be made as simple as possible. With type 2 DM, training is considered indispensable because lifestyle plays an enormously important role in the disease and in its treatment.
- Oral hypoglycemic drugs are medications that are taken by mouth. Most drugs promote insulin production or improve the effect of insulin. All oral antidiabetics require the body to produce at least a little more insulin. The drug group includes numerous active ingredients from different substance families such as the biguanides, sulfonylureas, glinides, glitazones, alpha-glucosidase inhibitors and DDP-4 inhibitors. They differ in effect, tolerability and exclusion criteria. If there is nothing medically against it, the active ingredient metformin is the drug of choice. Some active ingredients can be combined.
- Incretin analogues (incretin mimetics, GLP-1 receptor agonists) are injected into the subcutaneous fatty tissue like insulin. The substances lower blood sugar in several ways, including by improving insulin production and action. They also slow down the emptying of the stomach and lead to a feeling of satiety earlier. They can also contribute to weight loss. Incretin analogs mimic the action of natural gut hormones (incretins).
- Insulins and insulin analogues replace the body's own insulin if none or too little of it can be produced. Treatment is either with bioengineered human insulin (which is chemically identical to the natural human hormone), insulin of animal origin (usually porcine insulin that differs in one building block from human insulin) or insulin analogues. The latter are very similar to human insulin and have a comparable effect. Insulins are classified according to their duration of action. Short-acting insulins or insulin analogues work immediately or after a few minutes. They reach their greatest effect in one to two hours, the duration of action is four to eight hours. This group includes the chemically unmodified insulin without retarding additives, also known as normal insulin or old insulin, since it was the first insulin used to treat diabetes. With long-acting insulins or insulin analogues, the effect occurs slowly and runs evenly without peaks. Some remedies work for more than 40 hours. Insulin analogues achieve their longer effect through a slightly different chemical structure. Added substances (e.g. zinc, certain proteins), on the other hand, delay the effect of insulin. Such active ingredients are also called delayed insulin, depot insulin, basal insulin, basic insulin, long-term insulin or intermediate insulin. Combinations of short-acting and long-acting insulins are also called mixed insulin. The insulin preparations are almost exclusively injected into the subcutaneous fatty tissue, mostly on the abdomen. Unfortunately, it is impossible to take insulin orally because the gastric juices would destroy the hormone. Too little insulin gets into the blood with sprays. Inhalation powders are currently being tested, as are bioreactors with cells that produce insulin. Patients could receive the bioreactors in small containers as implants. An alternative to syringes and pens are currently jet injectors that force insulin through the skin.
Therapy stages for type 2 diabetes mellitus
The treatment of DM type 2 takes place in four stages:
- Because lifestyle is a major contributor to its development, the first step or basic therapy is usually to change a harmful lifestyle. Extremely helpful for this is diabetic training. After a while, measurements of the HbA1c value show whether these measures are sufficient. This is the case for many patients, they manage for a long time without medication.
- If the changed lifestyle does not have the desired effect after three to a maximum of six months, stage two begins: the patients also take an antidiabetic, in most cases the active ingredient metformin. In some cases, medication can also be used immediately after the diagnosis, for example in the case of very high blood sugar levels. As a rule, the HbA1c levels in all patients rise again at some point because the insulin production of the pancreas decreases over the years. Oral antidiabetics have a weaker effect or stop working, so the therapy must be adjusted or changed accordingly. At first, increasing the dose may be enough.
- If the dose increase is not enough, the third stage of treatment begins, it mostly works with combinations of two. Most of these contain metformin and another active ingredient, some of which include insulin. Alternatively, insulin alone can be used at step three.
- At level four, therapy with insulin is in the foreground. Other substances can support its effect. The type of treatment depends on individual circumstances. In DM type 2, insulin can also have unfavorable effects, which is why the use of these preparations only plays an important role from stage three onwards.
People with type 2 DM should have regular check-ups so that their therapy is always optimally adjusted to the current situation. In addition to the blood values, other measurements (e.g. kidney values) and sometimes specialist examinations are advisable. Complaints that could come from secondary diseases should also be clarified by doctors at an early stage.
Which values the therapy should achieve depends on the individual circumstances. Influencing factors include comorbidities, age, the severity of adverse effects and whether the diabetes has already caused damage. Initially, values such as these are often aimed for:
- Blood sugar: fasting and before meals 4.4-6.7 mmol/l (80-120 mg/dl), HbA1c 6.5-7.5% or lower
- Blood lipids: total cholesterol < 4.7 mmol/l (180 mg/dl), LDL < 2.6 mmol/l (100 mg/dl), HDL women < 1.3 mmol/l (50 mg/dl), HDL men < 1.1 mmol/L (40 mg/dL)
- Blood pressure: < 140 mmHg systolic, 80 mmHg diastolic
- Weight: A body mass index (BMI) under 25 and a waist circumference of under 80 cm for women and under 94 cm for men are ideal. Doctors usually advise patients with a BMI over 25 to reduce their weight by 5% to 10%.
Lifestyle change
The goal of the lifestyle change is to have a positive effect on blood sugar and general health. The three most important points are exercise, healthy eating and reducing excess weight. Motivated and disciplined patients who exercise more, lose excess weight and eat healthier foods lower their blood sugar. Other bodily functions also improve, such as blood lipid levels and blood pressure. Good levels can prevent secondary diseases from developing. Many patients who consistently pursue better lifestyles do not require medication. Lifestyle changes play a major role in the success of treatment.
It is advantageous if patients incorporate more physical activity into their everyday lives and do sports regularly. A good workload is 30 minutes a day, the sports should train endurance and strength. Patients who are new to exercise or who have been off for a long time should discuss with a doctor what level of exertion is appropriate for their level of fitness. Small amounts of sugar are allowed in the diet. Sugared drinks and diet products with fructose are considered to be problematic. Food should contain at least 30 grams of fiber per day. Saturated fats should make up no more than 10% of the energy you eat. Whether it is necessary to lose pounds depends on the individual weight. Doctors strongly advise smokers with diabetes to quit smoking. Training courses provide useful information about diabetes, instructions and help for changing one's lifestyle.
Diabetic education
Anyone who receives the diagnosis DM type 2 has to deal with a lot of new questions: Which sugars and which foods affect my blood sugar and how much? Where is sugar hidden in food? How much carbohydrate do vegetables contain? What influence does sport have? What about alcohol and sweeteners? What effect do drugs have? How and when is the best time to measure blood sugar? Why should I lose weight? It is very difficult to obtain all the important information yourself and to grasp all the important connections. That is why there are diabetic training courses. In it, patients learn about the importance of lifestyle, individual foods and many other circumstances for diabetes. You will receive practical tips on how to make your everyday life healthier. You will learn how to avoid common mistakes and how to take measurements easily and discreetly. Different treatment options with their advantages and disadvantages are discussed. Studies have shown that training improves personal competence, independence and the success of therapy.
Treatment with medication
People with type 2 DM have to reckon with the fact that at some point they will need antidiabetics: the sugar metabolism changes over time, so insulin production decreases in all people with age. That is why DM type 2 requires regular blood sugar checks to see if the current treatment is sufficient. If not, the doctor and patient will have to adjust them. The only thing that changes at all therapy levels is the basic therapy, maintaining healthy lifestyle habits.
The active substance metformin, the only approved one from the family of biguanides, is the drug of choice in drug treatment. If the desired HbA1c value cannot be achieved with this and a healthy lifestyle, the treatment usually continues with a double combination. At this stage, metformin is sometimes used together with another active substance or insulin alone. If this does not result in the desired success, so-called intensified insulin therapy follows. Insulin forms the basis here, but is sometimes combined with other active ingredients (e.g. metformin, DDP-4 inhibitors). There are different ways of using insulin, depending on when during the day the patient has high blood sugar. For example, it is possible to inject short-acting insulin only with the main meals (supplementary insulin therapy, SIT). With conventional insulin therapy (CT), patients inject themselves with a certain dose of mixed insulin in the morning and evening. Intensified conventional insulin therapy (ICT) usually consists of an evening shot of long-acting insulin for primary care. In addition, the patients administer adjusted doses of short-acting insulin with meals.