[Screening, diagnosis and management of diabetes mellitus and diabetic complications].

Diabetes mellitus comprises a group of metabolic disturbances that are characterized by hyperglycemia. In 1997 the American Diabetes Association (ADA) proposed new criteria for the diagnosis and classification of diabetes mellitus, which was also adopted by WHO. Although the criteria is the same, the ADA puts emphasis on the use of the fasting plasma glucose (FPG) for screening and diagnosis, whereas WHO maintains the use of the OGTT and recommends the FPG only if an OGTT can not be performed. Different pathogenetic processes are involved in the development of diabetes ranging from autoimmune destruction of beta-cells resulting in an absolute insulin deficiency to insulin with a defect on insulin secretion. The new classification is based on the etiology of the disease. Diabetes is classified into one of four categories: Type-1, type-2 Diabetes mellitus, specific forms of diabetes, and gestational diabetes. For screening and diagnosis FPG or the two hour value after the OGTT can be used. Glycosylated hemoglobin is not suitable for screening and diagnosis of diabetes despite some contradictory statements. For many decades clear evidence was missing that chronic hyperglycemia caused diabetic late complications; complications including dysfunction or failure of several organ systems, in particular eyes, kidneys, nerves, and the cardiovascular system. The results of two large prospective trials--the Diabetes Control and Complications Trial (DCCT; 1993) and the United Kingdom Prospective Study (UKPDS; 1998)--that were recently published provided the final proof that normoglycemia prevents or delays the progression of these late complications. Due to the insidious nature of these complications they are often not diagnosed and have to be looked for in each patients with diabetes and have to be controlled regularly. Based on the results of the UKPDS and other studies, evidence based therapeutic goals could be defined. Multifactorial interventions with increased physical activity, cessation of smoking, aspirin treatment, lowering of HbA1c, blood pressure, and lipids in patients with type 2 diabetes have been proven to drastically reduce the risk of developing diabetic nephropathy or cardiovascular complications drastically. We recommend the following treatment strategy for patients with type 2 diabetes in clinical practice: 1) Treatment should be individualized. 2) Treatment should be started step by step to document efficacy of treatment and compliance of patients. 3) Plasma glucose and blood pressure should be normalized in all patients with type 2 diabetes (up to an age of 70 years), since there are no threshold values for HbA1c and blood pressure. 4) Therapeutic goals should be checked every three to six months. 5) In the case that therapeutic goals can not be met, treatment should be intensified. Often a combination therapy with many different drugs is required. 6) A specialist for diabetes should be consulted, if the therapeutic goals can not be met over a period of six months.