Chasing the Sweet Spot: Managing Diabetes in the Modern Era

Gregory Weiss, MD

Diabetes mellitus is a spectrum of serious lifelong diseases characterized by abnormally elevated blood glucose levels either due to a failure in insulin production or a reduction in the sensitivity of tissues to intrinsic insulin. A steady rise in the prevalence of diabetes has been seen globally and is currently among the leading causes of morbidity and mortality in the world.¹ It is estimated that 6.8% to 15.3% of Americans suffer from some form of diabetes.²

With such a large proportion of the population suffering from diabetes general practitioners, specialists, and subspecialists are seeing these patients on a regular basis and in all healthcare settings. After the initial diagnosis, often by a primary care provider, a treatment plan is initiated and monitored follow-up is the standard of care. Monitoring in our health-system consists of quarterly visits where information on diet, physical activity, adherence and tolerance to medications, diabetes-related complications, and the presence of other cardiovascular risk factors are examined.

Such frequent follow-up visits not only reinforce our engagement with patients but also allow us to change treatment strategies more effectively as new therapies are developed and patient factors change. At these follow-up appointments, exams for foot ulcers are performed, blood pressure is checked, and eye exams may be repeated based on previous findings. Finally, lipid profiles are drawn annually and hemoglobin A1C levels are monitored at least every 6 months provided they have been stable on therapy and more frequently if they have not.

Most often, I see diabetic patients in the peri-operative period or in the intensive care unit. Chief concerns in these environments include increased risk for infections and metabolic disturbances that impair circulatory flow, impact electrolyte levels, impair gastric motility, and lead to diabetic renal dysfunction. Diabetes affects so many organ systems a comprehensive approach is required that takes into account both macrovascular and microvascular sequelae. Macrovascular concerns include systemic atherosclerosis, which may precede acute coronary syndromes and put diabetic patients at increased risk for myocardial infarction in the perioperative period. Microvascular concerns include retinopathy, neuropathy, and nephropathy.

In addition to regular screening and monitoring for response to therapy, patient education should take place at every opportunity. Both verbal and supplemental written information can be effective in keeping patients on track. Adherence to diet, exercise, and medication recommendations are essential to preventing major adverse events. Many patients prefer to get information online and with their portable devices. We utilize web resources approved by the American Diabetes Association as well as The American Heart Association as go-to places for educational materials. It is important to tell patients that a general web search may not give them the most accurate information. Regularly asking diabetic patients about their feelings and concerns about their regimen is very useful in determining their level of investment in their care and their knowledge deficiencies.

One of the most daunting aspects of modern diabetic care is the plethora of old and new treatments and the constant onslaught of sponsored advertisements to the general public. Crossover therapies have become the norm in diabetic care by addressing, not only blood glucose levels and HbA1c but also renal protection and reduction of cardiovascular risk. Providers should treat hyperglycemia, hypertension, and dyslipidemia aggressively.

Today, we have quite a few medical treatments that have been shown to facilitate more than just one of these goals at a time. While angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) primarily treat hypertension they, along with sodium-glucose co-transporter 2 (SGLT2) inhibitors, may also prevent or slow diabetes-associated renal dysfunction.³ In addition to the SGLT2 inhibitors which include empagliflozin, canagliflozin, and dapagliflozin, the glucagon-like Peptide-1 (GLP-1) receptor agonists which include liraglutide, semaglutide, and dulaglutide exhibit favorable atherosclerotic and renal outcomes.⁴, ⁵, ⁶

These crossover therapies represent powerful tools for clinicians in their effort to mitigate multiple adverse outcomes. While drug therapy is clearly pushing new frontiers and improving lives the most important crossover therapy we can provide is education and encouragement for patients to make long-term lifestyle modifications. Smoking cessation and weight loss are the quintessential crossover treatments for diabetics with and without cardiovascular disease.

Whether through exercise, diet, or both, weight loss in overweight or obese diabetics may dramatically reduce medication requirements and potentially eliminate their need altogether. Exercise, a healthy diet, and abstinence from smoking also dramatically reduce the risk for cardiovascular disease-related morbidity and mortality.

In conclusion, at no time before have we possessed more tools in our toolkit that improve glycemic control, reduce cardiovascular risk, and improve the quality of life in our diabetic patients. Every opportunity and interaction should be utilized in an effort to educate, evaluate treatments, uncover complications, and encourage our patients to reach their goals.