Diabetes mellitus – Treatment

The aim of treating both type 1 and type 2 diabetes mellitus is to keep blood glucose levels at a normal level. Although diabetes cannot be cured, well-controlled patients can lead a symptom-free life.

Therapy through medication and lifestyle

If you have your blood sugar under control, you can prevent the risk of secondary diseases. Intensive training is therefore very important for all sufferers. Those affected learn within this framework,

  • measure their blood sugar,
  • to deal with the medication,
  • to eat and behave healthily and
  • avoid consequential damage.

Specialists in private practice, diabetes outpatient clinics at hospitals, self-help groups and specialist diabetes practices offer courses for people with diabetes. The costs are covered by health insurance (not self-help groups).

Treatment of type 1 diabetes

If you have type 1 diabetes, your pancreas produces too little insulin or no insulin at all. You will have to inject the hormone every day for the rest of your life. The aim is to mimic the rise and fall of a healthy person’s blood sugar level. To determine the correct amount, measure your blood sugar several times a day, for example by pricking your fingertip and taking a drop of blood. A meter determines your current blood glucose level. There are also systems that measure blood glucose continuously over one to two weeks.

The standard treatment today consists of intensified conventional therapy (ICT), which proceeds according to the “basic bolus” principle. To do this, you inject yourself once (or twice) a day with a long-acting or ultra-long-acting insulin to cover your basic needs. You administer a fast-acting insulin at mealtimes and adjust the dose yourself according to your needs (bolus). You determine it by determining the current blood sugar level, the amount of carbohydrates in your meal (increase in blood sugar) and the level of physical activity (decrease in blood sugar).

A large number of those affected now wear an insulin pump permanently. This is a dosing device filled with insulin, about half the size of a pack of cigarettes. The insulin pump regularly delivers a preset amount of insulin via a cannula placed under the skin. You can then administer an extra dose of insulin before each meal. After diagnosis, you will acquire the knowledge required for therapy on your own in special training courses. The insulin pump can also be combined with a glucose sensor. The state-of-the-art system of a semi-automatic pump determines the basal requirement based on the measured blood glucose level and can also stop insulin release when blood glucose is low or increase insulin release when blood glucose is high. The availability of the available systems and which system is best suited to the patient will be explained to you by a diabetes specialist.

Treatment of type 2 diabetes

Type 2 diabetes is often caused by an unfavorable lifestyle, which leads to obesity as a result of physical inactivity and excessive calorie intake. If you have been diagnosed with diabetes, we will first advise you to lose weight by eating a balanced diet and getting more exercise. If you accept diabetes as a warning shot, changing your lifestyle can help you manage your blood sugar levels without medication. The therapy is based on a training and treatment program tailored to your needs. The USZ can provide information on this. Only if you are unable to regulate your values through lifestyle changes will further phases of treatment begin. It is important that all measures are always individually tailored to the patient.

Patients with type 2 diabetes are initially cared for by their family doctor. However, if the therapy is relatively complicated, insulin has to be injected or an individual combination therapy has to be chosen, a referral to the USZ is certainly a good choice of therapy.

The first stage: basic therapy

After three to six months, we check whether the change in lifestyle has been successful. To do this, we determine the HbA1c value. This value says something about the blood sugar level of the last 3 months = long-term sugar. If it is in the green range, you do not need to take any medication. If the values are still too high, the diabetes therapy is extended.

The second stage: therapy with one drug and early combination with a second drug

We will prescribe you a medication that lowers your blood sugar level. As a rule, this is metformin. If you cannot tolerate this active substance or if the blood sugar reduction is too low, other groups of medication can be added. Today, drugs that have been shown to prevent heart attacks or strokes and protect the kidneys (SGLT-2 inhibitors and/or GLP-1 receptor agonists) are mainly used. Sulfonylureas are generally no longer used. After a further three to six months, the HbA1c value is checked again.

The third stage: therapy with a third medication or with a long-term insulin

If the second stage has not brought the necessary success, you will be prescribed a third medication. Alternatively, long-term insulin can also be administered. Three to six months later, the HbA1c value is checked again.

The fourth stage: Intensified insulin therapy and combination therapies

At therapy level four, further adapted forms of insulin and combination therapy are used, which can be useful for some patients, such as the addition of a fast-acting insulin with meals or a mixed insulin (short-acting and long-acting insulin) or a combination of a GLP-1 receptor agonist with a long-acting insulin.

Oral antidiabetics

The first step in the treatment of type 2 diabetes is to change your lifestyle so that your blood glucose level is in the green zone. If this does not work, as a person affected by type 2 diabetes you have various groups of active ingredients at your disposal that you can take in tablet form, so-called antidiabetics.

Biguanides: The drug of first choice is metformin, the only biguanide approved in Switzerland. It makes your cells more sensitive to insulin, inhibits the liver in the formation of new sugar and possibly increases the excretion of sugar in the intestine.

Sulfonylureas: Experts use them as long as patients are still producing their own insulin. They stimulate the pancreas to release more insulin. With this medication there is a risk that you will have low blood sugar and gain weight.

DPP-4 inhibitors (gliptins): By inhibiting the breakdown of the intestinal hormone GLP-1, gliptins cause the pancreas to produce more insulin and inhibit the release of the insulin antagonist glucagon. Gastric emptying is delayed and the liver releases less sugar. They have virtually no side effects, but also have no benefits in terms of heart attacks and strokes or kidney function.

Glinides: work in a similar way to sulphonylureas by stimulating insulin production in the pancreas, but have a shorter effect and should be taken before meals. However, its use in Switzerland is very low.

GLP-1 receptor agonists: These mimic the effect of the intestinal hormone GLP-1 (see gliptins). Unlike other antidiabetic drugs, you have to inject them – like insulin. From fall 2020, however, there will also be a tablet with GLP-1 RA. This group prevents both heart attacks and strokes, reduces deaths and also protects the kidneys.

SGLT-2 inhibitors: These block the SGLT-2 protein, which transports sugar from the kidneys back into the bloodstream. As a result, the kidneys excrete more sugar in the urine. They are the only drugs that prevent or treat heart failure. They also protect the kidneys and prevent heart attacks and deaths.

Preferred medications: For the reasons described above, the preferred drugs today are metformin in combination with SGLT-2 inhibitors and/or GLP-1 RA.

Insulin therapy for patients with type 2 diabetes

At the beginning of type 2 diabetes, the sensitivity of the cells to insulin is reduced. The pancreas tries to compensate for this deficiency by producing larger quantities of the hormone. Over the years, however, the organ becomes exhausted, so that insulin production is significantly reduced. Then you need insulin therapy. You cannot take insulin in tablet form because it would not survive the passage through the stomach and the stomach acid would break it down. You must therefore inject the hormone. Short- and long-acting insulin or mixed insulins are available for therapy. The insulin is usually injected using a pen, a device that looks like a fountain pen

Basal insulin therapy for type 2 diabetes mellitus can also be intensified

Short-acting insulins lower blood sugar levels after just 15 to 30 minutes and are effective for a maximum of four hours. You inject them mainly at mealtimes as a so-called bolus. The effect of long-acting insulins, on the other hand, only occurs after two to four hours. They are effective for up to 24 or even 42 hours. They cover the basal insulin requirement without meals, for example at night. By combining “fast” and “slow” insulin, you can usually control your blood sugar well.

There are also various therapy regimens to choose from. Which one is used depends primarily on the patient’s circumstances: Some only need insulin at certain times to support the tablets, others need intensified insulin therapy.

At the beginning of 2020, the Swiss Society for Diabetes (SGED) published the latest treatment recommendations for type 2 diabetes mellitus, which took into account the results of all endpoint studies with the new diabetes drugs (SGLT-2 inhibitors, GLP-1 RA and DPP-4 inhibitors).

Both type 1 and type 2 patients can lead a relatively normal life without late effects if they adhere to the treatment guidelines and achieve and maintain a good HbA1c over many years.

Together with the Obstetrics Clinic, we also care for a large number of patients with gestational diabetes or pre-existing diabetes during pregnancy.

Rarer forms of diabetes, such as diseases of the pancreas or forms that are inherited dominantly, are often not diagnosed. A referral to us if specific forms of diabetes are suspected provides the patient with additional clarity as to which therapy should be used.

For patients

As a patient, you cannot register directly for a consultation. Please get a referral from your primary care physician, specialist.

For doctors

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