Treatment

Many diabetes organizations and professional associations recommend a treat-to-target approach to achieve and maintain glycemic control in patients with diabetes. While not all groups agree on the specific values to target, they do recommend early initiation of therapy and persistent titration to safely achieve and maintain glycemic targets in patients with diabetes. The same criteria have to be applied for Latinos with diabetes.

This includes the following principles:

1. Address postprandial glucose as well as fasting glucose to achieve target
   hemoglobin A1c.
2. Minimize glucose excursions throughout the 24-hour period.
3. Utilize therapy that is physiologic to address multiple defects.
4. Combine pharmacologic treatment with medical nutrition therapy and other
   lifestyle interventions when appropriate.

There is consistent evidence that sustained hyperglycemia can cause serious long-term complications. Hyperglycemia damages the large and small blood vessels. Cardiovascular disease is the number one cause of death in patients with diabetes. Damage to small blood vessels can lead to blindness, kidney failure and nerve damage. Improving blood sugar levels can help reduce the risk of complications. Three independent studies in both type 1 and type 2 diabetes show clearly significant benefits of similar magnitude by decreasing A1c.

The United Kingdom Prospective Diabetes Study, or UKPDS, showed that a 1% decrease in A1c can reduce micro-vascular complications by 35%, and produce a 7% decrease in all-cause mortality, a 25% decrease in diabetes-related mortality and an 18% decrease in myocardial infarction.

It is important to look at treatment algorithms. The Texas Department of Health’s Texas Diabetes Council Algorithm for Type 2 Diabetes recommends the following:

• Patients who do not reach glycemic goal after one month of lifestyle intervention
  should consider early combination therapy with a sulfonylurea plus metformin.
• After three months they should initiate modified dual therapy.
• After three to six months they need to add evening insulin or a third oral agent.
  Also, the general physician should consider referral to an endocrinologist.

The goal is to have the hemoglobin A1c less than 6.5%.

In the fall of 2008, the American Diabetes Association and the European Association for the Study of Diabetes issued a consensus Algorithm for the Initiation and Adjustment of Therapy.

INITIATING INSULIN THERAPY

One of the most common errors in clinical practice when dealing with Latinos is to delay insulin treatment. It is important to mention to the patient that no matter what type of diet or medication the patient uses, the hemoglobin A1c levels are going to increase in the range of .2 to .3% on a yearly basis. The UKPDS study clearly showed that almost 50% of the beta cells decline over time. This rate is the same for diet alone, or treatment with sulfonylurea plus metformin. This is an important point for your Latino patients with diabetes because combination treatments are needed and more aggressive interventions, including early insulin, are recommended.

There are several different types of insulin available.

• Rapid-acting (analog)
• Short-acting (human) – Regular
• Intermediate-acting (human) – NPH
• Long-acting (analog)

The following chart profiles some of the currently available insulin analogs

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