Main goals of treatment should be:

• Good glycemic control
• Prevention of acute complications
• Prevention of long term complications

STEP ONE: DIET, EXERCISE, WEIGHT CONTROL, and HEALTH EDUCATION

Diet:

• Fats - 30% of total energy intake
• Protein - 15%
• Carbohydrate - 50 - 55% of total intake
• Limit simple sugars like table sugar, fruits
• Eat complex carbohydrates like pasta, potato
• Multiple meals of smaller quantities

Weight reduction:

Reduced adipose stores restores tissue sensitivity to insulin. But weight reduction is difficult to achieve with current therapies.

STEP TWO: ORAL AGENTS

First monotherapy is tried. In obese patients metformin and sulphonylureas for lean people is recommended. Later oral agent combination therapy is recommended. In this combination therapy two different classes of drugs are used.

STEP THREE: INSULIN :

Soluble insulins, rapid acting insulins and prolonged acting insulins are used based on clinical situation.

STEP FOUR: INSULIN PLUS AN ORAL AGENT :

Here insulin is given along with oral hypoglycemic agent.

Breif description of drugs:

Sulphonylureas: They promote insulin secretion. Glibenclamide, Tolbutamide are popular drugs. Side effect is hypoglycemia which may be prolonged. These are not drugs for obese patients as they increase patients weight.

Biguanides: Metformin is popular drug. It reduces glucose production by the liver and sensitizes target tissue to insulin. Can be used in obese diabetics as it doesn’t increase weight. Main side effect is lactic acidosis in patients with liver or renal disease.

Alpha-glucosidase inhibitors: Acarbose slows glucose absorption and postprandial glucose peaks are reduced.

Thiazolidinediones: Exampleas are Rosiglitazone and Pioglitazone. They are contraindicated in patients with liver impairment or cardiac failure.

Insulin:

Soluble insulins start working within 30 - 60 minutes and lasts for 4 - 6 hours. Used in emergency situations like ketoacidosis and for surgical procedures.

Rapid-acting insulin start working quicker like in 15 minutes with shorter duration of action like 2 - 4 hours.

Prolonged-acting insulin acts between 12 - 24 hours. Protamine insulins and lente insulins are examples of these type of insulins.