Management of type 2 diabetes mellitus for general practitioners

Abstract

Diabetes causes approximately 5% of deaths globally each year. Eighty per cent of patients with diabetes live in low-income and middle-income countries. What is most disturbing is the World Health Organization (WHO) prediction that without urgent action, diabetes deaths will increase by more than 50% in the next 10 years.31 World Diabetes Day raises the global awareness of diabetes, thus providing an additional opportunity to educate patients, healthcare professionals, carers, spouses and family, as well as the public in general. This day, initiated by the International Diabetes Federation and the WHO, and celebrated on 14 November, marks the birthday of Frederick Banting, who, together with Charles Best, played a crucial role in discovery of insulin in 1922.32 Returning to the case scenario, this patient clearly has type 2 diabetes mellitus with major risk factors for CVD. Therapy should be initiated with lifestyle interventions, including a weight-reducing diabetic diet and a graduated exercise programme. Metformin should be first-line therapy. If glycaemic targets are not met, a sulphonylurea-type drug should be added. Basal insulin therapy is indicated if this combination of oral hypoglycaemic agents fails to achieve glycaemic targets. The patient should be made aware of new therapies such as incretins, which are now available. The patient's cardiovascular risk factors need to be addressed. His BP must be reduced to target, starting with an ACE inhibitor (or ARB if intolerant). Most often multiple drug therapy is required to reduce the BP to target. The dyslipidaemia needs to be addressed with lifestyle interventions and statin therapy. He meets the criteria for low-dose aspirin therapy. Screening for complications should be implemented at diagnosis, especially as this patient presented with visual symptoms and microalbuminuria. Comprehensive diabetes education is crucial to ensure successful management of this patient.