The Modern Approach to Comprehensive Management of Diabetes

May 02, 2020 at 04:49 pm by pj


By MATTHEW SHLAPACK, MD

Diabetes is a common disorder affecting millions of Americans and leading to a negative impact on their health and quality of life. Diabetes can be challenging to control and lack of glucose control can produce multiple, disabling symptoms and result in serious complications. Understandably, patients often feel that the medical management of their diabetes is too burdensome and requires them to make unsustainable changes to their routines. Fortunately, there has been tremendous growth in our understanding of how to treat diabetes. Further, medical providers now have available more tools and medications than ever to assist us in getting our patients’ diabetes under control and protecting their health. Modern management of diabetes is light years ahead of where it was even a decade ago.

One of the most important advantages to our expanded medication options is that providers can now select medications that have benefits beyond just glucose control. We can now pair medication choices to our patients’ unique needs and comorbidities. At the same time, we can do more to find medications that work with our patients’ unique lifestyles and schedules. In a world of night shift work, long days without meal breaks, varied physical activity, and unique dietary limitations, there is now much more that we can offer our patients beyond a one size fits all model.

New treatment options include a class of medications called SGLT-2 inhibitors, for example Jardiance and Farxiga. These medications do help to control blood glucose, but they also facilitate weight loss and help to protect against diabetic complications such as recurrent cardiovascular events and worsening renal failure. In my own clinical practice, I have seen that these medications tend to have an insulin sensitizing effect. In my Type 2 Diabetic patients who are on treatment with insulin, adding an SGLT-2 agent has allowed me to reduce insulin dosages, which leads to further weight loss and overall patient satisfaction.

We also now have once weekly formulations of GLP-1 Agonists such as Bydureon and Trulicity. These medications facilitate weight loss and have also been found to have favorable effects in terms of renal protection and possibly CV benefit. Generally, these medications are well tolerated and the injection devices themselves are user friendly and painless.

On the topic of insulin, we now have newer and better insulins that help to achieve glucose control with less risk of hypoglycemia. Most insurances cover at least one type of these new insulins and in my experience, patients find these preparations to be more convenient. Insulin pens are a convenient way for our patients to take their insulin on the go and the tiny pen needles means less risk of injection site reactions and no discomfort.  

At the same time, Insulin pumps and glucose sensors are becoming not only smaller, but smarter and less time demanding for those using them. The pairing of sensors and pumps has helped us to finally have options for the most brittle diabetic who till now, have often had to ride the roller coaster of glucose lows and highs, despite their best efforts.

Time and time again, research has shown us that the goal of diabetic management encompasses not only achieving ‘good glucose numbers’ but also the prevention of diabetic complications and addressing symptoms that can be associated with a diagnosis of diabetes. This is best achieved by working as a multiple provider-patient team to facilitate manageable lifestyle changes, and utilization of the best treatments for each patient. This often does require some changes on the part of our patients, but we can now tailor treatment to minimize the difficulty of these changes and to do more to preserve good quality of life.

Proper screening is essential to detect any emerging diabetic complications and to ensure that any potential complications are addressed before they worsen. For example, all diabetics need annual eye examinations to look for diabetic changes and to treat these changes if they are present.  The feet need to be inspected regularly and sensation assessed periodically, as diabetics can develop both impaired wound healing and loss of sensation.

Obviously, staying on top of all of this is challenging to say the least. For a provider to try to comprehensively manage diabetes while simultaneously treating their patient’s other conditions is difficult in the limited amount of time that we are allotted for each visit. That is why now, more than ever, modern diabetic management requires a team approach, with multiple providers working together to achieve the best outcomes for our patients. To be blunt, with all the factors in place, it is asking too much for one provider to try to do everything. Regular appointments and good communication between providers and patients facilitate essential monitoring, and provides an opportunity to discuss options for enhancing treatment

I would argue that while the management of diabetes remains challenging, we are now finally getting the tools and research results that we as providers need to be able to offer more to our patients. We are now seeing new medications, new study results and new technology emerging on a regular basis. In parallel to this, diabetic patients have more options and are seeing an improving clinical course and better quality of life.

Matthew Shlapack, MD, is a Board-Certified Endocrinologist and practices at Orlando Heart and Vascular Center. Shlapack completed both his Internal Medicine residency and his Endocrinology Fellowship at The University of South Carolina, School of Medicine. He attended Ross University Medical School. His clinic is located at: 11616 Lake Underhill Rd. Orlando. Contact him at 407-482-7788 or visit OHVC.net






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