Diabetes Treatment and Management

Millions of people around the world inject themselves with insulin every day. In many regions, syringes are used extensively for insulin injection.

The syringes that were initially used for insulin injection were large, bulky and had to be reused multiple times. Thankfully technology has come a long way since then. Modern syringes are disposable and have scale markings on the side specifically to help with accurate insulin dosing.

Modern needles have also improved significantly. Older variants were long and large-bore — these days, they have been replaced by smaller, shorter needles.

Insulin pens became available in the 1980s. They allow a dose to be selected using a dial, rather than drawing up from a vial with a syringe and needle.

Insulin pens consist of three components — a cartridge that contains the insulin, a disposable needle, and a one-click-per-unit dosing dial.

The insulin pen itself can either be disposable or reusable, where the insulin cartridge is replaced when empty.

A modern update is the ‘smart pen’. This device has memory functions for things like dose and timing, and can use USB or Bluetooth to integrate with digital platforms, such as a smartphone app. This allows for much more efficient ways to monitor diabetes.

Insulin pumps are different from injections, as they deliver a continuous ‘basal’ flow of rapid-acting insulin.

The pump typically consists of an insulin reservoir that sits inside the pump and an infusion set with tubing. The reservoir and infusion set are connected to a catheter in the skin to continuously deliver insulin to meet daily needs. A different variety is the ‘patch pump’. These devices are small, lightweight and attached directly to the skin (without an infusion set).

Much has changed since pumps were originally designed. The first pump prototype had to be worn as a backpack, but modern pumps are much smaller.

Modern ‘smart’ pumps have many features, including built-in calculators for bolus doses (additional one-off doses of insulin), computer interfaces and alarms. Rapid changes to the rate can be set by the user to respond to food intake, and insulin delivery can also be suspended to respond to hypoglycemia.

Some pumps can also work with glucose sensors to automate the delivery of basal insulin (called ‘hybrid closed loop systems’).

The cornerstone of type 2 diabetes treatment is a healthy lifestyle, which includes adopting a balanced diet, regular physical activity, smoking cessation and maintaining a healthy body weight.

There is strong evidence that nutrition therapy is an effective part of diabetes care. Nutrition therapy aims to:

• Promote healthy eating patterns
• Improve markers of good blood glucose management such as HbA1c
• Help meet blood pressure and cholesterol targets
• Achieve and maintain weight goals
• Delay or prevent the complications of diabetes
• Address individual nutrition needs and maintain the pleasure of eating
• Provide tools for day-to-day meal planning

In addition to diet changes, it is recommended that alcohol is only drunk in moderation.

Exercise also forms an important part of diabetes management. For adults, it is recommended that 150 minutes of moderate-intensity or 75 minutes of high-intensity aerobic exercise be performed every week. However, if you have heart disease, it is best to speak to your diabetes care team about what you can and can not do when it comes to exercise. If you want to take part in sports, your diabetes care team may suggest a screening for heart disease first.

There are a number of tablets that can be taken for type 2 diabetes.

The preferred medication to start on first, if the person with diabetes is not allergic to it, is metformin (at a lower dosage). Metformin lowers blood glucose levels by reducing the rate at which glucose is produced by the liver.

If the dose of metformin has been increased to its maximum and blood glucose targets (measured by HbA1c) are still not met, either a second tablet or insulin injections could be started.

There are several other tablets that could be prescribed, either instead of, or in addition to, metformin. These include:

• Biguanides
• Sulfonylureas
• ​​Sulfonamides (heterocyclic)
• Thiazolidinedione (TZDs)
• Alpha-glucosidase inhibitors
• Dipeptidyl peptidase 4 (DPP-4) inhibitors
• Sodium-glucose co-transporter 2 (SGLT2) inhibitors

Your healthcare team will help you decide what treatment is best for you, taking into account your preferences as well as the characteristics of the treatments available. The aim will be to meet your blood glucose goals while avoiding or minimizing side effects.

While tablets are the preferred first medication for type 2 diabetes, for some patients, other treatments may be needed. 

One type of injectable medication for type 2 diabetes is GLP-1 inhibitors. These increase insulin secretion but do not increase the risk of low blood glucose (hypoglycemia).

In newly diagnosed type 2 diabetes, if the blood glucose is very high or the person has symptoms of high blood glucose, the healthcare team may decide to start insulin treatment.

People with type 2 diabetes may be put onto a basal-bolus regimen. This involves taking a longer-acting form of insulin (which keeps blood glucose levels stable through periods of fasting) as well as separate doses of shorter-acting insulin (which prevent rises in blood glucose levels resulting from meals). If they experience significantly high blood glucose levels after meals and need to have a flexible insulin regimen to fit in with their lifestyle.

Type 2 diabetes can be a progressive condition, so many patients will eventually end up on insulin therapy.