The story begins with a fundamental understanding: diabetes is not a single disease. It presents a vast and diverse landscape of “pathogenetic ways” or paths, making a precise diagnosis paramount. This precision is not just academic; it’s essential because it directly defines the management strategy and, consequently, the outcomes for patients.
When a patient arrives, the assessment goes far beyond just identifying the medical condition. It’s crucial to diagnose the specific type and stage of diabetes and identify any existing comorbidities, such as hypertension, hypercholesterolemia, or thyrotoxicosis.
But the individual’s story doesn’t end there. Understanding their social and cultural background, including their ability to afford tests or medicines, is vital before prescribing treatments. Without this consideration, a patient might simply walk away, unable to follow through with the care. This emphasis on the individual underscores the concept of precision medicine, which aims to provide individualized diagnosis, treatment, prediction, monitoring, and prevention of disease, thereby minimizing errors. Simple clinical characteristics like age, BMI, sex, C-peptide, and genetic tests can guide this tailored approach.
A Tale of Progress and Ugandan Contributions
Globally, significant progress has been made in defining diabetes phenotypes, allowing for more tailored management and care. A point of pride in this ongoing narrative is Uganda’s contribution to defining Type 5 diabetes. Groundbreaking work by Dr. Davis Kibirige and colleagues has led to this understanding, which is particularly relevant for low and middle-income countries like Uganda.
This unique type mainly affects young people and is characterized by insulin deficiency without insulin resistance, often linked to malnutrition in the mother during pregnancy or in the child’s early life, impacting the development of pancreatic beta cells.
Uganda has also recently launched locally tailored national guidelines for diabetes, involving many dedicated individuals.
The Diverse Faces of Diabetes
To manage diabetes effectively, we must understand its different forms:
• Type 1 Diabetes: This is a condition of insulin deficiency, often leading to ketosis. It’s typically a disease of childhood with an autoimmune basis, where the body’s antibodies target and destroy the beta cells of the pancreas.
• Type 2 Diabetes: This is a much more heterogeneous group, marked by varying degrees of insulin resistance, impaired insulin secretion, and excessive hepatic glucose production. It frequently comes hand-in-hand with comorbidities like hypertension, obesity, and dyslipidemia.
• Type 3 Diabetes: This category refers to diabetes with specific identifiable causes, which can include genetic factors, diseases of the pancreas (like pancreatitis or tumors), or even be iatrogenic – caused by medical treatment, such as prolonged use of certain medications like dexamethasone.
The Pillars of Management: Prevention, Screening, and Lifestyle
The journey of managing diabetes often begins with prevention and lifestyle adjustments. Regular exercise and a healthy diet are fundamental.
Screening is crucial for high-risk individuals, such as those with a first-degree relative with diabetes, a history of gestational diabetes, obesity, or hypertension. Recommended screening tests include random blood sugar, post-prandial glucose, fasting blood glucose, and HbA1c. These tests should be performed regularly, ideally every six months or at least annually.
For individuals identified as pre-diabetic (impaired fasting blood glucose, impaired postprandial glucose, or HbA1c between 5.5% to 6.5%), lifestyle management is considered the best intervention. While some pre-diabetics might benefit from metformin, non-pharmacological methods are prioritized.
The Pharmacological Arsenal: A Spectrum of Treatments
When lifestyle changes aren’t enough, or for more advanced stages, pharmacological interventions come into play:
• Metformin (Biguanites): Often the first-line drug, metformin is an insulin sensitizer that enhances insulin activity in target organs like skeletal muscles and reduces hepatic glucose output. It can also aid in weight loss. A key contraindication is renal insufficiency. Despite its efficacy and widespread availability, there have been instances where it was out of stock in government facilities, which is “very unfortunate” given its importance.
• Insulin Sensitizers (Thiazolidinediones like Pioglitazone): These drugs have a similar action to metformin but should not be used in patients with heart disease or heart failure.
• Sulfonylureas (e.g., Glimiperide): These agents enhance the secretion of insulin from pancreatic beta cells. While they have been around for a long time, older sulfonylureas can cause prolonged hypoglycemia, especially in the elderly. Glimiperide is preferred due to a lower tendency for hypoglycemia. A common side effect of this class is weight gain, which makes them less ideal for patients who need to lose weight.
• DPP-4 Inhibitors (e.g., Sitagliptin, Vildagliptin): These drugs work by blocking an enzyme that breaks down incretin hormones, like GLP-1, thereby increasing their levels. This leads to stimulated insulin release, lower blood sugar levels after meals, and can promote satiety. They can be used alone or in combination with metformin.
• GLP-1 Receptor Agonists (e.g., Exenatide, Liraglutide): These are injectable analogues that enhance insulin action and have an effect opposite to glucagon.
• SGLT2 Inhibitors: These are a “very good molecule” with effects beyond just glycemic control. They offer cardiovascular and renal benefits, being used for heart failure and hypertension, and can help reverse or preserve the progression of kidney deterioration. They are recommended as first-line pharmacological therapy alongside metformin, especially for patients with chronic kidney disease, cardiovascular disease, or heart failure.
• Insulin: The “old insulin” remains crucial. It is used in Type 1 diabetes and in Type 2 diabetes when there is marked hyperglycemia (especially in newly diagnosed patients), during admission, or for general anesthesia. It’s also used when other pharmacological agents are inadequate or undesirable. A common practice is to start with insulin for severe hyperglycemia to reduce it quickly, then switch to oral hypoglycemics once the patient responds to small doses.
Addressing Specific Challenges and Complications
Diabetes can lead to various complications, and managing them requires specific approaches:
• Erectile Dysfunction: This common issue in diabetic patients is often pathological. While drugs like Sildenafil can be “add-ons,” reassurance and addressing the patient’s mindset are paramount. Sildenafil primarily helps maintain blood flow if some partial erection already exists. Extreme caution is advised when prescribing Sildenafil to patients with hypertension or ischemic heart disease due to potential catastrophic effects.
• Rosuvastatin and Type 2 Diabetes: The relationship between certain statins, like Rosuvastatin, and Type 2 diabetes is a concern. Rosuvastatin, used for hypercholesterolemia, has been shown to have a dose-dependent negative impact on insulin resistance, potentially contributing to the development of Type 2 diabetes. In such cases, Ezetimibe combined with lifestyle modification is suggested as an alternative to lower cholesterol levels.
The Art of Diagnosis: Symptoms and Tests
Finally, the story loops back to diagnosis. While classic symptoms like polyuria, polydipsia, weakness, and hypoglycemia can lead to an immediate diagnosis of diabetes, an oral glucose tolerance test (OGTT) is not always necessary. It’s primarily used for cases where the diagnosis is uncertain or for screening.
The clinical acumen of the practitioner is vital. Many symptoms associated with diabetes, such as polyuria or nocturia, can have other underlying causes. Therefore, clinicians are trained in differential diagnosis to ensure symptoms are correctly attributed. When uncertain if symptoms point to diabetes, a random blood glucose test is recommended. If the results are high and symptoms are present, it strongly indicates diabetes. For queries or further confirmation, repeat tests and HbA1c can be very helpful.
In conclusion, the story of diabetes is one of complexity, individual variation, continuous progress, and the essential need for precise, empathetic, and tailored care.
Disclaimer: Summarised using:Notebooklm
