Screening for coronary heart disease

To identify the presence of CHD in patients with diabetes without clear or suggestive symptoms of coronary artery disease (CAD), a risk factor-based Figure 5.13 Additional approaches to decrease CVD events Antiplatelet agents Use aspirin therapy (75-162 mg day) as a secondary prevention strategy in those with diabetes with a history of CVD. Use aspirin therapy (75-162 mg day) as a primary prevention strategy Combination therapy using other antiplatelet agents such as clopidogrel in addition to...

Macrovascular complications

These involve several organs, but predominantly the heart, where coronary artery disease is very common and is associated with decreased morbidity and mortality. Diabetes has been called a cardiovascular risk equivalent due to increased risk of heart disease, even in patients without known prior cardiovascular disease. In addition, congestive heart failure is much more common in patients with diabetes and of greater severity. Brain Several vascular diseases, including transient ischemic attack,...

Author biographies

Fonseca, MD, FRCP, FACE, is Professor of Medicine, the Tullis Tulane Alumni Chair in Diabetes, and Chief of the Section of Endocrinology at Tulane University Medical Center in New Orleans, Louisiana, USA. Dr Fonseca's current research interests include the prevention and treatment of diabetic complications and risk factor reduction in cardiovascular disease. He has a research program evaluating homocysteine and inflammation as risk factors for heart disease in diabetes. He is also an...

Biguanides

Metformin, the only biguanide available, works primarily by decreasing hepatic glucose production. It has been available in other countries since 1957 and in the USA since 1995. It is currently the most widely prescribed diabetes agent in the USA. Metformin has the advantages of not causing hypoglycemia and being associated with weight loss. Although it was found in the United Kingdom Prospective Diabetes Study (UKPDS) to have a beneficial effect on CVD outcomes 9 , this finding needs to be...

Conclusions

Over the past decade there have been enormous advances in the understanding of type 2 diabetes and its complications. Although multiple new antihyperglycemic medications have become available, changes frequently are not initiated soon enough, resulting in chronic, poor glycemic control 32 . In order for diabetic patients to achieve glucose goals, treatment must be promptly initiated, carefully monitored and rapidly advanced. If patients are not achieving goals with non-insulin therapy, insulin...

Diabetic autonomic neuropathy

The symptoms of autonomic dysfunction should be elicited carefully during the history and review of systems, particularly since many ofthese symptoms are potentially treatable. Major clinical manifestations of diabetic autonomic neuropathy include resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, sudomo-tor dysfunction, impaired neurovascular function, brittle diabetes, and hypoglycemic autonomic failure. GI disturbances (e.g....

Exercise

A recently released study revealed that the majority of patients with type 2 diabetes do not perform regular exercise or physical activities - in fact, they engage in physical activity at a rate much below national norms 22 . A recent meta-analysis of 27 studies to evaluate various types of exercise including aerobic, resistance, and combined training exercise, in a total of 1003 patients with type 2 diabetes, determined that all forms of exercise training produce small benefits in A1C, the...

Healthy eating and weight control

Recommendations for healthy eating and weight control Eat a well-balanced, wide variety of foods Eat 2-4 daily servings of fruits Eat 3-5 daily servings of vegetables Limit salt, alcohol, saturated fats, cholesterol, foods containing sugar and fast foods Eat smaller portions and never skip meals Choose whole grain foods whenever possible Consult with a diabetes educator and or registered dietitian for assistance in preparing an individualized meal plan. Carbohydrate counting, as a meal-planning...

Identifying and overcoming barriers to effective selfcare

Patients who have been diagnosed with diabetes are immediately faced with a multitude of challenges, all related to maintaining the quality of their daily life. Research has well demonstrated the galaxy of complications that can follow the onset of diabetes, in the absence of good diabetes management. Yet, good diabetes management requires acquiring numerous skills, making countless lifestyle changes and adjustments, and investing significant amounts of time and effort into a lengthy,...

Insulin secretion in individuals without diabetes

When considering insulin therapy, it is helpful to keep normal insulin patterns in mind. Euglycemia can best be achieved, and hypoglycemia minimized, by using insulin regimens that supplement insulin in as physiological a way as possible. In patients with normal glucose tolerance, insulin secretion is tightly regulated by the prevailing glucose level (see Figure 4.1). Basal insulin, which is secreted even in the absence of nutritional intake, suppresses hepatic glucose production and maintains...

Microvascular complications

Microvascular complications are specific for diabetes and are almost certainly related to hyperglycemia (see Figure 5.1). Hyperglycemia leads to multiple biochemical changes, some of which are listed in Figure 5.2, that cause tissue damage 1, 2 . These lead to changes in various organs as summarized in Figure 5.1. Most of these changes can be prevented by good glycemic control which prevents the development of the complications and slows their progression 3 . Eye Diabetic retinopathy is a...

Shared care the multidisciplinary approach

In the midst of the current diabetes epidemic, there appears to be consensus by diabetes experts on the need for a team approach to diabetes management and education 8 . A report by the American Association of Clinical Endocrinologists (AACE) indicated that two out of three patients with type 2 diabetes do not have hemoglobin A1C levels under control. Nevertheless, in a related survey reported by AACE, 84 of patients reported that their blood glucose levels were well controlled 9 which begs the...

Treatment goals to prevent diabetes complications

Figure 5.5 summarizes the risk reduction of various treatments for blood pressure, lipids, and glucose on microvascular and macrovascular events. Figure 5.3 Insulin resistance and atherosclerosis Figure 5.3 Insulin resistance and atherosclerosis CRP, C reactive protein HDL, high-density lipoprotein LDL, low-density lipoprotein MMP-9, matrix metalloproteinase 9 PAI-1, plasminogen activator inhibitor-1. CRP, C reactive protein HDL, high-density lipoprotein LDL, low-density lipoprotein MMP-9,...

Types of insulin

The approximate time of onset, peak activity, and duration of action of the available insulin preparations is shown in Figures 4.2 and 4.3. Insulin preparations vary with respect to onset and duration of action, which differ due to modifications to human regular insulin that either slow or hasten the time for it to be absorbed into the bloodstream. Relative to human regular insulin, the rapid-acting analogs (insulin lispro, insulin aspart, and insulin glulisine) have a more rapid onset of...

Symptomatic treatments

The first step in management of patients with DPN should be to aim for stable and optimal glycemic control. Although controlled trial evidence is lacking, several observational studies suggest that neuropathic symptoms improve not only with optimization of control but also with the avoidance of extreme blood glucose fluctuations. Most patients will require pharmacological treatment for painful symptoms (see Figure 5.11). The usefulness of the tricyclic drugs such as amitriptyline and imipramine...

Selection of initial antihyperglycemic agents

Choice of initial therapy is complex and depends on multiple factors including the patient's initial A1C, the agent's effect on glucose-lowering, cost, side effects, contraindications, dosing frequency, and acceptability to patients. Initial treatment for most patients is a single oral agent, although insulin may be preferred if the patient has very high initial blood glucose levels, is underweight, losing weight, or is ketotic (see Figure 3.5). Metformin, SUs, and TZDs are the most commonly...

Janka Hu Plewe G Riddle Mc Et Al. Diabetes Care. 2005 28 2 254-259.

1 Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2 diabetes A consensus algorithm for the initiation and adjustment of therapy a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2006 29 1963-1972. 2 Ryan EA, Imes S, Wallace C. Short-term intensive insulin therapy in newly diagnosed type 2 diabetes. Diabetes Care 2004 27 1028-1032. 3 Li Y, Xu W, Liao Z, et al. Induction of long-term...

References

1 Magee MF, Isley WL BARI 2D Trial investigators. Rationale, design, and methods for glycemic cortrol ir the Bypass Argioplasty Revascularizatior Irvestigatior 2 Diabetes BARI 2D Trial. Am J Cardiol 2006 97 20G-30G. 2 Gersteir HC, Riddle MC, Kerdall DM, et al ACCORD Study Group. Glycemia treatmert strategies ir the Actior to Cortrol Cardiovascular Risk ir Diabetes ACCORD trial. Am J Cardiol 2007 99 34i-343i. 3 Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2...

Diabetic neuropathy

Neuropathy Pathophysiology

The term diabetic neuropathy encompasses a wide range of conditions with diverse clinical manifestations see Figures 5.8 and 5.9 . The most common clinical presentation is with chronic sensorimotor DPN and autonomic neuropathy. Although DPN is a diagnosis of exclusion, complex investigations to exclude other conditions are rarely needed. Patients with diabetes should be screened annually for DPN using tests such as pinprick sensation, temperature and vibration perception using a 128 Hz tuning...

Hyperglycemic crisis

It is important to recognize the underlying precipitating factors in the development of severe hyperglycemia, because their treatment may be critical to recovery. The most common precipitating factor in the development of DKA or HHS is infection. Other precipitating factors include cerebrovascular accident, alcohol abuse, pancreatitis, myocardial infarction, trauma, and drugs steroids, antipsychotics, thiazide diuretics, etc. . In addition, new-onset type 1 diabetes or discontinuation of or...

Diabetes in Clinical Practice

Merri Pendergrass Harvard Medical School And and Hypertension Brigham and Women s Hospital Boston Roberta Harrison McDuffie Tulane University Health Science Center Diabetes Program New Orleans Louisiana USA ISBN 978-1-84882-102-6 e-ISBN 978-1-84882-103-3 Springer London Dordrecht Heideberg New York DOI 10.1007 978-1-84882-103-3 A catalogue record for this book is available from the British Library Library of Congress Control Number 2009935337 Springer-Verlag London Limited 2010 Previously...

Noninsulin agents in the management of type diabetes

Eight different classes of medication, in addition to insulin, are currently approved for treatment of hyperglycemia in type 2 diabetes. Beneficial effects of antihyperglycemic agents appear to be mediated predominantly through their ability to lower blood glucose. Studies are currently in progress to determine whether any particular agent or treatment strategy has specific advantages, beyond glucose lowering, in terms of reducing cardiovascular endpoints 1, 2 . Unfortunately, there are few...