e SGLT2 inhibitor, empagliflozin (EMPA), and the GLP-1 receptor agonist, liraglutide, reduce significant cardiovascular (CV) events and mortality. Hence, in patients with CV disease, these drugs should be considered next. For patients with T1DM, a regime of basal-bolus insulin is the mainstay of therapy. Also, insulin pump therapy is a reasonable choice. Since hypoglycemia portends increased mortality, preference should be given to therapies that do not induce hypoglycemia, for example, DPP-4 Inhibitors, SGLT-2 inhibitors, GLP-I receptor agonists, and pioglitazone with metformin. The other advantages of SGLT-2 inhibitors and GLP-I receptor agonists are a reduction in body weight, blood pressure (BP), and albuminuria.
To reduce microvascular complications in the majority, the goal Hb A1C should be less than 7%. Also, the BP goal should be less than 130/85 mmHg with a preference for angiotensin-converting enzyme (ACE)/angiotensin receptor blocker (ARB) therapy. Fundal exams should be undertaken as proposed by guidelines and urine albumin excretion at least twice a year.
For the lipid panel, the goal should be an LDL-C less than 100 mg/dl if no atherosclerotic cardiovascular disease (ASCVD) or less than 70 mg/dl if ASCVD present. The drug of choice is a statin since these drugs reduce CV events and CV mortality. Consider adding ezetimibe and PCSK9 inhibitors for patients with ASCVD who are not at goal.
Since the different complications and therapies have been detailed in other StatPearls review articles, we have outlined only the principles of therapy.
The list of differential diagnosis of diabetes mellitus consists of various conditions that would exhibit similar signs and symptoms:
- Drug-induced signs and symptoms due to corticosteroids, neuroleptics, pentamidine, etc.
- Genetic aberrations in beta-cell function and insulin action
- Metabolic syndrome (syndrome X)
- Endocrinopathies such as acromegaly, Cushing disease, pheochromocytoma, hypothyroidism, etc.
- Complications of iron overload (hemochromatosis)
- Conditions affecting the exocrine part of the pancreas such as pancreatitis, cystic fibrosis, etc.
DM is associated with increased atherosclerotic cardiovascular disease (ASCVD) and treating blood pressure, statin use, regular exercise, and smoking cessation are of great importance in ameliorating risk. The overall excess mortality in those with T2DM is around 15% higher but varies widely. The prevalence of vision-threatening diabetic retinopathy in the United States is about 4.4% among adults with diabetes, while it is 1% for end-stage renal disease. Today, with pharmacotherapy for hyperglycemia, as well as lowering LDL cholesterol and managing blood pressure with ACE/ARB therapy, with other antihypertensive medications and aspirin in secondary prevention, vascular complications can be managed adequately, resulting in a reduction in morbidity and mortality.
Persistent hyperglycemia in uncontrolled diabetes mellitus can cause several complications, both acute and chronic. Diabetes mellitus is one of the leading causes of cardiovascular disease (CVD), blindness, kidney failure, and amputation of lower limbs. Acute complications include hypoglycemia, diabetic ketoacidosis, hyperglycemic hyperosmolar state, and hyperglycaemic diabetic coma. Chronic microvascular complications are nephropathy, neuropathy, and retinopathy, whereas chronic macrovascular complications are coronary artery disease (CAD), peripheral artery disease (PAD), and cerebrovascular disease. It is estimated that every year 1.4 to 4.7% of middle-aged people with diabetes have a CVD event.
Deterrence and Patient Education
Patients must be educated about the importance of blood glucose management to avoid complications associated with DM. Stress must be given on lifestyle management, including diet control and physical exercise. Self-monitoring of blood glucose is an important means for patients to take responsibility for their diabetes management. Regular estimation of glucose, glycated hemoglobin, and lipid levels is necessary.
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