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ABSTRACT: Type 2 diabetes is characterized by progressive beta-cell failure. Indications for exogenous insulin therapy in patients with this condition include acute illness or surgery, pregnancy, glucose toxicity, contraindications to or failure to achieve goals with oral antidiabetic medications, and a need for flexible therapy. Augmentation therapy with basal insulin is useful if some beta-cell function remains. Replacement therapy with basal-bolus insulin is required for beta-cell exhaustion. Rescue therapy using replacement regimens for several weeks may reverse glucose toxicity. Replacement insulin therapy should mimic normal release patterns. Basal insulin, using long-acting insulins (i.e., neutral protamine Hagedorn [NPH], ultralente, glargine) is injected once or twice a day and continued on sick days. Bolus (or mealtime) insulin, using short-acting or rapid-acting insulins (i.e., regular, aspart, lispro) covers mealtime carbohydrates and corrects the current glucose level. The starting dose of 0.15 units per kg per day for augmentation or 0.5 units per kg per day for replacement can be increased several times as needed. About 50 to 60 percent of the total daily insulin requirement should be a basal type, and 40 to 50 percent should be a bolus type. The mealtime dose is the sum of the corrective dose plus the anticipated requirements for the meal and exercise. Adjustments should be made systematically, starting with the fasting, then the preprandial and, finally, the postprandial glucose levels. Basal therapy with glargine insulin provides similar to lower A1C levels with less hypoglycemia than NPH insulin. Insulin aspart and insulin lispro provide similar A1C levels and quality of life, but lower postprandial glucose levels than regular insulin.
Perioperative Management of Diabetes - Article
ABSTRACT: Maintaining glycemic and metabolic control is difficult in diabetic patients who are undergoing surgery. The preoperative evaluation of all patients with diabetes should include careful screening for asymptomatic cardiac or renal disease. Frequent self-monitoring of glucose levels is important in the week before surgery so that insulin regimens can be adjusted as needed. Oral agents and long-acting insulin are usually discontinued before surgery, although the newer long-acting insulin analog glargine may be appropriately administered for basal insulin coverage throughout the surgical period. The usual regimen of sliding scale subcutaneous insulin for perioperative glycemic control may be a less preferable method because it can have unreliable absorption and lead to erratic blood glucose levels. Intravenous insulin infusion offers advantages because of the more predictable absorption rates and ability to rapidly titrate insulin delivery up or down to maintain proper glycemic control. Insulin is typically infused at 1 to 2 U per hour and adjusted according to the results of frequent blood glucose checks. A separate infusion of dextrose prevents hypoglycemia. Potassium is usually added to the dextrose infusion at 10 to 20 mEq per L in patients with normal renal function and normal preoperative serum potassium levels. Frequent monitoring of electrolytes and acid-base status is important during the perioperative period, especially in patients with type 1 diabetes because ketoacidosis can develop at modest levels of hyperglycemia.
ABSTRACT: Gestational diabetes mellitus is a common but controversial disorder. While no large randomized controlled trials show that screening for and treating gestational diabetes affect perinatal outcomes, multiple studies have documented an increase in adverse pregnancy outcomes in patients with the disorder. Data on perinatal mortality, however, are inconsistent. In some prospective studies, treatment of gestational diabetes has resulted in a decrease in shoulder dystocia (a frequently discussed perinatal outcome), but cesarean delivery has not been shown to reduce perinatal morbidity. Patients diagnosed with gestational diabetes should monitor their blood glucose levels, exercise, and undergo nutrition counseling for the purpose of maintaining normoglycemia. The commonly accepted treatment goal is to maintain a fasting capillary blood glucose level of less than 95 to 105 mg per dL (5.3 to 5.8 mmol per L); the ambiguity (i.e., the range) is due to imperfect data. The postprandial treatment goal should be a capillary blood glucose level of less than 140 mg per dL (7.8 mmol per L) at one hour and less than 120 mg per dL (6.7 mmol per L) at two hours. Patients not meeting these goals with dietary changes alone should begin insulin therapy. In patients with well-controlled diabetes, there is no need to pursue delivery before 40 weeks of gestation. In patients who require insulin or have other comorbid conditions, it is appropriate to begin antenatal screening with nonstress tests and an amniotic fluid index at 32 weeks of gestation.
ABSTRACT: Impaired glucose tolerance and impaired fasting glucose form an intermediate stage in the natural history of diabetes mellitus. From 10 to 15 percent of adults in the United States have one of these conditions. Impaired glucose tolerance is defined as two-hour glucose levels of 140 to 199 mg per dL (7.8 to 11.0 mmol) on the 75-g oral glucose tolerance test, and impaired fasting glucose is defined as glucose levels of 100 to 125 mg per dL (5.6 to 6.9 mmol per L) in fasting patients. These glucose levels are above normal but below the level that is diagnostic for diabetes. Patients with impaired glucose tolerance or impaired fasting glucose have a significant risk of developing diabetes and thus are an important target group for primary prevention. Risk factors for diabetes include family history of diabetes, body mass index greater than 25 kg per m2, sedentary lifestyle, hypertension, dyslipidemia, history of gestational diabetes or large-for-gestational-age infant, and polycystic ovary syndrome. Blacks, Latin Americans, Native Americans, and Asian-Pacific Islanders also are at increased risk for diabetes. Patients at higher risk should be screened with a fasting plasma glucose level. When the diagnosis of impaired glucose tolerance or impaired fasting glucose is made, physicians should counsel patients to lose 5 to 7 percent of their body weight and engage in moderate physical activity for at least 150 minutes per week. Drug therapy with metformin or acarbose has been shown to delay or prevent the onset of diabetes. However, medications are not as effective as lifestyle changes, and it is not known if treatment with these drugs is cost effective in the management of impaired glucose tolerance.
Diabetic Ketoacidosis - Article
ABSTRACT: A diagnosis of diabetic ketoacidosis requires the patient's plasma glucose concentration to be above 250 mg per dL (although it usually is much higher), the pH level to be less than 7.30, and the bicarbonate level to be 18 mEq per L or less. Beta-hydroxybutyrate is a better measurement of the degree of ketosis than serum ketones. Intravenous insulin and fluid replacement are the mainstays of therapy, with careful monitoring of potassium levels. Phosphorous and magnesium also may need to be replaced. Bicarbonate therapy rarely is needed. Infection, insulin omission, and other problems that may have precipitated ketoacidosis should be treated. Myocardial infarction is a precipitating cause of diabetic ketoacidosis that is especially important to look for in older patients with diabetes. Cerebral edema is a major complication that occurs primarily in children. Education to prevent recurrence should be offered to all patients, including how to manage sick days and when to call a physician.
ABSTRACT: Tight control of blood glucose levels and risk factors for cardiovascular disease (e.g., hypertension, hypercholesterolemia) can substantially reduce the incidence of microvascular and macrovascular complications from type 1 diabetes. Physicians play an important role in helping patients make essential lifestyle changes to reduce the risk of these complications. Key recommendations that family physicians can give patients to optimize their outcomes include: take control of daily decisions regarding your health, focus on preventing and controlling risk factors for cardiovascular disease, tightly control your blood glucose level, be cognizant of potentially inaccurate blood glucose test results, use physiologic insulin replacement regimens, and learn how to manage and prevent hypoglycemia.
ABSTRACT: Home monitoring of blood glucose and blood pressure levels can provide patients and physicians with valuable information in the management of diabetes mellitus and hypertension. Home monitoring allows patients to play an active role in their care and may improve treatment adherence and clinical outcomes. Glucose meters currently on the market produce results within 15 percent of serum blood glucose readings and offer a variety of features. Although the data are somewhat conflicting, home glucose monitoring has been associated with improved glycemic control and reduced long-term complications from diabetes. These effects are more pronounced in patients who take insulin. Home blood pressure values predict target organ damage and cardiovascular outcomes better than values obtained in the office. Home blood pressure measurements are also effective at detecting borderline hypertension and monitoring the effectiveness of antihypertensive drugs. Validated arm cuffs are the preferred blood pressure devices for home use. Information from home monitoring should always be used in conjunction with that from regular office visits and other data to make appropriate therapeutic decisions.
ABSTRACT: Research has established the importance of maintaining blood glucose levels near normal in patients with type 1 (insulin-dependent) diabetes mellitus. Short-acting insulin analogs are designed to overcome the limitations of regular short-acting insulins. Compared with regular human insulin, the analog insulin lispro offers faster subcutaneous absorption, an earlier and greater insulin peak and a more rapid postpeak decrease. Insulin lispro begins to exert its effects within 15 minutes of subcutaneous administration, and peak levels occur 30 to 90 minutes after administration. Duration of activity is less than five hours. Rates of insulin allergy, lipodystrophy, hypoglycemia and abnormal laboratory test results are essentially the same in patients using insulin lispro and in those using regular human insulin.
ABSTRACT: Subopitmal glycemic control in hospitalized patients with type 2 (non-insulin-dependent) diabetes mellitus can have adverse consequences, including increased neurologic ischemia, delayed wound healing and an increased infection rate. Poor glycemic control can also affect the outcome of the primary illness. If possible, hospitalized diabetic patients should continue their previous antihyperglycemic treatment regimen. Decreased physical activity and the stress of illness often lead to hyperglycemia in hospitalized patients with type 2 diabetes. When indicated, insulin is given either as a supplement to usual therapy or as a temporary substitute. The overall benefit of the traditional sliding-scale insulin regimen has been questioned. Insulin supplementation given according to an algorithm may be a logical alternative. Any antihyperglycemic regimen should be administered and monitored in a manner coincident with the intake of food or other sources of calories. Factors that can alter glycemic control acutely, including specific medical conditions and medications, should be identified and anticipated.
ABSTRACT: New recommendations for the classification and diagnosis of diabetes mellitus include the preferred use of the terms "type 1" and "type 2" instead of "IDDM" and "NIDDM" to designate the two major types of diabetes mellitus; simplification of the diagnostic criteria for diabetes mellitus to two abnormal fasting plasma determinations; and a lower cutoff for fasting plasma glucose (126 mg per dL [7 mmol per L] or higher) to confirm the diagnosis of diabetes mellitus. These changes provide an easier and more reliable means of diagnosing persons at risk of complications from hyperglycemia. Currently, only one half of the people who have diabetes mellitus have been diagnosed. Screening for diabetes mellitus should begin at 45 years of age and should be repeated every three years in persons without risk factors, and should begin earlier and be repeated more often in those with risk factors. Risk factors include obesity, first-degree relatives with diabetes mellitus, hypertension, hypertriglyceridemia or previous evidence of impaired glucose homeostasis. Earlier detection of diabetes mellitus may lead to tighter control of blood glucose levels and a reduction in the severity of complications associated with this disease.