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Current management of diabetes mellitus and future directions in care.
Postgrad Med J. 2015 Nov; 91(1081):612-21.PM

Abstract

The last 90 years have seen considerable advances in the management of type 1 and type 2 diabetes. Prof MacLean of Guy's Hospital wrote in the Postgraduate Medical Journal in 1926 about the numerous challenges that faced patients and their healthcare professionals in delivering safe and effective diabetes care at that time. The discovery of insulin in 1922 heralded a new age in enabling long-term glycaemic control, which reduced morbidity and mortality. Thirty years later, the first oral agents for diabetes, the biguanides and sulfonylureas, appeared and freed type 2 patients from having to inject insulin following diagnosis. Improvements in insulin formulations over the decades, including rapid-acting and long-acting insulin analogues that more closely mimic physiological insulin secretion, have increased the flexibility and efficacy of type 1 diabetes management. The last two decades have seen major advances in technology, which has manifested in more accurate glucose monitoring systems and insulin delivery devices ('insulin pump'). Increased understanding of the pathophysiological deficits underlying type 2 diabetes has led to the development of targeted therapeutic approaches such as on the small intestine (glucagon-like peptide-1 receptor analogues and dipeptidyl-peptidase IV inhibitors) and kidneys (sodium-glucose cotransporter-2 inhibitors). A patient-centred approach delivered by a multidisciplinary team is now advocated. Glycaemic targets are set according to individual circumstances, taking into account factors such as weight, hypoglycaemia risk and patient preference. Stepwise treatment guidelines devised by international diabetes organisations standardise and rationalise management. Structured education programmes and psychological support are now well-established as essential for improving patient motivation and self-empowerment. Large multicentre randomised trials have confirmed the effectiveness of intensive glycaemic control on microvascular outcomes, but macrovascular outcomes and cardiovascular safety remain controversial with several glucose-lowering agents. Future directions in diabetes care include strategies such as the 'bionic pancreas', stem cell therapy and targeting the intestinal microbiome. All of these treatments are still being refined, and it may be several decades before they are clinically useful. Prevention and cure of diabetes is the Holy Grail but remain elusive due to lack of detailed understanding of the metabolic, genetic and immunological causes that underpin diabetes. Much progress has been made since the time of Prof MacLean 90 years ago, but there are still great strides to be taken before the life of the patient with diabetes improves even more significantly.

Authors+Show Affiliations

Leicester Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK.Leicester Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't
Review

Language

eng

PubMed ID

26453594

Citation

Chatterjee, Sudesna, and Melanie J. Davies. "Current Management of Diabetes Mellitus and Future Directions in Care." Postgraduate Medical Journal, vol. 91, no. 1081, 2015, pp. 612-21.
Chatterjee S, Davies MJ. Current management of diabetes mellitus and future directions in care. Postgrad Med J. 2015;91(1081):612-21.
Chatterjee, S., & Davies, M. J. (2015). Current management of diabetes mellitus and future directions in care. Postgraduate Medical Journal, 91(1081), 612-21. https://doi.org/10.1136/postgradmedj-2014-133200
Chatterjee S, Davies MJ. Current Management of Diabetes Mellitus and Future Directions in Care. Postgrad Med J. 2015;91(1081):612-21. PubMed PMID: 26453594.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Current management of diabetes mellitus and future directions in care. AU - Chatterjee,Sudesna, AU - Davies,Melanie J, Y1 - 2015/10/09/ PY - 2015/04/30/received PY - 2015/09/12/accepted PY - 2015/10/11/entrez PY - 2015/10/11/pubmed PY - 2016/9/10/medline KW - DIABETES & ENDOCRINOLOGY SP - 612 EP - 21 JF - Postgraduate medical journal JO - Postgrad Med J VL - 91 IS - 1081 N2 - The last 90 years have seen considerable advances in the management of type 1 and type 2 diabetes. Prof MacLean of Guy's Hospital wrote in the Postgraduate Medical Journal in 1926 about the numerous challenges that faced patients and their healthcare professionals in delivering safe and effective diabetes care at that time. The discovery of insulin in 1922 heralded a new age in enabling long-term glycaemic control, which reduced morbidity and mortality. Thirty years later, the first oral agents for diabetes, the biguanides and sulfonylureas, appeared and freed type 2 patients from having to inject insulin following diagnosis. Improvements in insulin formulations over the decades, including rapid-acting and long-acting insulin analogues that more closely mimic physiological insulin secretion, have increased the flexibility and efficacy of type 1 diabetes management. The last two decades have seen major advances in technology, which has manifested in more accurate glucose monitoring systems and insulin delivery devices ('insulin pump'). Increased understanding of the pathophysiological deficits underlying type 2 diabetes has led to the development of targeted therapeutic approaches such as on the small intestine (glucagon-like peptide-1 receptor analogues and dipeptidyl-peptidase IV inhibitors) and kidneys (sodium-glucose cotransporter-2 inhibitors). A patient-centred approach delivered by a multidisciplinary team is now advocated. Glycaemic targets are set according to individual circumstances, taking into account factors such as weight, hypoglycaemia risk and patient preference. Stepwise treatment guidelines devised by international diabetes organisations standardise and rationalise management. Structured education programmes and psychological support are now well-established as essential for improving patient motivation and self-empowerment. Large multicentre randomised trials have confirmed the effectiveness of intensive glycaemic control on microvascular outcomes, but macrovascular outcomes and cardiovascular safety remain controversial with several glucose-lowering agents. Future directions in diabetes care include strategies such as the 'bionic pancreas', stem cell therapy and targeting the intestinal microbiome. All of these treatments are still being refined, and it may be several decades before they are clinically useful. Prevention and cure of diabetes is the Holy Grail but remain elusive due to lack of detailed understanding of the metabolic, genetic and immunological causes that underpin diabetes. Much progress has been made since the time of Prof MacLean 90 years ago, but there are still great strides to be taken before the life of the patient with diabetes improves even more significantly. SN - 1469-0756 UR - https://www.unboundmedicine.com/medline/citation/26453594/Current_management_of_diabetes_mellitus_and_future_directions_in_care_ L2 - https://pmj.bmj.com/lookup/pmidlookup?view=long&pmid=26453594 DB - PRIME DP - Unbound Medicine ER -