Case

A 64-year-old obese African-American female presents with hemoglobin A1-C levels consistently between 7.5 and 8 and fluctuating blood sugars with episodes of hypoglycemia. Her weight gain has been progressive when using a split regimen of 30 U of 75 25 insulin before breakfast and 40 U before supper on a daily basis. Additionally, the patient takes 1000 mg of metformin twice daily, 15 mg of pioglitazone daily, and 10 mg of ramipril once daily. The patient has been continuously frustrated with...

Diabetic Neuropathy

Diabetic neuropathy afflicts up to 70 of patients with type 2 diabetes. Diabetic neuropathy does not represent one distinct disease but rather an adverse group of conditions that effect the peripheral nervous system, attacking the peripheral, proximal, and autonomic nerves, and causing both focal and systemic disease. Patients with diabetic neuropathy may have pain or impaired sensation in the feet and hands, slow digestion, carpal tunnel syndrome, or impaired cardiovascular responses (17)....

Diabetes Associated With Other Factors

Type 2 diabetes can also be associated with the following other clinical states, drugs, and chemicals 1. Genetic syndromes Huntington's chorea, muscular dystrophy, and lipodystrophic diseases. 2. Pancreatic diseases chronic pancreatitis, pancreatectomy states, hemochromotosis, and cystic fibrosis. 3. Endocrinopathies primary aldosteronism, Cushing syndrome, acromegaly, pheochro-mocytoma, glucogonoma, polycystic ovaries. 4. Drugs thiazide diuretics, P-blockers, glucocorticoids, phenytoin,...

The Biguanides

Currently in the United States, metformin is the only available member of the biguanides class. The previous biguanide, phenformin, was withdrawn from the US market in the 1970s because of episodes of severe recurrent lactic acidosis and death. Metformin also comes in an extended-release preparation and is approved for use in patients at least 10 years of age, with the extended-release preparation also approved for patients 17 years of age or older. In the UKPDS trial (5), metformin use was...

Premixed Insulins

Mixtures of short-acting and intermediate-acting insulins are a convenient method for primary care physicians to manage the basal bolus problem with one vial or pen. The following various mixtures currently exist 1. Humulin or Novolin 70 30 (70 insulin isophane suspension-NPH and 30 regular insulin). 2. NovoLog Mix 70 30 (70 protamine aspart and 30 aspart). 3. Humulin 50 50 (50 insulin isophane suspension-NPH and 50 regular insulin). 4. Humalog mix 75 25 (75 lispro protamine and 25 lispro). Of...

The aGlucosidase Inhibitors

The nonsystemic a-glucosidase inhibitors are used primarily to control postprandial hyperglycemia by delaying the absorption of polysaccharides and disaccharides in the intestinal brush border. They can be used as initial agents or in combination therapy. Recent trials have indicated that patients placed on acarbose can reduce their risk of developing cardiovascular events. Acarbose (Precose) was approved for use in the United States in 1995 and miglitol (Glycet) was approved for use in 1996....

Summary

Regardless of the combination used, there are some general principals to keep in mind 1. Fasting (premeal) hyperglycemia is caused by increased hepatic glucose production, decreased basal insulin secretion, reduced insulin sensitivity, and high sustained postprandial glucose levels. For individuals with AM fasting hyperglycemia, be aware of suppertime postprandial excursions and bedtime snacks. All oral agents are effective in lowering fasting or premeal glucose, although the glinides and the...

Human Insulin Preparations

Although undergoing some major improvements over the past several years, human insulin still has some limitations. The human insulins have variable and inconsistent absorption rates that cause erratic and unpredictable blood-glucose-lowering effects, resulting from the varying onset of actions, peak, and duration of action of these products. This is because when regular insulin is administered subcutaneously, its absorption into the circulation is slow, with a subsequent slow onset of action....

Diabetes And Minerals Vitamins And Dietary Supplements

It is important for patients with diabetes to be counseled about the importance of consuming adequate amounts of minerals and vitamins from natural food sources and to be aware of the potential toxic effects of megadoses of vitamin and mineral supplements. Interest in antioxidant vitamins in people with diabetes has increased with the knowledge that diabetes may be a state of increased oxidative stress. At present, megadoses of dietary antioxidants, such as selenium, P-carotene, vitamin E, and...

Finnish Diabetes Prevention Study

In the Finnish Diabetes Prevention Study (15), 522 patients with IGT and a mean BMI of 31 kg m2 were evaluated. A control group was compared with a lifestyle-changes group with the same exercise as the Diabetes Prevention Study and similar fat- and calorie-restricted diets, with a fiber intake of at least 15 g 1000 cal. Once again, a 58 relative risk reduction was seen. The number of patients needed to treat to prevent diabetes was 22 for 1 year and five for 5 years with this study.

Diabetes And Carbohydrates

Carbohydrates in the diet include monosaccharides and disaccharides, the starches and the indigestible carbohydrates, such as cellulose, pectins, gums, and psyllium. The American Diabetes Association (ADA) recommends the following terms sugars, starch, and fiber, whereas terms such as simple sugars, complex carbohydrates, and fast-acting carbohydrates should be avoided because they are not well-defined. Carbohydrates in the form of whole grains, fruits, vegetables, legumes, and low-fat milk are...

Combination Therapy

The ADA recommends the use of dihydropyridine CCBs only in combination with (but not instead of) ACE inhibitors or ARBs for patients with diabetes and elevated blood pressure. The combination therapy approach to hypertensive management in the patient with diabetes is extremely appealing. The increased efficacy of the combination over monotherapy has been well-established. The decreased side effects with combination therapy along with the increased efficacy and improved patient compliance make...

Continuous Subcutaneous Insulin Infusion Pumps

Continuous subcutaneous insulin infusion via the external insulin infusion pump is an alternative to multiple daily injections for patients with labile glucose levels and frequent episodes of hypoglycemia. These pumps attach to the body through flexible plastic tubing with a needle inserted subcutaneously in the abdominal area. Weighing 4-6 oz, and measuring 2-3 in wide by approximately 4 in long, these pumps can be easily worn on a belt or slipped into a pocket. The patient needs to clean the...

Diabetes And Protein

Protein intake accounts for 15-20 of average daily caloric intake this does not appear to vary in patients with diabetes. The effects of protein on appetite suppression, long-term weight loss, and regulation of energy intake has not been widely studied. Essential amino acids should be supplied in the diet to allow for protein synthesis. The proteins with the most essential amino acids are found in eggs, fish, poultry, lean meats, and dairy products. In general, protein will stimulate insulin to...

Clinical Trials

The results of large landmark clinical trials support the use of medication in the diabetic, vasculopathic population. The Scandinavian Simvastatin Survival Study was a secondary prevention trial using 20-40 mg day of simvastatin. This trial demonstrated a 36 reduction in LDL, a 7 increase in HDL, and an 11 reduction in triglyceride levels, with a 55 reduction of CHD event rate, which was of statistical significance in the diabetic cohort. Overall, there was a 30 reduction in total mortality...

Thrombosis Prevention

An important concept in enhanced diabetic risk is the production of advanced glycation end products. Advanced glycation end products are found in the vessel walls of patients with diabetes and have a strong association with diabetic complications. When lipopro-teins become glycosylated, the glycation matrix within the lining of the vessel wall changes the behavior of arterial smooth-muscle cells, macrophages, and endothelial cells. In a study in Diabetes Care (33), serum advanced glycation...

Peripheral Arterial Disease

In patients with peripheral arterial disease, claudication is the most common complaint or presentation in greater than 75 of patients. Claudication is characterized by exertional tightness, cramping, fatigue, or aching pain and is reproducible from day to day, resolves within 2-3 minutes of rest, and tends to reoccur at the same distance with activity resumption. These symptoms tend to be progressive. Claudication can be differentiated from the pseudoclaudication seen with spinal stenosis...

Weight Reduction

The BMI is calculated by dividing the weight in kilograms by the square of the height in meters (kg m2). More than half of the adults in the United States are considered overweight, with a BMI of greater than 25 one-third of the adults in the United States are obese, with a BMI greater than 30. Any diet can be effective if there is a deficit of caloric intake relative to caloric expenditure. In patients on diet alone, there is generally a 5-6 reduction in body...

Longacting Insulins

Ultralente is usually given before the evening meal or at bedtime, has a duration of action that is quite variable (13-18 hours),and has variable peaking times between 8 and 14 hours. Ultralente has fallen into disfavor because of the peaks and valleys in its coverage. Glargine (Lantus) is an analog insulin with significant advantages over the Ultralente preparation. Glargine has an onset of action of 1-2 hours, is virtually peakless, and has a duration of action of 24 hours. Glargine is...

The Natural History Of Type 2 Diabetes

Although both insulin resistance and impaired insulin secretion precede the development of postprandial hyperglycemia and the subsequent type 2 diabetic phenotype, insulin resistance is more prominent in the prediabetic state and plays an important role in the pathogenesis of macrovascular disease. Insulin resistance is commonly the earliest manifestation in the development of type 2 diabetes, typically originating 5-10 years before postprandial glucose levels in the diabetic range (200 mg dL)....

Multiple Riskfactor Reduction

Control of blood pressure plays a critical role in preventing the macrovascular and microvascular complications of diabetes and is a major contributor to excess mortality and morbidity caused by end-stage renal disease, stroke, and cardiovascular catastrophe. The Hypertensive Optimal Treatment trial (37) evaluated the effect of calcium-channel blockers in 18,790 hypertensive patients (8 of whom had diabetes). Overall, the results showed that patients with intensive blood pressure control...

References

Steiner G. (200) Lipid intervention trials in diabetes. Diabetes Care 23(Suppl 2) B49-B53. 2. Mykkanen L, Laakso M, Penttila I, Pyorala K. (1991). Asymptomatic hyperglycemia and cardiovascular risk factors in the elderly. Atherosclerosis 88 153-161. 3. Best JD, O'Neal DN. (2000) Diabetic dyslipidemia, current treatment and recommendations. Drugs 59 1101-1111. 4. Lamarche B, Tchernof A, Moorjani S, et al. 91997) Small, dense low-density lipoprotein particles as a predictor of the risk of...

Diabetic Nephropathy

Diabetic nephropathy is the most frequent cause of end-stage renal disease in the United States, Japan, and Europe. In Europe and the United States, the incidence of diabetic nephropathy has increased substantially, rising by 150 in the past 10 years in the United States alone. Among patients who require dialysis, 40 had diabetic nephropathy, with a 15 higher mortality at 5 years and a 22 higher mortality at 1 year than their nondiabetic cohorts (35). The American Diabetes Association (ADA)...

Diabetes And Fats

Because the essential component of the diabetic paradigm is atherogenesis, it is critically important for patients with diabetes to limit their intake of dietary cholesterol, saturated fat, and trans-fatty acids. These remain important determinants of the plasma LDL cholesterol. Unsaturated fatty acids in the diet are in the form of monounsaturated and polyunsaturated fats. Monounsaturated fats have a single double-bond in their long carbon chain, whereas polyunsaturated fats have two or more...

Types of Stress Tests

Stress echocardiography is effective in demonstrating the effects of exercise and regional wall motion in addition to valvular incompetence. Four views are routinely evaluated, parasternal long, parasternal short, apical four-chamber and apical two-chamber with rest and exercise images juxtaposed. New or significant wall-motion abnormalities suggest myocardial ischemia. In this technique, images are compared at rest and within 1-2 minutes of exercise. This can provide helpful information on...

Introduction

The microvascular complications of diabetes include the following 3. Neuropathy, including mononeuropathy, diabetic amyotrophy, symmetric distal neuropathy, diabetic gastroparesis, diabetic diarrhea, neurogenic bladder, impaired cardiovascular reflexes, and sexual dysfunction (1). Both the Diabetes Control and Complications Trial (DCCT) (2) and the United Kingdom Perspective Diabetes Study (UKPDS) (3) have shown the importance of tight glycemic control in preventing microvascular disease. The...

Lipid Control

For lipid control, there have been several important primary-prevention and secondary-prevention trials. For primary prevention, seven studies with diabetic patients are noteworthy 1. The Prevention Study Texas Coronary Atherosclerosis Prevention Study (3). This study randomly assigned patients with average cholesterol levels of 221 mg dL, LDL of 150 mg dL, and lower than normal HDL of 36 mg dL for men and 40 mg dL for women, to 20-40 mg day of lovastatin or placebo, and followed them for an...

The Meglitinides

The meglitinides are more properly referred to as the glinides because repaglinide and nateglinide are not members of the same chemical class. Repaglinide is a benzoic acid derivative and nateglinide is a phenylalanine derivative. The glinides specifically target postprandial hyperglycemia, and, compared with sulfonylureas, have less risk of hypoglycemia and less continuous stimulation of the P-cells. The glinides are designed to return insulin levels to baseline between meals and to stimulate...