The goals of therapy for type 1 or type 2 diabetes mellitus (DM) are to (1) eliminate symptoms related to hyperglycemia, (2) reduce or eliminate the long-term microvascular and macrovascular complications of DM (Chap. 419), and (3) allow the patient to achieve as normal a lifestyle as possible. To reach these goals, the physician should identify a target level of glycemic control for each patient, provide the patient with the educational and pharmacologic resources necessary to reach this level, and monitor/treat DM-related complications. Symptoms of diabetes usually resolve when the plasma glucose is <11.1 mmol/L (200 mg/dL), and thus most DM treatment focuses on achieving the second and third goals. This chapter first reviews the ongoing treatment of diabetes in the outpatient setting and then discusses the treatment of severe hyperglycemia, as well as the treatment of diabetes in hospitalized patients.
The care of an individual with either type 1 or type 2 DM requires a multidisciplinary team. Central to the success of this team are the patient’s participation, input, and enthusiasm, all of which are essential for optimal diabetes management. Members of the health care team include the primary care provider and/or the endocrinologist or diabetologist, a certified diabetes educator, a nutritionist, and a psychologist. In addition, when the complications of DM arise, subspecialists (including neurologists, nephrologists, vascular surgeons, cardiologists, ophthalmologists, and podiatrists) with experience in DM-related complications are essential.
ONGOING ASPECTS OF COMPREHENSIVE DIABETES CARE
A number of names are sometimes applied to different approaches to diabetes care, such as intensive insulin therapy, intensive glycemic control, and “tight control.” The current chapter, and other sources, uses the term comprehensive diabetes care to emphasize the fact that optimal diabetes therapy involves more than plasma glucose management and medications. Although glycemic control is central to optimal diabetes therapy, comprehensive diabetes care of both type 1 and type 2 DM should also detect and manage DM-specific complications (Chap. 419) and modify risk factors for DM-associated diseases. The key elements of comprehensive diabetes care are summarized in Table 418-1. In addition to the physical aspects of DM, social, family, financial, cultural, and employment-related issues may impact diabetes care. The International Diabetes Federation (IDF), recognizing that resources available for diabetes care vary widely throughout the world, has issued guidelines for “recommended care” (a well-developed service base and with health care funding systems consuming a significant part of their national wealth), “limited care” (health care settings with very limited resources), and “comprehensive care” (health care settings with considerable resources). This chapter provides guidance for this comprehensive level of diabetes care. The treatment goals for patients with diabetes are summarized in Table 418-2 and should be individualized.
TABLE 418-1Guidelines for Ongoing, Comprehensive Medical Care for Patients with Diabetes |Favorite Table|Download (.pdf) TABLE 418-1 Guidelines for Ongoing, Comprehensive Medical Care for Patients with Diabetes
Optimal and individualized glycemic control
Self-monitoring of blood glucose (individualized frequency)
HbA1c testing (2–4 times/year)
Patient education in diabetes management (annual); diabetes-self management education and support
Medical nutrition therapy and education (annual)
Eye examination (annual or biannual; Chap. 419)
Foot examination ...
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