FP Report -- 1999 Post-Assembly Edition
Deadly diabetes deserves attention
Diabetes is one of the deadliest and most costly diseases known to humankind, noted William Miser, M.D., associate professor of family medicine at the Ohio State University in Columbus and speaker for a clinical seminar Sept. 17, "Office Management of Type 2 Diabetes," at the Assembly in Orlando, Fla.
It's estimated that more than 16 million Americans have diabetes mellitus, but the condition goes undetected at least half the time, Miser said.
Screening for diabetes may be done as part of a routine medical exam if the patient has one or more risk factors: is obese, has a first-degree relative with diabetes mellitus, has hypertension, has a high-density lipoprotein cholesterol level below 35 mg/dl or a triglyceride level above 250 mg/dl, is a member of a high-risk ethnic group, had a previous test indicating impaired glucose tolerance or impaired fasting glucose, or has borne a baby weighing more than nine pounds or has been diagnosed with gestational diabetes.
The diagnosis of diabetes may be made in one of three ways, Miser said. If the patient has symptoms of diabetes, such as polyuria, polydipsia or weight loss, along with random serum glucose levels above 200 mg/dl; if the patient has fasting plasma glucose levels above 126 mg/dl; or if the patient has an oral glucose tolerance test two-hour value above 200 mg/dl, he or she may have diabetes. However, each of these tests must be confirmed on a subsequent day. Miser said the fasting glucose test is preferred; it is the easiest to perform and the least costly.
"Diet and exercise are the cornerstones of therapy for diabetic patients," he said. "Eighty percent of type 2 diabetes could be controlled with diet alone." However, up to 60 percent of patients don't follow the diets they are prescribed, and exercise carries some risks, including hypoglycemia, cardiovascular events and foot or soft-tissue injury. Patients may need a stress test before starting to exercise.
When diet and exercise fail to control diabetes, physicians need to consider prescribing drugs, Miser said.
Sulfonylureas are indicated for type 2 diabetic patients who have some pancreatic function left and whose plasma glucose can no longer be controlled by diet and exercise. More than 60 percent of type 2 diabetics respond initially to sulfonylureas, but after five years of use, half of all patients taking these drugs require other medications to control their glucose levels, he said.
One of the newer drugs, metformin, is effective in lowering fasting glucose levels, does not cause weight gain and works by decreasing hepatic glucose output and increasing glucose uptake. Metformin used in combination with sulfonylureas is capable of improving glycemic control in adults refractory to sulfonylureas alone.
Another new class of drugs, alpha-glucosidase inhibitors, delays glucose absorption, reduces postprandial serum glucose and fasting insulin responses, and decreases postprandial hyperglycemia, he said. They may cause flatulence, cramps, abdominal distention and diarrhea. They are contraindicated in patients with renal dysfunction or diseases of the large intestine.
The glitazone drugs -- troglitazone, rosiglitazone and pioglitazone -- decrease insulin resistance and increase insulin sensitivity. In rare cases, however, they have been associated with liver toxicity, he said.
The final class of diabetes drugs, repaglinide, is similar to sulfonylureas but much more short-acting, Miser said. This class of drugs is effective for patients who skip meals or do not eat regularly.
FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.
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