Diabetes is diagnosed when a Hemoglobin A1c (HbA1c) becomes greater than or equal to 6.5. At this time, or even earlier, when patients are diagnosed with Pre-Diabetes (a HbA1c of 5.7-6.4) initiation of an antihyperglycemic medication is often prescribed.

Prior to the diagnosis of Pre-Diabetes or Diabetes the metabolic pathogenesis responsible for the propagation of this syndromic state begins years (10-20) before the diagnosis is made.

The general consensus for first-line treatment remains Metformin due to the relative safety margin and multiple mechanisms of action that it has upon conferring slowed progression of a hyperglycemic state. The effect of Metformin or single agent therapy is most effective within the first 6 months of being diagnosed with a maximum reduction in the HbA1c by 1.5. Delayed initiation of antihyperglycemic agents results in decreased effectiveness in HbA1c reduction. Additionally, the longer a single oral antihyperglycemic agent is prescribed the less effective it becomes in controlling the HbA1c.

The progressive pathology of diabetes necessitates the frequent checking of the HbA1c every 3 to 6 months with accordant adjustments in the prescribed medications. The addition of multiple oral antihyperglycemic agents becomes necessary within years of the diagnosis. When the combination of oral antihyperglycemic agents fails to keep the HbA1c from increasing a point of insulin initiation is assumed.

Insulin is utilized in a short-acting formulation at meal time and a long-acting form as a basal dose. Dosing ranges and capabilities differ amongst the insulin formulations; however when insulin requirements become greater than 200 units/day; concentrated forms of insulin may be employed (U-500). Progression beyond concentrated forms of insulin requires insulin pump administration of which provides an advantage when compared with the previously stated forms due to its ability to continuously administer the required dose of insulin throughout the day.

The progression of diabetes can be defined as a rising HbA1c or an increasing dose of antihyperglycemic agents, insulin dose, a combination of the two, or the onset of medical complications associated with diabetes.

The worsening of the HbA1c or increased dose of insulin serves as a marker for deteriorating health due to worsening of an underlying inflammatory process that leads to the acceleration of the aging process.

The Metabolism Clinic is established as the destination for weight loss and reversal of diabetes. Based in Charlotte, North Carolina. www.themetabolismclinic.com