DM2 is the most common form of diabetes. The most delicate and difficult problem in the management of the patient with DM2 is the maintenance of a normal glycemic level in 24 hours. Normal blood glucose values ​​in a healthy subject are ≤ 110 mg / dl on fasting and ≤ 140 mg / dl 2 hours after a meal. In a diabetic patient the values ​​commonly accepted as indices of a good glycemic control are respectively 90-130 mg / dl on fasting and <180 mg / dl 2 hours after a meal. In the standard management of the diabetic patient, even if repeated checks of the glycaemia are measured with meals and quarterly measures of the HB-A1C, often it is not possible to maintain good blood glucose levels for 24 hours. In most cases, two important changes in blood sugar can not be avoided:
1) post-prandial hyperglycemia;
2) nocturnal hypoglycemia;
This is particularly true in some unstable patients with high levels of Hb-A1C, with a tendency to hypoglycaemia, nocturnal species, with difficulty adjusting the doses of oral hypoglycemic agents and / or insulin, with disorderly conduct in self-monitoring, in dietary control, exercise and / or lifestyle, as well as in patients who intentionally maintain high glycemic targets for fear of hypoglycaemia.
50% of hypoglycemia events occur during sleep hours. Significant proportions occur without symptoms, when patients are awake, for coexisting neuropathy and sensory defect and alert reactions. Although the diagnosis of hypoglycaemia is commonly reported for a plasma glucose level of 45-50 mg / dl, the threshold of symptoms that hypoglycemia produces varies greatly from patient to patient and is often significantly higher. A criterion followed by many doctors for the diagnosis of hypoglycemia is given by the so-called Triad of Whipple. That is:
1) presence of consistent symptoms with hypoglycemia;
2) low plasma glucose concentration;
3) disappearance of symptoms after rising glucose levels.
It is evident the importance of a rapid diagnosis of any hypoglycemia episode in order to give the patient timely assistance. Self-monitoring of blood glucose may not be sufficient. In selected cases, continuous monitoring or CGMS (Continuous Glucose Monitoring System) is required, as shown in the literature.Most of the evidence concerns the DM1, but the prevalence of hypoglycaemia is very relevant in DM2 and the much greater diffusion of DM2 compared to DM1 makes the problem quantitatively more consistent in DM2. Hyperglycemia is the other major metabolic problem in the management of the patient with DM2.
Hyperglycaemia can cause serious acute complications and chronic complications of DM2.The most fearful acute complication is the hyperglycemic hyperosmolar state (HHS).It is associated with an absolute or relative insulin deficiency, a strong prolonged increase in plasma glucose concentration (600-1200 mg / dl), increased plasma osmolarity (330-380 mOsm / ml).It is potentially serious and fatal if not promptly diagnosed and properly treated.The chronic complications of DM2 are:
1) Microvascular which include proliferative and non-proliferative retinopathy, macular edema, and diabetic, sensory, motor neuropathies and of the autonomic nervous system;
2) Macrovascular diseases that include diseases of the coronary arteries, peripheral vasculopathies and cerebrovascular diseases;
3) Nephropathy with multifactorial pathogenesis;
4) Others, including gastrointestinal, dermatological, ophthalmological (cataract and glaucoma) and infectious diseases.
There is ample documentation of the preventative effect of chronic complications by good glycemic control. It is therefore evident the need to avoid chronic hyperglycemia in diabetics, but also the risks of hypoglycemia.The need to avoid chronic hyperglycemia in diabetics is therefore evident. The DCCT (Diabetes Control and Complications Trial) definitively tested in 2006 that the reduction of chronic hyperglycemia can prevent many of the even early complications of diabetes. This large multi-center clinical trial randomized more than 1,400 patients with both intensive and conventional diabetes, and prospectively evaluated the development of retinopathy, nephropathy and neuropathy. Diabetics in the intensive care group received many insulin doses per day together with extensive medical, dietary, educational and psychological support.Diabetics under conventional treatment received two to three injections of insulin per day and had a quarterly clinical, dietary, and educational assessment. The target of the first group was normoglycemia, the second group was the prevention of diabetes symptoms. Those in the first group had significantly lower Hb-glycosylated values ​​than those of the second group