Vnitr Lek 2009, 55(Suppl 1):34-40

Patient with diabetes - internal medicine patient

R. Češka^1,2

¹ Centrum preventivní kardiologie III. interní kliniky 1. lékařské fakulty UK a VFN Praha, přednosta prof. MUDr. Štěpán Svačina, DrSc., MBA

² Česká internistická společnost České lékařské společnosti J. E. Purkyně, předseda prof. MUDr. Richard Češka, CSc.

Patients with type 2 diabetes mellitus (DM2T) are a part of all physicians', including internal medicine physicians', everyday practice. Furthermore, it is possible to presume that the number of patients with diabetes mellitus will increase consequent to the obesity and metabolic syndrome epidemic as well as deteriorating lifestyle within the population. What is the role of an internal medicine physician, primary or secondary care-based, in the care of a DM2T patient? It first needs to be taken into account that a patient with diabetes is a patient with polymorbidity who is at risk of cardiovascular disease as well as nephropathy, infections and other T2DM-related complications. At the same time, DM2T does not usually stand alone, as an isolated disorder, but is often found in a cluster together with dyslipidemia (DLP), hypertension (HT), visceral obesity and other disorders. This cluster of disorders could be called metabolic syndrome, cardiometabolic risk or we could simply accept the fact that these disorders occur frequently, together and that they jointly lead to serious complications. Who should then take care of such a patient? An internal medicine physician, primary as well as secondary care-based (for whom this is the basis of professional practice) is not only optimally placed for care of such a patient but represent a model of how care for a patient with polymorbidity should be conducted. Obviously, care for a DM2T patient should be comprehensive. We have to optimize the DM2T therapy as well as to provide effective treatment of DLP, HT, obesity and other complications. Early diagnosis of DM2T as well as diagnosis of subclinical stages of micro- and macroangiopathies are equally important. Evidence-based medicine should always be considered during therapeutic decision-making and drugs that provide the most significant benefit to the patients should be prescribed. Metformin is the mainstay of DM2T treatment itself and might be given in combination with sulphonylurea derivatives or, possibly, pioglitazone. Incretins, particularly gliptins sitagliptin and vildagliptin, and GLP-1 analogues, mainly exenatide, are interesting drug groups for a combination therapy. Hypertension treatment should include metabolically neutral or positive drugs, ACE-I, calcium channel blockers or sartans - among these, metabolically positive telmisartan is preferred. Statins have the most extensive evidence for use in treatment of DLP in diabetics. Microangiopathy is best managed with fibrates. Sibutramine is the leading agent in the treatment of obesity. Even though the therapeutic overview above focuses on pharmacotherapy, it needs to be emphasised that lifestyle changes, including diet, are the core of treatment.

Keywords: type 2 diabetes mellitus; macroangiopathy; microangiopathy; metformin; pioglitazone; sitagliptin; statins; fibrates; ACE-I; telmisartan; calcium channel blockers

Received: May 6, 2009; Published: February 1, 2009  Show citation