Type 2 diabetes mellitus in therapeutic practice: it's not all that simple

Background. The prevalence of type 2 diabetes mellitus is high in Russia. This disease usually develops in middle-aged and older people over a period of several months or even years. At the initial stage, clinical symptoms are mild, which is why type 2 diabetes mellitus is diagnosed late. Type 2 diabetes mellitus is often detected for the first time during a preventive or random examination. The management of patients with type 2 diabetes mellitus in outpatient therapeutic practice has a number of specific features: the patient is always polymorbid and, in addition to type 2 diabetes, usually exhibits pathology in a number of organs and systems, which may precede type 2 diabetes, develop as a result of its complications, or be exacerbated by it. Multimorbidity always leads to polypharmacy, especially when patients consult different specialists and treatment approaches are not coordinated, so the polyclinic therapist must be the "coordination center" for working with patients. If type 2 diabetes mellitus is suspected, the physician must confirm the presence of the disease based on clinical and laboratory data, in accordance with the diagnostic criteria for type 2 diabetes mellitus, and prescribe individual treatment, the main goal of which is to compensate for carbohydrate metabolism. The main role in this is played by a balanced diet, optimal physical activity, and timely pharmacotherapy. Preference should be given to drugs that demonstrate a broad therapeutic effect, have sufficient hypoglycemic activity, affect metabolism, and have organoprotective properties. The main drug is metformin, a hypoglycemic agent from the biguanide group. By reducing hyperglycemia, it does not lead to the development of hypoglycemia, increases the sensitivity of peripheral receptors to insulin and glucose utilization by cells, reduces glucose production by the liver, delays its absorption in the intestines, and improves the lipid profile. Pharmacotherapy for type 2 diabetes mellitus should always be comprehensive, therefore, the treatment regimen, especially in cases of multimorbidity, should include drugs with a disease-modifying effect, namely, sodium-dependent glucose transporter type 2 inhibitors – gliflozins, which reduce fasting and postprandial blood glucose concentrations, as well as glycated hemoglobin concentration by reducing glucose reabsorption in the renal tubules, have a beneficial effect on the cardiovascular system and kidneys due to osmotic diuresis, associated hemodynamic action, and metabolic effects. In addition, gliflozins act as geroprotectors, delaying aging and preventing the development of age-related diseases. Metformin and gliflozins combine well, are convenient for use in outpatient therapeutic practice, and promote the formation of stable adherence to drug treatment in patients.

Results. Issues related to the diagnosis, treatment, and management of patients with type 2 diabetes mellitus in outpatient therapeutic practice are considered. Emphasis is placed on the polymorbidity of patients and the associated polypharmacy. Criteria for clinical and laboratory diagnosis are provided, and recommendations for rational nutrition and physical activity for patients are given. The role of key pharmacotherapy drugs is argued: metformin, a hypoglycemic agent from the biguanide group, and gliflozins, inhibitors of the sodiumdependent glucose transporter type 2. The disease-modifying effects of the drugs, the breadth of their therapeutic action, the possibility of combining them, and the convenience of their use in outpatient and polyclinic practice are emphasized. 

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