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Exp Clin Endocrinol Diabetes 2022; 130(S 01): S9-S18
DOI: 10.1055/a-1624-5080
German Diabetes Association: Clinical Practice Guidelines

Fundamentals of Diabetes Management

Bernhard Kulzer
1   Diabetes Centre Mergentheim, Research Institute of the Diabetes Academy Bad Mergentheim, University of Bamberg, Germany
,
Jens Aberle
2   Department of Endocrinology and Diabetology, University Obesity Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
,
Thomas Haak
3   Diabetes Centre Mergentheim, Bad Mergentheim, Germany
,
Matthias Kaltheuner
4   dialev, Diabetes Centre for Internal and General Medicine, Leverkusen, Germany
,
Jens Kröger
5   diabetesDE- German Diabetes Aid, Berlin, Germany
,
Rüdiger Landgraf
6   German Diabetes Foundation, Düsseldorf, Germany
,
Monika Kellerer
7   Department of Internal Medicine 1, Marienhospital, Stuttgart, Germany
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Diabetes therapy goals

Diabetes is a chronic disease that poses considerable challenges for people with diabetes in their daily therapy. In addition to drug therapy, the therapy behaviour of the person with diabetes plays a significant role in the prognosis of the disease. In diabetes therapy, it is therefore important to define therapy goals together with the person with diabetes, taking into account a multitude of biological, somatic, social and behavioural factors, and to support those affected as best as possible in implementing therapy goals into their personal living environment and their self-management.

The most important superordinate therapy goals for diabetes are described in the evidence-based guidelines for type 1 and type 2 diabetes [1] [2], as well as in the Disease Management Program (DMP) requirements guideline (DMP-A-RL) [3].

  • Maintaining or improving the quality of life limited by diabetes: For people with diabetes, maintaining the quality of life is the most important goal of diabetes therapy [4]. This means remaining as physically and psychologically healthy as possible despite and with diabetes, being able to realise one’s own life goals and being socially integrated – without being limited in areas of life that are important for people, such as family/relationship, job, interests, leisure time, etc. Study results show relatively consistently that these goals, which are important for people with diabetes, have not yet been achieved worldwide [5] [6].

  • Preventing symptoms of the disease: Elevated, decreased or even highly-fluctuating glucose levels (increased glucose variability) can lead to symptoms such as an increased urge to urinate (polyuria), a strong feeling of thirst (polydipsia), fatigue, weakness and tiredness. Symptoms that should be avoided during therapy also include dry or itchy skin, neuropathic symptoms and fluctuations in lens refractive power due to osmotic effects of increased glucose levels.

  • Preventing acute complications: It is important to prevent side effects of antihyperglycaemic therapy, in particular hypoglycaemia – especially severe hypoglycaemia in which the affected person is dependent on external help (e. g., by relatives or medical staff). As well, it is important to prevent severe hyperglycaemic metabolic derailments (e. g., diabetic ketoacidosis) because of the associated burdens and dangers for the person with diabetes, as well as the associated health risks, which can be lethal in some cases.

  • Preventing diabetes-associated diabetes complications: This mainly concerns the prevention of micro- and macrovascular sequelae, in particular retinopathy with severe visual impairment or blindness, renal insufficiency with the need for renal replacement therapy, coronary heart disease, peripheral arterial occlusive disease and ischaemic stroke. The goal is also to prevent neuropathies and diabetic foot syndrome with neuro-, angio- and/or osteoarthropathic lesions and amputations.

  • Preventing diabetes-associated increased morbidity and mortality: One major goal is to reduce the increased risk of cardiac, cerebrovascular and other macroangiopathic morbidity and mortality associated with diabetes. Using data from 65 million insured persons in Germany, the excess mortality due to diabetes in Germany could be estimated at 174,627 people. Overall, 21% of all deaths in Germany were associated with diabetes in this study [7].

In the case of a chronic disease such as diabetes mellitus, the therapy goals should always be set in consultation with the person affected. It must be taken into account that the therapy goals may differ between people with diabetes and the physician of the diabetes team. While people with diabetes often name “maintenance of quality of life” and “preventing acute complications” as the most important therapy goals, physicians often focus on “preventing diabetes-associated increased mortality” and “ preventing diabetes complication”. The therapy goals agreed individually with the people with diabetes should be evaluated regularly and as needed during the course of treatment and followed up or adjusted according to the results [2].

Different categories of therapy goals

According to Elwyn et al. [8], the guideline group of the Type 2 Diabetes [2] guideline suggests dividing the therapy goals into three categories:

  • Fundamental goals: These are general goals of people such as autonomy, self-determination, participation in life, maintaining health or quality of life. A possible question on the superordinate life goals could be: “When you think about your diabetes, what is particularly important to you for your life?”

  • Functional goals: These are goals that aim to prevent or reduce functional impairments that interfere with a self-determined and healthy life, such as the treatment of a functional impairment, the promotion of activities of daily living, the improvement of sporting activities, cognitive performance or also the ability to work, keeping a job. A question about function-related goals could be formulated, for example, as follows: “What drives you to take good care of your diabetes – what do you want to achieve with it in your daily life?” or “Which activities in your life are so important that you do not want to jeopardise them through poor diabetes control?”.

  • Disease-specific goals: These include all goals that are directly associated with the treatment of diabetes and its complication. This refers to somatic goals (e. g., preventing complications, less pain, better sleep) as well as psychological (e. g., preventing diabetes-related stress, anxiety, depression) and social goals (e. g. safe participation in road traffic). “In concrete terms, what would you like to achieve if you make maintain your diabetes therapy well, what would you get out of it?” could be a question about the disease-related goals.

When agreeing on individual therapy goals, the authors of the Type 2 Diabetes guideline recommend starting with the higher-level life goals, as these influence the function-related and disease-specific goals (“top-down approach”). If patients find it difficult to formulate higher-level life goals, more concrete, function-related and disease-specific goals can also be worked out together first. Building on this, it can then be easier to derive higher-level life goals from them (“bottom-up approach”). Since the prioritisation of therapy strategy goals can change, in practice the question of individual therapy strategies should be asked again at regular intervals [2] and this should also be recorded in writing.


 


Publication History

Article published online:
29 April 2022

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