Standards of medical care in diabetes include clinical practice recommendations provided by the American Diabetes Association (ADA) and aim to provide details of diabetes care, general treatment goals and guidelines, and tools to assess quality of care. In this article, drug therapy for diabetes will be discussed.
2- Drug treatment
2-1- Type 1 diabetes
2-1-1-insulin
Type 1 diabetes is characterized by the inactivity of pancreatic beta cells, so insulin treatment is necessary for all people with type 1 diabetes. Based on evidence accumulated over the past three decades, insulin replacement via multiple insulin injections (basal and prandial) throughout the day or continuous subcutaneous injection (CSII) with an insulin pump has the best combination of efficacy and safety in people with type 2 diabetes. first had The DCCT study has shown that this method of insulin replacement is associated with a 50% reduction in microvascular and macrovascular complications. However, in these methods, the risk of hypoglycemia is higher. With the introduction of continuous glucose monitors at the bedside, this risk has decreased. For example, the reduction of nocturnal hypoglycemia in people with type 1 diabetes has been observed using insulin pumps with glucose sensors with automatic suspension of insulin delivery at a predetermined glucose level.
Recently, two new types of insulin with faster-acting profiles have been formulated:
A) Inhaled human insulin, which reaches the peak effect faster and has a shorter duration of action compared to rapid-acting insulins or RAA, and may be associated with a lower risk of hypoglycemia and weight gain.
b) Faster-acting insulin aspart[5] and insulin lispro-aabc[6] probably lower prendial blood glucose better than RAA. More research is needed to establish a clear place for these factors in diabetes management.
In addition, newer, longer-acting basal insulin analogs (glargine U-300 (such as Togeo) or degludec[7]) may have a lower risk of hypoglycemia compared with glargine U-100 in patients with type 1 diabetes.
In general, patients with type 1 diabetes receive 50% of their daily insulin as basal and 50% as insulin. The total daily insulin requirement can be estimated based on weight; In this way, 0.4-1 unit per kilogram of the patient’s weight per day is considered, which may require the upper limit of the insulin dose during puberty, pregnancy or some disease conditions. But normally, in people who are metabolically stable, a dose of 0.5 units/kg per day of insulin (half of the dose to control basal blood sugar and the other half to control blood sugar after meals) is started.
The insulin regimen in the form of injections several times a day includes long-acting insulin injections at night to control blood sugar at night and fasting, and short-acting insulins to control blood sugar after meals.
The appropriate timing of prandial insulin injection depends on the pharmacokinetics of insulin (regular, rapid-acting (RAA), inhaled), premeal blood glucose levels, and carbohydrate intake. Physiological insulin secretion varies according to blood sugar, meal size, and tissue requirements for glucose. Therefore, educating patients on how to adjust prandial insulin, taking into account the amount of carbohydrates consumed, glucose levels before meals, and anticipated activity, can help. be effective.
2-1-2-non-insulin treatments
Pramelinitide[8]
Pramlintide is based on the amylin peptide that is naturally secreted from beta cells and has been approved for use in adults with type 1 diabetes. Results from clinical trials showed variable reductions in A1C (0-0.3%) and body weight (1-2 kg). ) has shown by adding pramelinitide to insulin.
metformin
Addition of metformin in adults with type 1 diabetes causes a small reduction in body weight and lipid levels, but does not improve A1C.
GLP-1 receptor agonists[9]
Addition of GLP-1 receptor agonists (liraglutide[10] or exentide[11]) to insulin in type 1 diabetes patients caused a slight decrease (0.2%) in A1C compared to insulin alone, and the average weight It has reduced 3 kg.
SGLT2 inhibitors[12]
Addition of an SGLT2 inhibitor to insulin therapy is associated with improvements in A1C and body weight compared with insulin alone. However, the use of SGLT2 inhibitors in type 1 diabetes is associated with a two- to four-fold increase in ketoacidosis.
According to what has been mentioned, so far only pramelinitide has been approved for the treatment of type 1 diabetes, and further studies are needed for other adjunctive agents.
2-1-3-Surgery
Transplantation of pancreas and islet cells of Langerhans[13] can normalize blood glucose levels and reduce microvascular complications of type 1 diabetes. However, such patients need to receive immunosuppressors to prevent transplant rejection for life. Therefore, considering the potential side effects of treatment with immunosuppressors, pancreas transplantation should be considered for patients who are undergoing kidney transplantation at the same time, or for people who have frequent episodes of ketoacidosis or severe hypoglycemia despite focused and intense blood sugar treatment.