Eugenio Cersosimo*, Carolina Solis-Herrera and Curtis Triplitt
Natural history and Pre-diabetes – Type-2 diabetes (T2DM) is a chronic disease with various metabolic and hormonal disorders derived from genetic and environmental factors that compromise organs and functional systems. Prevention must be initiated in the pre-diabetes phase aimed at high-risk individuals using aggressive measures to reduce excessive body fat with a concerted effort to improve tissue insulin resistance and to protect residual beta-cell insulin secretion. Healthy nutritional adjustments must include low-calorie and low-simple carbohydrate diets with preference for fresh fruits, vegetables, whole grains, more nuts and vegetable oils, lean meats and fish. Less consumption of animal-derived fat, whole-milk dairy products and red meat, and avoidance of sugared beverages. Regular exercises and daily physical activities are recommended. Pharmacotherapy with either metformin and/or pioglitazone is indicated in pre-diabetes individuals with signs of deterioration in glycemic control.
Early T2DM - Once the diagnosis is confirmed, the main goal of therapy shifts and control of hyperglycemia to avoid hospitalization for acid-base and hydro-electrolytic disturbances, acute infections and/or coronary events becomes a top priority. A short trial of insulin therapy or sulfonylurea may be warranted, although these should be rapidly substituted for SGLT- 2i agents with/without GLP-1 RA. A thorough evaluation of glucosedependent microvascular complications such as retinopathy, nephropathy and neuropathies are mandatory. Measures instituted in pre-diabetes must remain in place and, together with new medications; therapeutic objectives are more likely to be achieved.
Late T2DM - As diabetes progresses, efforts to reduce the risk for the development of cardiovascular and renal complications take priority. Dietary recommendations, tailored exercise programs, physical therapy, smoking cessation and promotion of a healthier lifestyle become necessary. A review of anti-atherogenic medications must be implemented. Ultimate objectives in advanced T2DM are to provide quality of life and to help reduce precocious mortality with an extended healthier survival.
