Type 2 diabetes: what is it and how is it treated?
Type 2 diabetes is currently one of the most serious diseases of mass occurrence. The number of diabetics is increasing significantly all over the world. Today, the incidence of diabetes in the Czech Republic is around 10%, and approximately every third citizen of the Czech Republic will probably develop type 2 diabetes during their lifetime. The prevention of type 2 diabetes is therefore important (see separate article ).
What are the symptoms of type 2 diabetes ?
Newly diagnosed diabetes is classically manifested by great thirst, frequent urination, weight loss and often skin inflammation . These symptoms are now unusual, and diabetes should be detected by taking blood during a preventive examination, preferably already at the stage of so-called prediabetes – i.e. at a time when diabetes does not yet cause any problems.
How is type 2 diabetes diagnosed ?
In type 2 diabetics , diabetes usually runs in the family. The risk for the closest relative is up to 60% and for the offspring of two diabetics up to 100%. The development of overweight and obesity and hypertension is frequent in an endangered individual . The so-called prediabetes phase is coming. Today, prediabetes ( fasting blood glucose 5.6 to 6.9 mmo/l) is not just a pre-diabetes stage: it is a disease that requires treatment and brings vascular risk ( heart attack , stroke). Atherosclerosis and often nerve damage already develop in prediabetes before the patient meets the so-called diagnostic criteria for diabetes (glycemia of 7 mmol/l more, or high glycemia in 2 hours during a sugar test ).
On the other hand, so-called microangiopathic complications (affecting the eyes, kidneys and small vessels) arise only in the case of a long-lasting disease. Over 90% of patients with type 2 diabetes are overweight or obese. Others always have at least some accumulation of fat in the abdominal area. At the time of diagnosis, the level of insulin or C-peptide* is usually higher than normal. However, it is lower than would correspond to the degree of obesity and insulin insensitivity present. Therefore, even for type 2 diabetes, when diabetes occurs, insulin secretion in the beta cells of the pancreas is insufficient.
*Explanation: C-peptide is a part of the proinsulin molecule that is suitable for assessing insulin secretion.
How is type 2 diabetes treated?
The disorder is very complex in type 2 diabetes and involves the interaction disorder of many organs . Originally, type 2 diabetes was treated with only two groups of drugs ; these provided either an increase in insulin secretion or an increase in insulin sensitivity. Modern drugs affect many organs, such as, in particular, the kidneys, adipose tissue , liver and brain . The human liver produces glucose , which is why a person does not fall into unconsciousness even during a long period of starvation . After a meal, the liver of a healthy person reduces the production of glucose to about 20%. However, the liver of a person with impaired sensitivity to insulin produces glucose continuously, and even increases the production. High fasting blood glucose in a diabetic is therefore not post-dinner blood glucose: it is an internal process where the liver makes excess glucose. This can affect modern antidiabetic drugs .
Long-term disappearance, i.e. remission of type 2 diabetes , can be induced by surgical treatment of obesity, so-called bariatric surgery . Diabetics with a body mass index ( BMI ) of around 30 kg/m2 now routinely undergo the operation, although patients with higher degrees of obesity were previously operated on.
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Treatment with diet and physical activity and prevention of diabetes is discussed in the article Prevention of type 2 diabetes , which also contains information on the risk of this type of diabetes and its prevention.
Type 2 diabetes is usually treated with diet and antidiabetic drugs in tablet form. In some cases, the doctor chooses injectable incretin analogues or insulin treatment .
The choice of drugs is determined by the doctor, and during the patient’s life the treatment is usually gradually increased: from the administration of a single drug to double combinations and combinations of several drugs. The goal is to achieve the target values of fasting and postprandial glycemia and glycated hemoglobin ; these targets vary depending on how long the diabetes has lasted. Target values for newly diagnosed type 2 diabetics are very strict. The so-called phenomenon of metabolic memory applies . The body remembers how the patient was treated at the beginning (i.e. after the onset of the disease) – and patients whose blood glucose levels were quickly adjusted to normal have a reduced incidence of complications for 10-15 years. If diabetes lasts for a long time, such results can no longer be achieved. Therefore, it is important for the patient to realize that type 2 diabetes is a very serious disease and carries higher risks than, for example, hypertension, blood lipid disorders or smoking . It is particularly difficult to convince the patient to undergo treatment (ie weight reduction , diet and physical activity) at a time when he does not have any problems and when, as he himself says, he is not in pain. It is sometimes said that type 2 diabetes is something like an infection in quotation marks: it should be eliminated quickly and at the beginning, whether by weight reduction, bariatric surgery or modern drugs – then the effect is best.
The treatment of diabetes using drugs, so-called antidiabetics , has a long history. Diet and exercise therapy is hundreds of years old. Insulin has been used since the 1920s, tablet antidiabetic drugs until World War II, injectable non-insulin antidiabetic drugs until 2000. In Europe, antidiabetic drugs from 8 different groups are used today, and in the USA even from 11 groups. Individual groups of antidiabetic drugs used in Europe are listed in the following overview. Antidiabetics often exist under many different names and often in fixed combinations of two drugs in one tablet or injection.
- Metformin is the first-line antidiabetic drug that every type 2 diabetic should be treated with, if tolerated and if not contraindicated .
- Sulfonylureas are old cheap and effective antidiabetic drugs that promote insulin secretion. There is a slight risk of hypoglycemia when they are administered. Substances related to it are the so-called glinides, which are given less in our country. They usually cause weight gain.
- Insulin sensitizers , or thiazolidinediones, are substances that increase sensitivity to insulin, partly affecting insulin secretion and adipose tissue. They can lead to retention of edema and heart failure , but reduce the risk of stroke in diabetics.
- Inhibitors of the breakdown of carbohydrates in the intestine mainly reduce the rise in glycemia after a meal.
- Gliptins , or dipeptidase-4 inhibitors, are drugs that affect the effectiveness of so-called incretins ( hormones of the digestive tract ). The secretion of both insulin and glucagon is affected , and especially the hepatic production of glucose is suppressed. The advantage is that they do not cause hypoglycemia and do not increase weight.
- Incretin analogs are injectable drugs that mimic the action of digestive tract hormones (incretins). They reduce weight (newly, some are also used in the treatment of obesity without diabetes) and do not cause hypoglycemia. The first variants were given by injection twice a day, later once a day and now also once a week. Incretin analogues can be given in a single injection together with insulin. Most of these drugs have been shown to have a positive effect on the heart , as they reduce the risk of a heart attack.
- Gliflozins are new antidiabetic drugs that are administered in one tablet per day and block the reabsorption of glucose in the kidneys. In addition to increasing the level of sugar in the urine, they also have a very complex effect on the body: they reduce weight, lead to fat burning, have no risk of hypoglycemia, and lower blood pressure . Like incretin analogues, they reduce the risk of myocardial infarction , in addition, they also reduce the risk of heart failure.
- Insulin can be used in the treatment of diabetes already in the 2nd step (by adding to metformin). In particular, an evening injection of long-acting insulin is used, which suppresses the production of glucose by the liver. In the later stages of the disease, intensified therapy is also used with three daily doses of short-acting insulin and one dose of depot insulin (longer-acting insulin). For elderly patients who are unable to inject themselves 3 times a day, fixed combinations of short-term and long-term insulin are also administered 1 or 2 times a day.
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Opinions on the treatment of type 2 diabetes vary, and a common guideline is usually applied worldwide . The current one states the following principles:
- The drug of first choice is metformin. If the patient tolerates it or is not contraindicated, it should be given as the first choice and left even later in combination with other drugs.
- Subsequently, the doctor should ask himself whether the patient already has heart, blood vessel or kidney disease. If so, in the 2nd step, the patient should receive treatment with an injectable incretin analogue or gliflozin, i.e. drugs with a proven effect on these diseases. In our country, however, this option of treatment is only possible for poorly compensated diabetics with an unsatisfactory level of glycated hemoglobin.
- The next question should be: is the patient obese? If so, then he should also be treated with gliflozin or an incretin analogue in the 2nd step (see previous point).
- If the patient is at risk of hypoglycemia, it is possible to use insulin sensitizers in addition to gliflozins and incretin analogues.
- Other drugs are chosen according to the clinical situation.
The choice of antidiabetics is therefore left to doctors. The doctor should explain the risks and benefits of each group to the patient. The patient should pay attention to the regularity of the treatment and adherence to the diet regimen measures, he should know his target values and strive to achieve them.
What are the risks for type 2 diabetics?
Type 2 diabetics mainly face vascular risks . With long-term high blood sugar levels, there is a risk of kidney damage, which can lead to the need for dialysis , eye damage up to blindness, and further, for example, heart attacks, strokes or limb amputations . Cancer risks are also very high : Type 2 diabetics are at increased risk of malignant tumors of the kidneys and urinary tract , digestive tract, liver and pancreas , and women are at risk of malignant tumors of the breast and uterus .
However, in a well-trained and cooperative patient, the risk of complications is minimal, and his life expectancy from diagnosis can be close to that of non-diabetics.