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Your search term(s) "insulin and drug therapy" returned 136 results.

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2008 Resource Guide. Diabetes Forecast. 61(1): RG1-RG60. January 2008.

This special section of Diabetes Forecast offers the annual guide to diabetes products and services. The guide lists items in seven categories: new diabetes products, type 2 oral medications, insulin, insulin delivery, blood glucose monitoring and data management systems, products for treating low blood glucose, and urine testing. Specific products include human and analog insulin, syringes, injection aids, insulin pens and pen needles, insulin pumps, aids for people who are visually and physically impaired, blood glucose meters, ways to pair the blood glucose meter with software, blood-sampling supplies, meter supplies, glycohemoglobin tests, microalbuminuria testing kits, and over-the-counter products for meal replacement. Each category includes a section of text, bringing readers up to date on the changes in that area, and charts summarizing the products available. The guide includes a list of manufacturers and distributors, arranged alphabetically. 10 figures. 20 tables.

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AADE Quick Guide to Medications. Rev. ed. Chicago, IL: American Association of Diabetes Educators. 2008. 39 p.

Nearly everyone with diabetes will require medications, from oral glucose-lowering drugs to insulin, or both, to reach blood glucose goals. In addition to these medications, drug therapies for people with diabetes often include other agents to treat the various associated comorbid conditions or complications of diabetes. This booklet is designed to help health care professionals and educators understand the total range of therapies available for comprehensive diabetes care, not just those used to improve glycemic control. The booklet includes seven sections: glucose-lowering agents, insulin, common agents for blood pressure control, common agents for cholesterol control, recommended priorities and suggested drug therapy for people with diabetes and dyslipidemia, miscellaneous topics, and a resource list. Most of the information is provided in chart form. Specific topics and drugs covered include sulfonylureas, biguanides, thiazolidinediones, alpha-glucosidase inhibitors, incretins, amylin analog, DPP-IV inhibitors, bile acid sequestrants, fixed-dose combinations, guidelines for mixing insulin and prefilling syringes, starting insulin, ACE inhibitors, ARBs, diuretics, beta-blockers, calcium channel blockers, statins, fibric acid derivatives, absorption inhibitors, bile acid sequestrants, nicotinic acid, omega-3 fatty acids, drug-disease interactions, drug-drug interactions, the treatment of hypoglycemic emergencies, and complementary and alternative medicine (CAM). The pocket-sized booklet is spiral bound for easy use. 12 references.

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Bariatric Surgery in Patients With Morbid Obesity And Type 2 Diabetes. Diabetes Care. 31(Suppl 2): S297-S302. February 2008.

This article brings readers up to date on current options of bariatric surgery in patients with morbid obesity and type 2 diabetes. The authors briefly review the various approaches to weight loss, including lifestyle intervention, diet therapy, behavior modification, exercise programs, and drug therapy, noting that these usually result in only modest and transient weight loss, particularly in patients with severe obesity. Recent studies show that surgical treatment was significantly more effective than nonsurgical therapy in reducing weight, resolving the metabolic syndrome, and improving quality of life during a 24-month treatment program. The authors summarize the different types of bariatric surgical procedures that can be used, and report the results found with each type. They discuss the reversibility of type 2 diabetes after bariatric surgery, observing that euglycemic and normal insulin levels can occur within days after surgery, long before there is any significant weight loss. Other topics discussed include perioperative risk and care of bariatric surgery and the complications, failures, and weight gain that can be seen as long-term results after bariatric surgery. The authors conclude that the only effective and enduring therapy for morbid obesity is weight loss surgery. Certain risks exist for weight loss surgery that can be reduced by surgical experience and patient selection, education, and lifelong surveillance. 65 references.

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Bariatric Surgery in Patients With Morbid Obesity And Type 2 Diabetes. Diabetes Care. 31(Suppl 2): S297-S302. February 2008.

This article brings readers up to date on current options of bariatric surgery in patients with morbid obesity and type 2 diabetes. The authors briefly review the various approaches to weight loss, including lifestyle intervention, diet therapy, behavior modification, exercise programs, and drug therapy, noting that these usually result in only modest and transient weight loss, particularly in patients with severe obesity. Recent studies show that surgical treatment was significantly more effective than nonsurgical therapy in reducing weight, resolving the metabolic syndrome, and improving quality of life during a 24-month treatment program. The authors summarize the different types of bariatric surgical procedures that can be used and report the results found with each type. They discuss the reversibility of type 2 diabetes after bariatric surgery, observing that euglycemic and normal insulin levels can occur within days after surgery, long before there is any significant weight loss. Other topics discussed include perioperative risk and care of bariatric surgery; and the complications, failures, and weight gain that can be seen as long-term results after bariatric surgery. The authors conclude that the only effective and enduring therapy for morbid obesity is weight-loss surgery. Certain risks exist for weight-loss surgery that can be reduced by surgical experience and patient selection, education, and lifelong surveillance. 65 references.

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Combined Therapy with Insulin Plus Oral Agents: Is There Any Advantage? An Argument in Favor. Diabetes Care. 31(Suppl 2): S125-S130. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the use of combined therapy with insulin plus oral agents for patients with type 2 diabetes. The authors describe an argument in favor of combined therapy in a recent debate examining the advantages and limitations of this approach. They describe the pharmacologic rationale for combining agents, present some new physiologic evidence for combining an oral agent with insulin, and offer a few examples of clinical studies showing advantages of combined therapy over insulin used alone. The authors conclude that, when oral therapy is continued during insulin therapy, enhancing either the availability or effectiveness of endogenous insulin, glycemic stability may improve and may lead to better overall glycemic control with similar hypoglycemic risk, or equal glycemic control with less hypoglycemia. In the case of metformin, combination with insulin limits the risk of weight gain. The authors call for additional, longer term medical outcome studies that compare insulin alone with insulin plus oral therapy. 5 figures. 28 references.

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Coming of Age for the Incretins. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press.2008. pp 269-290.

This chapter about the incretin hormones, glucose-dependent insulinotropic polypeptide (GIP), and glucagon-like peptide-1 (GLP-1), is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter consider the role of these incretin hormones in postprandial insulin secretion, which is insulin secretion that happens after a meal. They note that, in type 2 diabetes, the incretin effect is severely reduced. Substitution therapy with GLP-1 can result in glucose-induced insulin secretion, up-regulation of insulin and other beta-cell genes, stimulation of beta-cell proliferation, neogenesis and inhibition of beta-cell destruction, inhibition of glucagon secretion, inhibition of gastric emptying, and inhibition of appetite and food intake. However, GLP-1 is rapidly destroyed by an enzyme called dipeptidyl peptidase IV (DPP-IV), so any drug therapy that uses GLP-1 will require orally active DPP-IV inhibitors. The authors describe the animal studies and clinical trials that have focused on these incretins. One GLP-1 receptor activator (Byetta) and one of the DPP-IV inhibitors are already on the market and other compounds are in late phases of development or awaiting approval. 110 references.

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Insulin And Incretins. Clinical Diabetes. 26(1): 35-39. Winter 2008.

This article is part of a 12-part series for physicians in training that reviews the fundamentals of diabetes care; this article summarizes the use of insulin and Incretins. The author notes that insulin has been combined with additives and modified at the molecular level to changes its pharmacokinetic properties. Some insulin preparations accelerate insulin’s effects in the bloodstream, and others prolong the pharmacokinetic profile. The author describes specific drugs, including regular insulin, insulin analogs, inhaled insulin, protamine solutions, zinc solutions, and long-acting insulin analogs, including glargine and detemir. The article outlines standard insulin regimens, newer insulin regimens, the approach to initiating insulin therapy, and the use of incretins, such as exenatide, and the amylin analog, pramlintide. The author emphasizes that good understanding of the pharmacokinetics of insulin action and proper management on insulin regimens allow health care providers and patients to control blood glucose levels and safely avoid hypoglycemia and hyperglycemia. 32 references.

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Insulin as a First-Line Therapy in Type 2 Diabetes: Should the Use of Sulfonylureas be Halted?. Diabetes Care. 31(Suppl 2): S136-S139. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the use of insulin as a first-line therapy in patients with type 2 diabetes, supplanting the use of sulfonylurea compounds. The authors explore the advantages and drawbacks to each therapy, focusing on the evidence base, the limitations of present information, other treatment options, pathogenesis, and the impact of specific drug regimens on cardiovascular disease (CVD). The authors conclude that it is not easy to recommend a simple treatment regimen for patients with type 2 diabetes, and the complexities are not only based on whether or not insulin should be a first-line therapy. They stress that appropriate therapy of type 2 diabetes needs to be highly individualized, taking contraindications and potential downsides of treatment options into account and trying to define and target the leading pathogenetic defects behind the prevailing metabolic phenotype. Cost considerations must be figured into the decision. A patient care algorithm for the management of hyperglycemia in type 2 diabetes is presented. 1 figure. 23 references.

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Long-Acting Insulin Analogs Versus Insulin Pump Therapy for the Treatment of Type 1 And Type 2 Diabetes. Diabetes Care. 31(Suppl 2): S140-S145. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reports on the use of long-acting insulin analogs versus insulin pump therapy for the treatment of patients with either type 1 or type 2 diabetes. The authors consider whether multiple daily injection (MDI) regimens based on new long-acting insulin analogs such as glargine and detemir have now replaced the need for continuous subcutaneous insulin infusion (CSII). They discuss hypoglycemia, elevated glycosylated hemoglobin (A1C ) levels and glycemic variability, the dawn phenomenon, the problems of poor control in type 2 diabetes, and CSII as a management strategy in type 2 diabetes. They conclude that long-acting insulin analogs have not yet replaced the need for insulin pump therapy in type 1 diabetes, and CSII is the best current treatment option for some people with type 1 diabetes. In type 2 diabetes, CSII and MDI produce similar glycemic control, although there is little research on the use of MDI based on long-acting analogs compared with insulin pumps. 4 figures. 2 tables. 47 references.

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Targets for Intervention in Dyslipidemia in Diabetes. Diabetes Care. 31(Suppl 2): S241-S248. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reviews the targets used for intervention in dyslipidemia in people with diabetes. Topics include atherosclerosis and blood glucose control, atherosclerosis and diabetic dyslipidemia, diabetes and hypertriglyceridemia, low-density lipoprotein (LDL) in diabetes, high-density lipoprotein (HDL) activity, fatty acids and insulin secretion, the lipoprotein cascade, regulation of the chylomicron, and plant sterols and diabetes. The author notes that the abnormalities in fatty acid metabolism caused by diabetes result in an abnormal lipoprotein cascade from the large chylomicron particle to the small HDL particle. Thus, drugs that alter formation of the chylomicron particle might have a very important role in diabetic dyslipidemia. The author reviews some of the newer treatment options, including drug therapy and dietary recommendations, for patients with dyslipidemia and diabetes. 2 figures. 79 references.

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Treatment of Type 2 Diabetes with Combined Therapy: What Are the Pros and Cons?. Diabetes Care. 31(Suppl 2): S131-S135. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the advantages and limitations of the treatment of type 2 diabetes with combination therapy. The authors recommend a stepwise approach for the treatment of type 2 diabetes, tailored according to the natural course of the disease, including adding insulin when hypoglycemic oral agents fail. They stress that treatment with insulin alone should eventually be considered in a relevant number of cases. Insulin can result in protective effects on beta-cell survival and function, resulting in more stable metabolic control. In comparison, treatment with most insulin secretagogues has been associated with increased beta-cell apoptosis, reduced responsiveness to high glucose, and impairment of myocardial function during ischemic conditions. Insulin treatment, particularly with rapid-acting analogs, has been demonstrated to successfully control postprandial hyperglycemia. The authors voice a final concern about combination regimens in the evidence that polypharmacy can reduce patient compliance to the treatment regimen. 56 references.

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Understanding Insulin And Amylin. 3rd ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).

This DVD program reviews how insulin works in the body and how it can be used to help people with diabetes keep their blood glucose levels in a healthy range. The program introduces amylin, another pancreatic hormone, and explains how taking the drug pramlintide (Symlin) can help people who use insulin maintain greater control of their blood glucose levels. Other topics include insulin and amylin safety, storage, recordkeeping, hypoglycemia, and how to handle sick days. Viewers are reminded of the importance of a comprehensive self-management plan for keeping diabetes under control. The video depicts a variety of people who share their experiences with diabetes management, insulin use, and pramlintide use. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.

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What I Need to Know About Diabetes Medicines. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 16 p.

This booklet helps readers with diabetes understand how diabetes medicines help keep their blood glucose levels in healthy target ranges. Written in nontechnical language, the booklet describes how these medications work; recommended targets for blood glucose levels, including for before and after meals; how blood glucose levels are affected by the presence of diabetes; medicines that may be used for each of the types of diabetes, including type 1, type 2, and gestational diabetes; and the types of diabetes medications and their forms, including insulin injections and insulin pumps, the side effects of insulin, the different types of insulin, oral medications, and injections other than insulin. Inside the back cover of the booklet is a folder with numerous inserts that provide information about specific drugs. The first insert is a form on which readers and their health care providers can record the medications currently prescribed. A second insert offers a list of questions patients might want to ask about their diabetes medications, and a third insert summarizes the different types of insulin. The remaining inserts provide specific information about the following drugs: the alpha-glucosidase inhibitors Glyset (miglitol) and Precose (acarbose); the biguanides Glucophage (metformin), Glucophage XR (long-acting metformin), and Riomet (liquid metformin); Starlix (nateglinide); the DPP-4 inhibitor Januvia (sitagliptin); a meglitinide called Prandin (repaglinide); sulfonylurea compounds including Amaryl (glimepiride), DiaBeta (glyburide), Diabinese (chlorpropamide), Glucotrol (glipizide), Glucotrol XL (long-acting glipizide), Glynase (glyburide), Micronase (glyburide), and the generics tolazamide and tolbutamide; thiazolidinediones Actos (pioglitazone) and Avandia (rosiglitazone); the combination pill Actoplus Met (pioglitazone and metformin); and the amylin mimetic Symlin (pramlintide). Each drug insert explains what the drug is supposed to do, who should and should not take the drug, and possible side effects. A final insert discusses low blood glucose levels. Blank spaces in different sections of the booklet allow readers to note their own individual prescriptions. The booklet concludes with a list of resources from which readers can get more information and a brief description of the goals and activities of the National Diabetes Information Clearinghouse.

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Clinical Practice Recommendation 3: Diabetes and Chronic Kidney Disease in Special Populations [KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease]. American Journal of Kidney Diseases. 49 (2 Suppl 2): s120-s130. February 2007.

The increasing incidence of diabetes in children, young adults, the elderly, and members of disadvantaged and transitional populations is responsible for a concurrently increasing incidence of diabetic kidney disease (DKD) in these groups. In pregnant women, the presence of diabetes and chronic kidney disease (CKD) may adversely affect the health of both the mother and her baby. This article is from a special supplement to the American Journal of Kidney Diseases that presents the Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. This is the first set of guidelines that considers the unique aspects of the evaluation, diagnosis, and management of the complex patient with both diabetes mellitus and CKD. The guidelines emphasize these patients’ high risk of cardiovascular disease. This article presents and discusses the third clinical practice recommendation: management of diabetes and CKD in special populations. The article focuses on six clinical practice recommendations: screening and interventions for diabetes and CKD should focus on populations at greatest risk; treatment of children, adolescents, and older adults warrants special considerations; population-based interventions may be the most cost-effective means for addressing the burden of CKD in special populations; specialists in high-risk pregnancy and kidney disease should co-manage pregnancy in women with diabetes and CKD; treatment of DKD with RAS inhibitors before pregnancy may improve fetal and maternal outcomes, but these medicines should be discontinued during pregnancy; and insulin should be used to control hyperglycemia if drug therapy is necessary in pregnant women with diabetes and CKD. A final section discusses implementation issues. The article features tables that summarize the research studies used to establish the guidelines. 2 figures. 6 tables.

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Diabetes and Incretin-Based Therapy. Chevy Chase, MD: Hormone Foundation. 2007. 1 p.

This brief fact sheet reviews the use of incretin-based therapy for treating diabetes, a disease characterized by blood glucose levels that are higher than normal. Diabetes occurs when the pancreas does not produce enough insulin or when the body becomes resistant to the effects of insulin. The fact sheet first outlines the three main types of diabetes: type 1, type 2, and gestational diabetes. The fact sheet then answers common questions about treatments for diabetes, a type of incretin called GLP-1, the effects of incretins on blood glucose levels, the details of incretin-based therapy, the use of incretin mimetics such as exenatide, the use of DPP-IV inhibitors, and indications for incretin-based therapy. The fact sheet notes that both exenatide and DPP-IV inhibitors are used primarily in people with poorly controlled diabetes, often in conjunction with other antidiabetic medications. The fact sheet concludes with a section of practical strategies for incorporating this information into one’s daily diabetes care. Readers are referred to the Hormone Foundation’s website at www.hormone.org and other resources for more information. The fact sheet is also available in Spanish. 4 references.

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Diabetes and New Insulins. Chevy Chase, MD: Hormone Foundation. 2007. 1 p.

This brief fact sheet reviews some of the new insulins that are available to help treat diabetes, a disease characterized by blood glucose levels that are higher than normal. Diabetes occurs when the pancreas does not produce enough insulin or when the body becomes resistant to the effects of insulin. The fact sheet first outlines the three main types of diabetes: type 1, type 2, and gestational diabetes. The fact sheet then answers common questions about how diabetes is treated, the different types of insulins, the differences between mealtime or bolus insulin and basal insulin, and the new insulin preparations, including insulin analogs and inhaled insulin. The fact sheet concludes with a section of practical strategies for incorporating this information into one’s daily diabetes care. Readers are referred to the Hormone Foundation’s website at www.hormone.org and other resources for more information. The fact sheet is also available in Spanish. 4 references.

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Diabetes and New Insulins. Chevy Chase, MD: Hormone Foundation. 2007. 1 p.

This brief fact sheet provides an overview of diabetes and new insulins. Insulin is a hormone that takes the glucose from the bloodstream and carries it inside the body’s cells, where it is used for energy. Diabetes occurs when the pancreas does not produce enough insulin or when the body becomes resistant to the effects of insulin. Written in nontechnical language, the fact sheet answers common questions about the three major types of diabetes, how diabetes is treated, the different types of insulin, and new insulin analogs, including glargine, detemir, lispro, aspart, glulisine, and inhaled insulin. Readers are referred to the Hormone Foundation (www.hormone.org or 1–800–HORMONE) for more information. The fact sheet is also available in Spanish. 1 figure.

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Diabetic Retinopathy and Diabetic Neuropathy. Diabetes Care. 30(3): 760-763. March 2007.

This is the sixth in a series of articles on presentations given at the American Diabetes Association’s 66th Scientific Sessions held in Washington, DC, in June 2006. In this entry, the author summarizes some of the presentations on diabetic retinopathy and neuropathy and lower extremity vascular disease. Topics include the use of insulin-like growth factor (IGF)-1 antagonists for treating diabetic retinopathy, octreotide, the relationship between dyslipidemia and diabetic retinopathy, the use of statins, the idea of the eye as a risk marker for cardiovascular disease (CVD), new therapies for diabetic retinopathy, drug therapy for patients with painful diabetic neuropathy, and the clinical syndrome and symptoms of diabetic neuropathy. The author includes results from the presentations and extensive references for readers wishing to obtain additional information. 45 references.

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Diagnosing and Managing the Metabolic Syndrome in Adults, Children, and Adolescents. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 43-87.

The term “metabolic syndrome” refers to a clustering of specific cardiovascular disease (CVD) risk factors whose underlying pathophysiology is believed to be related to insulin resistance. This chapter about diagnosing and managing metabolic syndrome in adults, children, and adolescents is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author briefly reviews the history of understanding metabolic syndrome, including its epidemiology, and then covers the risk factors; the role of obesity; treatments that focus on behavioral and lifestyle interventions; drug therapy, particularly for risk reduction intervention; the role of primary care physicians; and the importance of early recognition of symptoms and aggressive behavioral intervention. The author concludes by reiterating that health care providers should screen all at-risk children and adolescents for components of metabolic syndrome while promoting healthy lifestyle interventions with both the parents and the patient. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 6 figures. 16 tables. 118 references.

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Focal Fatty Liver: More Than Just a Radiographic Curiosity?. Gastroenterology and Hepatology. 3(3): 199-200. March 2007.

This article comments on an accompanying case report of a woman with multifocal nodular nonalcoholic steatohepatitis (NASH), in whom radiologic abnormalities dramatically resolved after she received the drug rosiglitazone. Nonalcoholic fatty liver disease (NAFLD) has been associated with insulin resistance, and insulin sensitizers have been previously shown to improve liver biochemistry and histology in NASH. This patient’s response to rosiglitazone included improvement in glycemic control, as well as improvement in insulin sensitivity in both the fasting and the fed states. In the commentary article, the authors review the different types of focal hepatic steatosis, note the lack of current understanding of focal fatty liver, briefly consider the natural history of focal hepatic steatosis, and discuss the physiology of vascular supply to the liver. The commentary concludes that the case report demonstrates an interesting variant of a very common cause of liver disease among both adults and children in the United States. The case also underscores the importance of liver imaging techniques in distinguishing focal hepatic steatosis from other mass lesions in the liver. 16 references.

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Guide to Insulin And Type 2 Diabetes. Alexandria, VA: American Diabetes Association. 2007. 234 p.

This handbook helps people with type 2 diabetes understand the role of insulin in a comprehensive program of care to manage their disease. The author first reminds readers that type 2 diabetes is a progressive disease, so even patients who are doing all the recommended strategies of diet, exercise, and medications may still find the need to incorporate insulin to maintain appropriate blood glucose levels. The book includes chapters that cover the basics of blood glucose physiology and the normal progression of type 2 diabetes, the psychological aspects of adding insulin into a care regimen, the myths surrounding insulin, the different types of insulin, the usual insulin regimen, using insulin to cover meals, carbohydrate counting, sliding scales and pattern management, preventing and treating hypoglycemia, sick-day guidelines, and special circumstances such as traveling, pregnancy, and religious fasting. A final section walks readers through the practical aspects of buying, storing, and injecting insulin. Throughout the book are lengthy quotes from people who have experienced the shift to insulin therapy and who share their thoughts and perspectives about the topics under consideration. The book concludes with a subject index, a description of some of the other titles available from the American Diabetes Association (ADA), and a summary of the activities and contact information for various components of the ADA.

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Insulin Analogs and Pregnancy. Diabetes Spectrum. 20(2): 94-101. Spring 2007.

Diabetes during pregnancy is a major risk factor for poor fetal, neonatal, and maternal outcomes; however, this risk can be greatly reduced by the early use of medical nutrition therapy (MNT) and insulin treatment. This article explores the use of insulin analogs and pregnancy, focusing on the newer, rapid-acting insulin analogs lispro and aspart. The author stresses that maintaining maternal glycemic as near to normal as possible reduces the risk of congenital anomalies, macrosomia, neonatal hypoglycemia, and large-for-gestational-age infants. Topics include pregestational diabetes; gestational diabetes mellitus (GDM); the use of NPH insulin during pregnancy; current categories for drug use in pregnancy; long-acting insulin analogs, such as glargine and detemir, problems with retinopathy and insulin analogs; concerns about congenital anomalies and insulin analogs; and macrosomia and insulin analogs. The author concludes that, when compared with human regular insulin, the rapid-acting insulin analogs are effective at reducing hyperglycemia during pregnancy, with a safety profile that resulted in a lower incidence of neonatal complications. The long-acting insulin analogs do not yet have sufficient safety evaluation in clinical studies to warrant their use during pregnancy. The article includes a patient treatment algorithm as a guideline for all insulin-requiring pregnant women with type 2 diabetes, GDM, or type 1 diabetes. 1 figure. 7 tables. 67 references.

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Insulin Delivery. Diabetes Forecast. 60(1 Suppl RG): RG20-RG35. January 2007.

This article, from the annual resource guide that is published as a supplement to Diabetes Forecast, brings readers up-to-date on the equipment and supplies that can help patients use insulin. The author notes that these devices carry insulin through the outermost layer of skin and into fatty tissue so it can be used by the body. The author describes syringes, pumps, jet injectors, pens, and infusers; a separate section considers injection aids. Much of the information is presented in a detailed chart that lists the product name, size, name of manufacturer, needle gauge, needle size, and packaging. Additional charts list insulin pens, pen needles, and other delivery systems; insulin pumps; aids for people who are visually or physically impaired; and jet injectors. 7 tables.

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Insulin Pump Therapy. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 265-320.

Insulin pump therapy allows patients to manage their diabetes intensively by using a method that is pharmacologically superior to multiple daily injections (MDI). This chapter about insulin pump therapy is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author discusses the evolution of modern insulin pump technology, patient selection for pump therapy, improved overall glycemic control and reduced glycemic variability in patients using insulin pumps, talking about pump therapy with prospective patients, initiating pump therapy in the primary care setting, fine-tuning pump therapy, long-term follow-up of insulin pump patients, exercising with an insulin pump, and the use of insulin pump therapy in patients with type 2 diabetes. The author concludes that, compared with MDIs, insulin pump therapy has better insulin pharmacokinetics, less variability in insulin absorption, and decreased risk of hypoglycemia. Patients using insulin pumps enjoy greater lifestyle flexibility and often become more proactive in their approach to diabetes self-management. Although more expensive than MDIs, pump therapy offers patients a much more physiologic approach to controlling their diabetes. Careful evaluation of pump candidates, ongoing patient education, and timely follow-up visits are vital to the success of pump therapy. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 3 appendices. 9 figures. 9 tables. 32 references.

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Management of Type 2 Diabetes in Youth: An Update. American Family Physician. 76(5): 658-664. September 1, 2007.

Type 2 diabetes is emerging as an important disease in children and adolescents, accounting for 8 to 45 percent of new childhood diabetes. This article provides an update from the National Diabetes Education Program (NDEP) on the management of type 2 diabetes in youth. High-risk youths older than 10 years would be those who have a body mass index (BMI) greater than the 85th percentile for age and sex plus two additional risk factors such as family history, high-risk ethnicity, acanthosis nigricans, polycystic ovary syndrome, hypertension, or dyslipidemia. The authors stress that reducing overweight and impaired glucose tolerance with increased physical activity and healthier eating habits may help prevent or delay the development of type 2 diabetes in high-risk youths. Although population-based screening of high-risk youths is not recommended, physicians are encouraged to closely monitor these patients because early diagnosis is beneficial. Young patients who are diagnosed with diabetes need to received self-management education, behavior interventions to promote healthy eating and physical activity, appropriate drug therapy for hyperglycemia––usually metformin and insulin––and treatment of any comorbidities. A final section briefly describes ongoing clinical studies of youths with diabetes. The article includes a side bar that summarizes the related key recommendations for practice. 6 tables. 25 references.

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Modifying Insulin Resistance to Prevent Stroke: The IRIS Trial. Practical Diabetology. 26(2): 19-23. June 2007.

Decades of epidemiologic studies have strongly suggested a major, and probably independent, role of insulin resistance in the genesis and progression of macrovascular diseases, including stroke. New drug agents that enhance insulin sensitivity present an opportunity to test the link between insulin resistance and macrovascular diseases. After an introductory section on the role of insulin resistance in stroke, this article describes the Insulin Resistance Intervention after Stroke (IRIS) Trial, undertaken to help resolve the controversy about insulin resistance and stroke. The IRIS trial will assess the effectiveness of pioglitazone in improving cardiovascular outcomes in insulin-resistant nondiabetic ischemic stroke survivors. The primary end points are recurrent stroke and myocardial infarction. The secondary end points include the individual components of the primary end point, acute coronary syndrome, development of overt type 2 diabetes mellitus, all-cause mortality, cognitive decline, and hospitalization for heart failure. Patients were still being recruited to the trial as of June 2007. 1 table.

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Multifocal Nodular Nonalcoholic Steatohepatitis: Resolution With Rosiglitazone. Gastroenterology and Hepatology. 3(3): 196-198. March 2007.

This article presents a case report of a woman with multifocal nodular nonalcoholic steatohepatitis (NASH), in whom radiologic abnormalities dramatically resolved after she received the drug rosiglitazone. Nonalcoholic fatty liver disease (NAFLD) has been associated with insulin resistance, and insulin sensitizers have been previously shown to improve liver biochemistry and histology in NASH. This patient’s response to rosiglitazone included improvement in glycemic control, as well as improvement in insulin sensitivity in both the fasting and the fed states. The authors report on the patient’s diagnosis, including concerns that a 10.5 centimeter mass found in the patient’s liver would be cancerous. The patient’s condition did not respond to diet, exercise, and vitamin E—the first therapy attempted—but improvement was marked after the addition of rosiglitazone to the regimen. The authors conclude that this case demonstrates the importance of insulin resistance in the development and treatment of NASH. 2 figures. 19 references.

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New Agents for the Treatment of Diabetes. Review of Endocrinology. 1(2): 42-46. June 2007.

This article reviews new delivery methods for insulin and new agents for the treatment of diabetes, notably those based on the incretin phenomenon. The authors describe inhaled human insulin; pramlintide, which is an injectable synthetic analog of amylin; the incretin effect, which explains up to 60 percent of the postprandial insulin secretion of the pancreas; GLP-1 agonists, including exenatide and liraglutide; DPP-4 inhibitors, notably sitagliptin and vildagliptin; and the benefits of using these newer drugs in combination with older antidiabetic agents, particularly in patients with type 2 diabetes. The authors conclude that the GLP-1 receptor agonists and DPP-4 enzyme inhibitors offer comparable HbA1c lowering with few side effects and may also lead to weight loss. 1 figure. 3 tables. 24 references.

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Physiologic Insulin Replacement Therapy. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 192-264.

This lengthy chapter about physiologic insulin replacement therapy is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author stresses that understanding the pharmacokinetics and glucodynamic profiles of different insulin preparations is necessary to direct patients toward the treatment protocols that will allow them to maintain a safe and practical level of hemoglobin A1C. Patients with type 2 diabetes may be able to attain their target goal of A1C using “treat-to-target” protocols that use either basal insulin or mixed insulin analog in addition to oral agents. Most patients with type 1 diabetes should optimize their management using basal-bolus insulin. The author covers the history of insulin, the pathogenesis of type 1 diabetes, determining appropriate glycemic targets, strategies to reduce the costs of managing diabetes, the psychological impact of introducing insulin therapy, hypoglycemia, reducing hyperglycemia, ways to optimize patient adherence and remove barriers to insulin therapy, and insulin analogue formulations. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 13 figures. 18 tables. 101 references.

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Pills for Type 2 Diabetes: A Guide for Adults. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ). 2007. 14 p.

This patient education guide provides information about the various drugs that may be used to treat type 2 diabetes. In type 2 diabetes, the body either does not make enough insulin or it does not use insulin as effectively as it should. The guide reviews the common kinds of diabetes medications, how they work in type 2 diabetes, their side effects, and costs. The authors remind readers that different kinds of diabetes pills work in different ways to control blood glucose levels, and sometimes combining two different kinds of diabetes pills can work better to lower blood glucose than a single medication can. Specific medications covered include biguanides, sulfonylureas, meglitinides, thiazolidinediones, and alpha-glucosidase inhibitors. The guide also describes self-monitoring of blood glucose (SMBG) tests, and readers are encouraged to perform an SMBG test and to have their glycosylated hemoglobin levels checked a few times a year. Some common side effects of diabetes medications include weight gain, stomach problems, swelling, effects on cholesterol levels, hypoglycemia, lactic acidosis, and congestive heart failure. The guide does not cover the other components of treating type 2 diabetes, including diet and exercise. Readers are encouraged to consult the Agency for Healthcare Research and Quality’s website at www.effectivehealthcare.ahrq.gov or the Medline Plus website at www.nlm.nih.gov/medlineplus/diabetes.html for more information.

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Probe to Bone: What Do the Data Tell Us?. Diabetes Care. 30(6): 1663-1669. June 2007.

This article is the second in a series of four articles about presentations at the World Congress on the insulin resistance syndrome (IRS), reviewing the relationship between insulin resistance and nonalcoholic fatty liver disease (NAFLD) and aspects of insulin resistance in children and adolescents. Topics include diagnostic approaches to NAFLD, the increases in hepatic free cholesterol and lipid peroxidation in NAFLD, the evaluation and management of NAFLD, tests used to diagnose and monitor liver function, management approaches, the avoidance of alcohol and drugs, correction of underlying risk factors, the problem of liver complications arising after bariatric surgery in obese patients, drug therapy for diabetes that may affect NAFLD, cardiovascular disease risk factors, diagnosing insulin resistance in childhood and adolescence, the incidence of metabolic syndrome, the impact of parents with insulin resistance on the incidence of metabolic syndrome in their children, the fetal origins of IRS, long-term complications of IRS, type 2 diabetes in youth, the spectrum of insulin resistance among obese children, nonalcoholic steatohepatitis (NASH) in children and adolescents, and insulin sensitivity changes during puberty. 53 references.

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Products, Innovative Delivery Systems for Type 2 Diabetes. Review of Endocrinology. 1(2): 56-58. June 2007.

This article reviews new products and innovative delivery systems for managing type 2 diabetes mellitus. The author stresses that alternative drug delivery systems are becoming an important trend in diabetes therapy. The article describes the h-Patch (Valeritas), which is a basal bolus insulin delivery system; the U-strip insulin patch (Encapsulation Systems), an ultrasonic drug delivery system; AIR inhaled insulin (Eli Lilly and Alkermes), which is in phase 3 clinical trials for both type 1 and type 2 diabetes patients; a digital insulin pen (Eli Lilly) that has a memory and delivers insulin lispro; the I-PORT injection port (Patton Medical Devices), a 3-day delivery device through which injected medications can be administered without the need to puncture the skin with each injection; and the Cleo 90 infusion set (Smiths Medical), a single-use disposable infusion set. The author explains how each of these products and devices might be used in everyday management of diabetes. Quotations from manufacturers, users of the devices, and physicians are included.

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Treatment With Insulin and Its Analogs in Pregnancies Complicated by Diabetes. Diabetes Care. 30(Suppl 2): S220-S224. July 2007.

This article presents a literature review about the safety and effectiveness of insulin analogs in pregnancy, with the goal of enabling clinicians to choose the optimal insulin treatment protocol to achieve and maintain normoglycemia throughout pregnancies complicated by diabetes. Topics include the rationale for the use of nonimmunogenic insulins during pregnancy, long-acting insulin analogs such as insulin glargine and insulin detemir, and the potential risks associated with insulin analogs. The authors note that, if postprandial glucose is the target of treatment, the rapid-acting insulin lispro and insulin aspart appear to be as safe and effective as regular human insulin in women with GDM and they achieve better postprandial glucose concentrations with less late prandial hypoglycemia. If the patient has elevated fasting and postprandial blood glucose levels and requires multiple daily injections to achieve good glycemic control, a basal-bolus regimen should be considered. 1 table. 44 references.

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Uncompromising Approach to Achieving Glycemic Goals. Diabetes Educator. 33(Supl 3): S52-S59. March-April 2007.

This section on achieving glycemic goals is from a special, supplement of the Diabetes Educator that presents a continuing education program on early intervention with insulin analogs, from the American Association of Diabetes Educators (AADE) 2006 Annual Meeting in Los Angeles. The author addresses concerns that, despite excellent treatment options, a large number of people with diabetes are not meeting treatment goals, putting them at high risk for diabetes-related morbidity and mortality, including vascular complications and early death. The author describes the use of new diabetes medications and management tools in a program of earlier, more aggressive, and more comprehensive diabetes treatment. For example, some patients may benefit from earlier use of insulin replacement in their treatment programs. Maximal use should be made of both lifestyle changes and drug therapy to achieve targeted goals. In general, treatment strategies for type 2 diabetes should emphasize lifetime control of risk factors with specific treatment targets. Targets should include goals for glycemia as well as blood lipids and blood pressure. 5 figures. 2 tables. 20 references.

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What's New in Diabetes Care?. Diabetes Wellness News. 13(4): 1-2. April 2007.

This article briefly summarizes some new medications, new ways to deliver insulin, and new ways to monitor blood glucose levels for people with diabetes. The author discusses inhaled insulin, Exubera; two new injectable medications: Byetta and Symlin, which have effects in addition to lowering blood glucose levels, notably in reducing hunger and helping patients to lose weight; a new class of oral medications, the DPP–4 inhibitors: Januvia and Galvus, which lower blood glucose levels but also help control blood glucose levels after meals when they tend to be highest; the use of the oral medication Avandia to prevent or delay type 2 diabetes; the use of continuous blood glucose monitoring; and work on islet transplants. 1 figure.

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Art and Science of Diabetes Self-Management Education: A Desk Reference for Healthcare Professionals. Chicago, IL: American Association of Diabetes Educators. 2006. 821 p.

This comprehensive text serves as a resource for all health professionals, community professionals, and individuals who provide education to individuals with diabetes. The book follows the American Association of Diabetes Educators (AADE) strategic mission and vision and is intended to enhance the contribution of skilled diabetes educators to the patient care team. The first section of six chapters on understanding the individual’s health behavior and choices presents background and theoretical foundations essential to providing effective self-management education. The second section includes 18 chapters discussing various aspects of the disease, therapies, and chronic complications. And the final section of 11 chapters focuses specifically on well-designed diabetes education. Specific topics covered include the emotional and psychological challenges of chronic illness, community and society support for diabetes self-management, the pathophysiology of the metabolic disorder, hyperglycemia, Type 1 diabetes, Type 2 diabetes, pregnancy with preexisting diabetes, gestational diabetes mellitus (GDM), medical nutrition therapy (MNT), physical activity, drug therapy for glucose management, patient empowerment, intensive insulin therapy, dyslipidemia and hypertension in people with diabetes, biological complementary therapies in diabetes, chronic complications, macrovascular disease in diabetes, diabetic eye disease, diabetic kidney disease, diabetic neuropathies, the implementation of diabetes education, and evaluating and documenting patient education outcomes. Each chapter includes a list of key points, a series of case studies, a summary of teaching strategies, suggested Internet resources, a glossary of key terms, and a lengthy list of references. The text concludes with a detailed subject index and a brief overview of the goals and activities of the AADE.

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Bariatric Surgery: A Promising Solution for Nonalcoholic Steatohepatitis in the Very Obese. Journal of Clinical Gastroenterology. 40(Suppl): S44-S50. March 2006.

This article reviews the use of bariatric surgery for management of nonalcoholic steatohepatitis (NASH) in obese patients. The author notes that the mainstays of treatment for NASH, diet and physical activity plus behavioral modifications, are not always successful, particularly in the very obese. Only limited evidence exists that liver enzymes improve with reduction in body weight. The drug therapy in current use has focused on treating insulin resistance and oxidative stress, but again with rather limited success. The author emphasizes that, in the severely obese, the best treatment option is bariatric surgery, which is safe and has been successful in producing a 61 percent weight loss overall. The result is improvement in diabetes mellitus, the metabolic syndrome, and presumably its sequelae. Early reports (and procedures) were attended with dramatic weight loss but markedly aggravated the inflammatory liver disease. In recent trials with more modest weight loss and less malnutrition, bariatric surgery reduced the fat, inflammation, and even the fibrosis in well-documented NASH. The laparoscopic adjustable banding procedure is deemed most suitable for this purpose. The author cautions that ongoing care will be necessary with a lifetime follow-up because of the metabolic and other complications from the weight loss. 4 figures. 59 references.

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Can Medication Help?. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 126-138.

This chapter on drug therapy is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author describes the use of medications to help lower the risk of developing diabetes. There are glucose-lowering medications for people with diabetes which can work by helping the pancreas release more insulin, making the cells more sensitive to insulin, reducing the amount of glucose made by the liver, blocking digestion of carbohydrates or fat, or substituting for human insulin to help the cells use glucose. The author also outlines non-diabetes medications that may be useful, including anti-hypertensive agents or cholesterol-lowering drugs. Vitamin, mineral, and herbal supplements may also be used; the author outlines some of the studies on these alternative therapies, commenting on benefits, efficacy, and side effects reported. Readers are encouraged to work closely in tandem with their health care providers and to become an active, educated member of their own health care team. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. 2 tables.

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Conclusion. IN: Sharing the Burden: The Role of Incretins in Glucose Control. Chicago, IL: American Association of Diabetes Educators. 2006. p. 15.

New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This concluding section is from a clinical monograph on the role of incretins in glucose control; the monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators' 2005 Annual Meeting. The authors briefly review the limitations of current treatments for type 2 diabetes mellitus and consider the role of glucagon in disease pathophysiology. The authors then summarize the role of incretins and incretin-based therapies in suppressing glucagon secretion, as well as their contributions to reducing the burden of glucose control. The incretin GLP-1 has been identified as a critical player in glucose homeostasis, and a number of antihyperglycemic therapies targeting this pathway are now under development or in use. GLP-1 is released in response to a meal and acts on pancreatic islets to increase insulin secretion and inhibit glucagon release. GLP-1 also exerts a number of effects beyond those on the islet cells, including improved gastric function and suppression of food intake. The authors conclude that knowledge of GLP-1 and its roles in glucose regulation provides new methods of controlling glucose concentration, as it helps address some of the pathologic aspects of type 2 diabetes that are not covered by present treatments.

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Conclusions. IN: Clinical Impact of Incretin-Based Therapies on Type 2 Diabetes Management. Littleton, CO: Medical Education Resources. p. 19.

New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This chapter is from a clinical monograph on the role of incretins in glucose control; the monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators’ 2005 Annual Meeting. In this conclusion, the authors briefly review the limitations of current treatments for type 2 diabetes mellitus and consider the role of glucagon in disease pathophysiology. The authors then summarize the role of incretins and incretin-based therapies in suppressing glucagon secretion, as well as their contributions to reducing the burden of glucose control. The incretin GLP-1 has been identified as a critical player in glucose homeostasis, and a number of antihyperglycemic therapies targeting this pathway are now under development or in use. GLP-1 is released in response to a meal and acts on pancreatic islets to increase insulin secretion and inhibit glucagon release. GLP-1 also exerts a number of effects beyond those on the islets, including improved gastric function and suppression of food intake. The authors conclude that knowledge of GLP-1 and its roles in glucose regulation provides new methods of controlling glucose concentration, as it helps address some of the pathologic aspects of type 2 diabetes that are not covered by present treatments.

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DPP-4 Inhibitors. IN: Clinical Impact of Incretin-Based Therapies on Type 2 Diabetes Management. Littleton, CO: Medical Education Resources. p. 13-15.

New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This chapter on the DPP-4 inhibitors is from a monograph on the clinical impact of incretin-based therapies on the management of people with type 2 diabetes. The monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators’ 2005 Annual Meeting. The authors describe DPP-4 inhibitors, which are used to prolong the effect of endogenous glucagon-like peptide (GLP-1); one of the DPP-4 inhibitors under study is called vildagliptin. These drugs inhibit DPP-4, so GLP-1 concentrations rise, resulting in benefits similar to a direct infusion of GLP-1. Vildagliptin decreases blood glucose levels, increases active GLP-1, decreases glucagon, and lowers glycosylated hemoglobin (A1C) with once-daily oral dosing. The chapter concludes with a discussion of sitagliptin, another DPP-4 inhibitor that was approved for treatment in type 2 diabetes mellitus in October 2006. One table summarizes the approval status, route and effective dose, and adverse effects of four incretin therapies: exenatide, liraglutide, vildagliptin, and sitagliptin. 3 figures.

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Exhuberance Over Exubera. Clinical Diabetes. 24(3): 110-114. Summer 2006.

This article reviews the history of the development of insulin used to treat diabetes, culminating in the newest entry in the insulin world, inhaled insulin (brand name Exubera). Exubera is recombinant-engineered human insulin that is delivered to the bloodstream via the lung's alveoli; approximately one-third of the administered dose is absorbed into the bloodstream. The onset of inhaled insulin acts as quickly as subcutaneously administered rapid-acting insulin and more quickly than subcutaneous regular insulin. The authors review the effectiveness of inhaled insulin, initiating inhaled insulin, tools for patients starting inhaled insulin, monitoring guidelines, and candidates for inhaled insulin use. The authors conclude that clinical data have shown increased patient acceptability with inhaled insulin compared to injectable insulin. More patients using insulin who need it results in better glycemic control, thereby reducing microvascular and macrovascular complications and leading to improved quality of life. Thus, although there are safety and cost considerations, inhaled insulin also offers potential adherence and satisfaction advantages. 4 tables. 22 references.

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Full Speed Ahead: Progressing Toward Better Diabetes Management. Today's Dietitian. 8(7): 26-30. July 2006.

This article brings dietitians and nutrition specialists up-to-date with advances in diabetes care. The author discusses the history of home blood glucose monitoring (SMBG) and insulin; the physiology and pharmacology of both old and new insulin analogues, including lispro, aspart, glulisine, detemir, and glargine insulins; exubera, the first inhaled insulin; and new therapies that mimic glucagon-like peptide (GLP-1) and amylin. The newer, rapid-acting insulin analogues (lispro, aspart, glusiline) have a structural difference that promotes rapid absorption. The longer-acting insulin analogues (detemir and glargine) are designed to produce a smooth, reliable basal insulin profile. Inhaled insulin (exubera) is a powdered form of insulin taken into the lungs via inhalers. Exubera has an onset of action similar to the rapid insulin analogues, with peak activity at 30 to 90 minutes after administration. Exenatide mimics the actions of native GLP-1 which controls blood glucose by stimulating insulin secretion, slowing gastric emptying, reducing glucagon release, and enhancing the sense of satiety. Pramlinitide is an amylin analogue that, when injected 15 minutes before a meal, slows gastric emptying, suppresses the release of glucagon, and improves satiety after a meal.

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GLP-1 Analogues. IN: Clinical Impact of Incretin-Based Therapies on Type 2 Diabetes Management. Littleton, CO: Medical Education Resources. pp. 11-13.

New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This chapter on the glucagon-like peptide (GLP-1) analogues is from a monograph on the clinical impact of incretin-based therapies on the management of people with type 2 diabetes. The monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators’ 2005 Annual Meeting. The authors describe the current research on exenatide, an incretin mimetic that has been shown to effectively lower blood glucose levels and improve glycosylated hemoglobin levels (a measure of blood glucose over time). Currently, exenatide is indicated for patients who are failing on metformin, sulfonylureas, or combination therapies. The chapter also mentions liraglutide, previously known as NN2211, which has a longer plasma half-life, enabling once-daily administration. The chapter includes a side bar summarizing the information that patients should know about exenatide injection. 2 figures. 1 table.

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Insulin Delivery. Diabetes Forecast. 59(1): RG23-RG39. January 2006.

Syringes, pumps, jet injectors, pens, and infusers are all ways to deliver insulin. These items carry insulin through the outermost layer of skin and into fatty tissue so it can be used by the body. This section on insulin delivery is from a special issue of Diabetes Forecast that offers the annual guide to diabetes products and services. The author discusses each type of insulin delivery method in turn, covering questions to ask one's doctor, purchasing guidelines, cost considerations, and patient selection. An additional section discusses injection aids and alternatives that can make giving injections easier, including those designed for people with visual impairment. The section concludes with lengthy, detailed charts that summarize the devices discussed. 7 tables.

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Insulin. Diabetes Forecast. 59(1): RG14-RG20. January 2006.

There are many different insulins available for different situations and lifestyles. This section on insulin is from a special issue of Diabetes Forecast that offers the annual guide to diabetes products and services. The author first reviews the three characteristics of insulin: onset, peak time, and duration. The author then summarizes these characteristics for each type of insulin: rapid-acting insulins, such as insulin lispro (Humalog) or insulin aspart (NovoLog), glulisine (Apidra); regular or short-acting insulin (human); intermediate-acting insulin, such as NPH and lente insulin; long-acting insulin, including ultralente, insulin glargine (Lantus), and insulin detemir (Levemir); and premixed insulins. The remainder of the article discusses sources of insulins, strengths used, mixing insulin, additives, consumer advice, and storage and safety considerations. The article includes tables that summarize the insulins currently available, covering the generic and brand names, form, manufacturer, duration, and physical appearance of each type. 3 tables.

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Intensifying Insulin Therapy: Multiple Daily Injections to Pump Therapy. IN: Mensing, C., ed. Art and Science of Diabetes Self-Management Education. Chicago, IL: American Association of Diabetes Educators. pp. 372-398.

Meticulous metabolic control minimizes the long-term complications of diabetes and improves the quality and length of life for individuals with the disease. To achieve this kind of glycemic control, insulin therapy often needs to be intensified. This can be undertaken either through multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII), also known as insulin pump therapy. This chapter on the use of intensive insulin therapy is from a comprehensive text that serves as a resource for all health professionals, community professionals, and individuals who provide education to individuals with diabetes. The authors stress that educators must understand the benefits, risks, and limitations of intensive therapy to counsel and assist patients who are using MDI or insulin pumps. Patients considered appropriate candidates for intensive insulin therapy include those who can reliably demonstrate and use safe, consistent self-care behaviors such as frequent blood glucose monitoring (SMBG), insulin injections, carbohydrate counting, and problem solving for high and low blood glucose and sick day management. Preparing the patient and support persons in problem-solving skills with intensive insulin therapy prior to pump therapy initiation is critical to using an insulin pump safely and effectively. Pump therapy is most commonly used by people with type 1 diabetes, but may also be of value for people with type 2 diabetes, older adults with profound insulin deficiency, and pregnant women with diabetes. The chapter includes a list of key points, a summary of teaching strategies, case studies, suggested Internet resources, a glossary of key terms, and a list of references. 5 tables. 87 references.

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Liver Disease in Patients with Diabetes Mellitus. Journal of Clinical Gastroenterology. 40(1): 68-76. January 2006.

In addition to the well-known cardiovascular, renal, and ophthalmologic complications of diabetes, liver-related complications occur commonly and are often underrecognized. This article reviews the relationship between diabetes mellitus and two common liver diseases: chronic hepatitis C and nonalcoholic fatty liver disease. The author also discusses the association of diabetes and cirrhosis, acute liver failure, hepatocellular carcinoma, and outcomes following orthotopic liver transplantation. The liver plays a significant role in energy homeostasis and glucose metabolism; insulin enhances glycogen synthesis within the liver and prevents glucose production. These normal physiologic processes become dysregulated with insulin resistance and type 2 diabetes mellitus. Insulin resistance may work synergistically with hepatitis C infection to make changes in the liver, in the form of steatosis, inflammation, and fibrosis development. Once this occurs, progression to diabetes may occur in patients with underlying genetic susceptibility. Current treatment for preventing liver complications is focused on therapies that improve underlying insulin resistance, including weight loss or drug therapy. 1 figure. 2 tables. 158 references.

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Liver Disease in Patients with Diabetes Mellitus. Journal of Clinical Gastroenterology. 40(1): 68-76. January 2006.

In addition to the well-known cardiovascular, renal, and ophthalmologic complications of diabetes, liver-related complications occur commonly and are often underrecognized. This article reviews the relationship between diabetes mellitus and two common liver diseases: chronic hepatitis C and nonalcoholic fatty liver disease. The author also discusses the association of diabetes and cirrhosis, acute liver failure, hepatocellular carcinoma, and outcomes following orthotopic liver transplantation. The liver plays a significant role in energy homeostasis and glucose metabolism; insulin enhances glycogen synthesis within the liver and prevents glucose production. These normal physiologic processes become dysregulated with insulin resistance and type 2 diabetes mellitus. Insulin resistance may work synergistically with hepatitis C infection to make changes in the liver, in the form of steatosis, inflammation, and fibrosis development. Once this occurs, progression to diabetes may occur in patients with underlying genetic susceptibility. Current treatment for preventing liver complications is focused on therapies that improve underlying insulin resistance, including weight loss or drug therapy. 1 figure. 2 tables. 158 references.

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Medical Treatment of the Obese Patient with Type 2 Diabetes. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 471-486.

This chapter, from a comprehensive textbook on diabetes and obesity, focuses on the medical treatment of type 2 diabetes, with a special emphasis on the approach to the obese patient with this disease. Topics include the pathophysiology and natural history of type 2 diabetes, the goals of therapy and monitoring in type 2 diabetes, medical nutrition therapy (MNT) and exercise, oral antihyperglycemic agents, available insulin formulations, the approach to insulin use in obese patients with type 2 diabetes, and future therapies. The authors conclude that the goal of treatment is to achieve and maintain near-normal glycemic control without increasing the risk of hypoglycemia. MNT and exercise form the cornerstone of a comprehensive management program, but the vast majority of patients require drug therapy to achieve and maintain optimal blood glucose levels. For the obese patient with diabetes, insulin sensitizers are effective medications, and combination therapy with insulin secretagogues and sensitizers should be considered in patients with suboptimal control. Insulin remains an important component of the treatment regimens for patients not achieving target blood glucose goals with oral agents. 1 figure. 4 tables. 110 references.

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Metformin: Now or Later?. Harvard Health Letter. 32(1): 4. November 2006.

This newsletter article considers the use of metformin (Glucophage) and when it should be started in people newly diagnosed with type 2 diabetes. Metformin lowers blood sugar levels by decreasing the liver’s production of sugar and by increasing the effectiveness of insulin, the hormone that escorts sugar into the cells where it can be used. Insulin resistance is one of the main features of type 2 diabetes. Metformin is a first-line medication for several reasons: It is effective, lowering blood sugar levels by about 20 percent; people do not tend to gain weight when they take it, in contrast to insulin and the sulfonylurea drugs; and it is relatively inexpensive. Proponents of this type of drug therapy say that these medications tame conditions that are too serious to allow to progress. Critics counter that not nearly enough has been invested in devising ways to make diet and exercise programs work; approaches that do not carry the side effects that medications cause. The author concludes that the most important thing for people with newly diagnosed type 2 diabetes is to get their blood glucose levels under control. If this can be achieved without the drug therapy, that is fine, but if metformin is required to reach appropriate glycosylated hemoglobin levels, patients should not hesitate to include the drug in their diabetes management plan.

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New Drug Therapies. IN: Sharing the Burden: The Role of Incretins in Glucose Control. Chicago, IL: American Association of Diabetes Educators. 2006. p. 11-14.

New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This section on new drug therapies is from a clinical monograph on the role of incretins in glucose control; the monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators' 2005 Annual Meeting. The authors describe the current research on exenatide, an incretin mimetic that has been shown to effectively lower blood glucose levels and improve glycosylated hemoglobin levels—a measure of blood glucose over time. Currently, exenatide is indicated for patients who are failing on metformin, sulfonylureas, or combination therapies. The chapter continues by describes DPP-4 inhibitors, used to prolong the effect of endogenous glucagon-like peptide (GLP-1); one of the DPP-4 inhibitors under study is called vildagliptin. These drugs inhibit DPP-4, so GLP-1 concentrations rise, resulting in benefits similar to a direct infusion of GLP-1. Vildagliptin decreases blood glucose levels, increases active GLP-1, decreases glucagon, and lowers glycosylated hemoglobin (A1C) with once-daily oral dosing. One sidebar explains the differences between incretins and pramlintide, a drug that is a synthetic analog of human amylin—a naturally occurring hormone that is made by the beta cells of the pancreas and is co-secreted with insulin. 6 figures.

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New Therapies in Diabetes. IN: Katsilambros, N., et al. Diabetes in Clinical Practice: Questions and Answers From Case Studies. . Somerset, NJ: John Wiley & Sons. 2006. pp 409-436.

This chapter on new therapies in diabetes is from a book that deals with various aspects of diabetes in clinical practice, presented in the form of questions concerning diabetes diagnosis, management, and therapy, all based on real-life case studies. Topics covered include the use of continuous subcutaneous insulin infusion pumps, the different types of insulin pumps available, the components of an insulin pump, how the basal rate is determined, how the boluses are determined, patient indications for the use of an insulin pump, the use of an insulin pump to help prevent hypoglycemia unawareness, complications associated with an insulin pump, patient care management and follow up for a patient using an insulin pump, the use of inhaled insulin, the metabolism of inhaled insulin, complications regarding the use of inhaled insulin, the use of inhaled insulin in patients who smoke, kidney and pancreas transplantation, transplantation of pancreatic islets, glucagon-like peptide (GLP-1) in patients with type 2 diabetes, amylin, pramlintide, and the artificial pancreas. The chapter presents one detailed case study, with relevant questions posed and answered. Readers are walked through the diagnostic and patient care management process for the case study presented. 1 figure. 28 references.

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Nonalcoholic Fatty Liver Disease: A Clinic Approach and Review. Canadian Journal of Gastroenterology. 20(5): 345-349. May 2006.

This article reviews advances in nonalcoholic fatty liver disease (NAFLD), the most common cause of incidental elevation of liver enzymes in North America and Europe. Risk factors for NAFLD include a body mass index of 25 or greater, central obesity, and diabetes mellitus. The spectrum of disease is wide, ranging from simple steatosis with benign prognosis to nonalcoholic steatohepatitis and cirrhosis, with associated increases in morbidity and mortality. Topics covered include epidemiology and risk factors, diagnosis, pathogenesis, and patient care management, notably drug therapy in NAFLD, bariatric surgery, and the role of liver biopsy. The first abnormality in NAFLD is insulin resistance leading to hepatic steatosis. The second problem involves multiple proinflammatory cytokines, resulting in nonalcoholic steatohepatitis. Treatment is aimed at aggressive risk factor control and weight loss. 1 figure. 3 tables. 38 references.

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Pathophysiology of the Metabolic Disorders. IN: Mensing, C., ed. Art and Science of Diabetes Self-Management Education. Chicago, IL: American Association of Diabetes Educators. pp. 144-161.

Diabetes is a disease characterized by abnormal metabolism of carbohydrates, proteins, and fats. This chapter on the pathophysiology of the metabolic disorder is from a comprehensive text that serves as a resource for all health professionals, community professionals, and individuals who provide education to individuals with diabetes. The authors note that newly discovered hormones and systems that regulate energy balance have increased understanding of normal physiology and the pathophysiology of diabetes. The chapter covers normal fuel metabolism, the role of hormones, the different types of diabetes, and the pathogenesis of type 1 diabetes and of type 2 diabetes. Type 1 diabetes results from autoimmune beta cell destruction, leading to absolute insulin deficiency. Type 2 diabetes is a multihormonal pathophysiology involving a progressive insulin secretory defect along with insulin resistance. This disease progresses from an early asymptomatic state with insulin resistance, to mild postprandial hyperglycemia, to clinical diabetes requiring drug therapy. Obesity, weight gain in adulthood, and physical inactivity are environmental factors affecting the progression at all points along the continuum. The chapter includes a list of key points, a summary of teaching strategies, suggested Internet resources, a glossary of key terms, and a list of references. 2 figures. 3 tables. 79 references.

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Switching from Insulin to Oral Sulfonylureas in Patients with Diabetes Due to Kir6.2 Mutations. New England Journal of Medicine. 355(5): 467-477. August 3, 2006.

In diabetes patients diagnosed at six months of age or younger, approximately 30 to 58 percent of cases are caused by heterozygous activating mutations in KCNJ11, encoding the Kir6.2 subunit of the ATP-sensitive potassium channel. These patients present with ketoacidosis or severe hyperglycemia and are treated with insulin. This article reports on a study of glycemic control in 49 patients with Kir6.2 mutations who received appropriate doses of sulfonylureas. The authors also investigated, in smaller subgroups, the insulin secretory responses to intravenous and oral glucose, a mixed meal, and glucagon. A total of 44 patients (90 percent) successfully discontinued insulin after receiving sulfonylureas. Glycated hemoglobin levels improved in all patients who switched to sulfonylurea therapy. Improved glycemic control was sustained at one year. Sulfonylurea treatment increased insulin secretion, which was more highly stimulated by oral glucose or a mixed meal than by intravenous glucose. The authors conclude that sulfonylurea therapy is safe in the short term for patient with diabetes caused by KCNJ11 mutations and is probably more effective than insulin therapy. This pharmacogenetic response to sulfonylureas may result from the closing of the mutant ATP-sensitive potassium channels, thereby increasing insulin secretion in response to incretins and glucose metabolism. 4 figures. 1 table. 30 references.

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Therapy of NAFLD: Insulin Sensitizing Agents. Journal of Clinical Gastroenterology. 40(Suppl 1): S61-S66. March 2006.

Insulin resistance is an integral part of the underlying pathophysiology in most patients with nonalcoholic fatty liver disease (NAFLD), a chronic liver disease that can lead to cirrhosis and liver cancer. This article reviews the current literature on the use of insulin-sensitizing agents in the treatment of patients with NAFLD, particularly in those patients with the more severe form known as nonalcoholic steatohepatitis (NASH). The authors review the use of two major insulin-sensitizing agents: the thiazolidinediones and metformin (the only available biguanide). Thiazolidinedione administration in human NAFLD has been shown to decrease hepatic fat by several different measures and to decrease evidence of cellular injury, but it has also been associated with increased peripheral fat and weight gain. In contrast, metformin has been shown to improve biochemical markers without weight gain, but with more variable improvement in histology. Neither agent has current FDA approval for use in NAFLD, but existing studies provide hope for the benefits of incorporating these medications into NAFLD management strategies in selected patients. In addition, most of the studies do not determine the relative contribution of lifestyle changes compared with drug therapy, which can confound the results. 4 figures. 1 table. 61 references.

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Treatment of Diabetes With Insulin. IN: Katsilambros, N., et al. Diabetes in Clinical Practice: Questions and Answers From Case Studies. Somerset, NJ: John Wiley & Sons. 2006. pp 371-408.

This chapter on treating diabetes with insulin is from a book that deals with various aspects of diabetes in clinical practice, presented in the form of questions concerning diabetes diagnosis, management, and therapy, all based on real-life case studies. Topics covered include how insulin is produced commercially, the different types of insulin preparations available, insulin analogues, the speed of insulin absorption, insulin bioavailability, insulin pens and their indications, the side effects of insulin treatment, the use of an intensified insulin regimen, basal-bolus insulin regimens, recommended basal insulins, prandial insulins, dosing and administration, the use of insulin in patients with type 2 diabetes, and the use of premixed insulin preparations. The chapter presents five detailed case studies, with relevant questions posed and answered. Readers are walked through the diagnostic and patient care management process for the case studies presented; insulin dosages are noted for each. 5 figures. 16 tables. 17 references.

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Care of Children and Adolescents With Type 1 Diabetes: A Statement of the American Diabetes Association. Diabetes Care. 28(1): 186-212. January 2005.

In caring for children with diabetes, professionals need to understand the importance of involving adults in the child's diabetes management. The education about how to care for a child or adolescent with diabetes must be provided to the entire family unit, emphasizing age and developmentally appropriate self-care and integrating same into the child's diabetes management. This American Diabetes Association Statement provides a single resource on current standards of care pertaining specifically to children and adolescents with type 1 diabetes. It is not meant to be an exhaustive compendium on all aspects of the management of pediatric diabetes. However, relevant references are provided and current works in progress are indicated as such. The information provided is based on evidence from published studies whenever possible and, when not, supported by expert opinion or consensus. The Statement discusses and provides recommendations in the areas of diagnosis, initial care, diabetes education, identification (medical tags), appropriate self-management by age, glycemic control, insulin management of diabetes, blood glucose monitoring, nutrition, medical nutrition therapy (MNT), exercise, assessment of child and family risk factors at diagnosis, psychosocial issues, acute complications, immunization, chronic complications, associated autoimmune conditions, adjustment and psychiatric disorders, adolescence, adherence to self-management, and special situations, including sick day management, and diabetes care at school and day care. A final section considers risk behaviors, including use of tobacco and recreational drugs and unprotected sexual intercourse. 4 tables. 237 references.

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Elevated Liver Function Tests in Type 2 Diabetes. Clinical Diabetes. 23(3): 115-119. Summer 2005.

Individuals with type 2 diabetes have a higher incidence of liver function test (LFT) abnormalities than individuals who do not have diabetes. This article reviews the pathology, incidence, causes, and drug therapy related to type 2 diabetes and elevated LFTs. Mild chronic elevations of transaminases often reflect underlying insulin resistance. Elevation of transaminases within three times the upper limits of normal is not a contraindication for starting oral antidiabetic or lipid-modifying therapy. In contrast, antidiabetic agents have generally been shown to decrease alanine aminotransferase levels as tighter blood glucose levels are achieved. The most common cause of elevated LFTs in type 2 diabetes patients in non-alcoholic fatty liver disease (NAFLD). Hepatitis C virus (HCV), the leading cause of liver disease in the United States, is a known independent predictor of type 2 diabetes. The author notes that, for diabetes patients over the age of 40 years, and certainly in the setting of multiple cardiovascular risk factors or know cardiovascular disease, the potential risk of statin therapy (hepatotoxicity) is far outweighed by the proven benefit from CVD risk reduction. The author concludes by reviewing relevant research studies on the use of oral antidiabetes agents in type 2 diabetes patients with elevated transaminases.

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Exenatide Versus Insulin Glargine in Patients with Suboptimally Controlled Type 2 Diabetes. A Randomized Trial. Annals of Internal Medicine. 143(8): 559-569. October 2005.

This article reports on a study that compared the effects of exenatide and insulin glargine (both injectable drugs) on blood glucose control in patients with type 2 diabetes mellitus that is suboptimally controlled with metformin and a sulfonylurea (oral hypoglycemic agents). The 26-week multicenter, open-label, randomized, controlled trial utilized 82 outpatient study centers in 13 countries and included 551 patients with type 2 diabetes and inadequate glycemic control. Inadequate glycemic control is defined as hemoglobin A1c (HbA1c, a measure of blood glucose over time) level ranging from 7.0 percent to 10.0 percent, despite combination metformin and sulfonylurea therapy. Baseline mean HbA1c level was 8.2 percent for patients receiving exenatide and 8.3 percent for those receiving insulin glargine. At week 26, both exenatide and insulin glargine reduced hemoglobin A1c levels by 1.11 percent. Exenatide reduced postprandial glucose excursions (changes in blood glucose levels after a meal) more than insulin glargine, while insulin glargine reduced fasting glucose concentrations more than exenatide. Body weight decreased 2.3 kilograms with exenatide and increased 1.8 kilograms with insulin glargine. Rates of symptomatic hypoglycemia were similar, but nocturnal hypoglycemia occurred less frequently with exenatide. Gastrointestinal symptoms were more common in the exenatide group than in the insulin glargine group, including nausea (57.1 percent versus 8.6 percent), vomiting (17.4 percent versus 3.7 percent) and diarrhea (8.5 percent versus 3.0 percent). The authors conclude that exenatide and insulin glargine achieved similar improvements in overall glycemic control in this patient population. Exenatide was associated with weight reduction and had a higher incidence of gastrointestinal adverse effects than insulin glargine. 3 figures. 3 tables. 34 references.

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Inhaled Insulin Improves Glycemic Control When Substituted for or Added to Oral Combination Therapy in Type 2 Diabetes: A Randomized, Controlled Trial. Annals of Internal Medicine. 143(8): 549-558. October 2005.

Patients with type 2 diabetes who do not achieve glycemic control with oral drug therapy eventually require insulin. This article reports on a study undertaken to determine the effect on glycemic control of inhaled insulin alone or added to dual oral therapy (insulin secretagogue and sensitizer) after failure of dual oral therapy. The open-label, randomized, controlled trial set in 48 outpatient centers in the United States and Canada included 309 patients with type 2 diabetes, no clinically significant respiratory disease, and HbA1c (glycosylated hemoglobin, a measure of blood glucose over time) level of 8 percent to 11 percent who were receiving dual oral therapy. The patients were given inhaled insulin (Exubera), titrated to blood glucose, administered alone (n = 104) or added to dual oral agents (n = 103) versus oral therapy alone (n = 99). Results showed that reductions in HbA1c level were greater with inhaled insulin. HbA1c level less than 7 percent was achieved by 32 percent of the patients using inhaled insulin plus oral agents and by 1 percent of patients on oral agent therapy. Hypoglycemia, mild weight gain, mild cough, and insulin antibodies were more frequent with inhaled insulin than with oral agent therapy alone. Pulmonary function was similar in all groups. The authors conclude that inhaled insulin improved overall glycemic control and HbA1c level when added to or substituted for dual oral agent therapy with an insulin secretagogue and sensitizer. Similar to other insulin therapies, hypoglycemia and mild weight gain occurred. 4 figures. 3 tables. 42 references.

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Insulin and Type 2 Diabetes Management. Today's Dietitian. 7(9): 19-20. September 2005.

This article reviews the use of insulin in the management of type 2 diabetes. Recent research has established the importance of intensive blood glucose control in reducing diabetes-related morbidity and mortality. The author notes that aggressive treatment with oral medications and the early introduction of insulin therapy may improve metabolic outcomes and reduce hyperglycemia-associated morbidity in people with type 2 diabetes. The author explains the pathophysiology of type 2 diabetes and the indications for drug therapy, primarily when medical nutrition therapy (MNT) and physical activity fail to maintain blood glucose levels within healthy guidelines. When multiple oral agents fail to achieve metabolic control, insulin is added to the treatment regimen. The author reviews some of the studies that indicate the benefits of early intervention with insulin. A final section discusses the resistance to initiating insulin therapy that is often encountered in patients with type 2 diabetes.

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Medications and Supplements. IN: Thomas, A.M.; Gutierrez, Y.M., eds. American Dietetic Association Guide to Gestational Diabetes Mellitus. Chicago, IL: American Dietetic Association. 2005. pp. 65-80.

This chapter on medications and supplements in gestational diabetes mellitus (GDM) is from a Guide that serves as a resource for health professionals involved in the care of women who develop diabetes during their pregnancy. The Guide helps readers to promote sound nutrition principles in GDM, to achieve optimal outcomes for the woman and her infant. The author of this chapter begins by summarizing the types, action, peak times, and duration of insulin used in pregnancy. Other topics covered include the treatment modalities used for hypoglycemia, the use of oral agents used to treat diabetes in pregnancy, the use of multivitamin-mineral supplements in pregnancy, and the benefits and adverse effects of herbal and botanical supplements on pregnancy outcome. The author concludes that the goal in the management of GDM is normoglycemia. The first course of treatment is medical nutrition therapy (MNT); if blood glucose levels cannot be maintained by MNT, insulin must be initiated. The author emphasizes that nutrition assessment and counseling are recommended for all pregnant women. 6 figures. 4 tables. 64 references.

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Neonatal Diabetes Mellitus: From Understudy to Center Stage. Current Opinion in Pediatrics. 17(4): 512-518. August 2005.

Neonatal diabetes mellitus (NDM) is defined as persistent hyperglycemia occurring in the first months of life, lasting more than 2 weeks, and requiring insulin for management. NDM is currently the focus of research for the insights it provides into the genes regulating pancreatic islet formation, differentiation, and function, including the regulation of insulin secretion. This review article highlights recent discoveries concerning the genetic and molecular basis of the spectrum of disorders constituting neonatal diabetes mellitus. Recent reports, primarily in 2005, have identified activating mutations in the ATP-sensitive potassium channel that prevent its closure and hence insulin secretion as the major cause of permanent NDM. The authors report on a transgenic mouse model being used to study transient NDM. The authors conclude that these studies are exciting milestones on the way to understanding and treating the more common forms of type 1 and type 2 diabetes mellitus in children and adolescents. 1 figure. 2 tables. 65 references.

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Rapid-Acting Insulin: Timing It Just Right. Diabetes Self-Management. 22(1): 20-26. January-February 2005.

This article describes rapid-acting insulin and gives information to help readers use this type of insulin more effectively. In most cases, rapid-acting insulin (insulin lispro, brand name Humalog) is absorbed quickly and begins lowering blood glucose quickly. The author begins by describing the different ways that insulin may be used to help people with diabetes match the way that insulin is normally secreted by people without diabetes. The author then discusses the three phases of insulin action: onset, when the insulin starts to lower blood glucose; peak, when insulin has its greatest effect on blood glucose; and duration, how long the insulin continues to have some blood-glucose-lowering effect. In addition to understanding this action curve of the insulin, patients must learn how the food they choose affects blood glucose levels, so appropriate insulin can be used. The article includes a section of practical tips for special situations: high blood glucose before a meal, low blood glucose before a meal, low glycemic index foods, uncertain carbohydrate intake, large meals, drawn-out meals, and snacks. A final section addresses the importance of good recordkeeping, both for food intake and insulin use, to help fine-tune blood glucose control. One sidebar lists resources for readers wishing to learn more about insulin. 1 figure. 5 references.

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Type 2 Diabetes in Children and Adolescents: Risk Factors, Diagnosis, and Treatment. Clinical Diabetes. 23(4): 181-185. Fall 2005.

Due to the current epidemic of obesity among children and adolescents, physicians can logically expect to encounter increasing numbers of young patients presenting initially with signs and symptoms associated with uncontrolled hyperglycemia (high blood glucose) and relatively advanced cases of diabetes. This article reviews the risk factors, diagnosis, and treatment of type 2 diabetes in children and adolescents. The authors use the case of a young adolescent (a 13-year-old Hispanic girl) with multiple risk factors for type 2 diabetes. The authors first discuss the role of family history and genetics, insulin resistance, criteria for diagnosis of diabetes, and classification of diabetes. One section covers some of the issues to consider when initiating a therapeutic regimen for this patient population, including illness severity and stage, anticipated adherence, developmental stage, and family socioeconomic status and level of support. Lifestyle changes that involve the entire family, including detailed attention to diet and exercise, constitute the foundation of an effective treatment plan. The authors also discuss drug therapy, including the use of insulin. Health care providers are encouraged to match a younger patient's level of commitment with an appropriately designed therapy, considering any possibilities to increase the likelihood of adherence and compliance to therapy. 2 figures. 27 references.

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Effect of Oestrogen Plus Progestin on the Incidence of Diabetes in Postmenopausal Women: Results from the Women's Health Initiative Hormone Trial. Diabetologia. 47(7): 1175- 1187. July 2004.

This article reports on a randomized, double-blind trial that compared the effect of daily 0.625 milligrams of conjugated equine estrogen plus 2.5 milligram of medroxyprogesterone actate (progestin) with that of a placebo during 5.6 years of follow up in 15,641 postmenopausal women enrolled in the Women's Health Initiative Hormone Trial. The women were aged 50 to 79 and all had an intact uterus. Diabetes incidence was determined by self-report of treatment with insulin or oral hypoglycemic medications. The results showed a cumulative incidence of treated diabetes of 3.5 percent in the hormone therapy group and 4.2 percent in the placebo group. There was little change in the hazard ratio after adjustment for changes in body mass index (BMI) and waist circumference. During the first year of follow up, changes in fasting glucose and insulin indicated a significant fall in insulin resistance in actively treated women compared to the control subjects. The authors conclude that combined estrogen and progestin therapy reduces the incidence of diabetes, possibly mediated by a decrease in insulin resistance unrelated to body size. 2 figures. 5 tables. 61 references.

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Impact of a Decade of Changing Treatment on Rates of Severe Hypoglycemia in a Population-Based Cohort of Children with Type 1 Diabetes. Diabetes Care. 27(10): 2293-2298. October 2004.

This article reports on a study undertaken to determine the impact of changes to treatment on the incidence of severe hypoglycemia (low blood glucose) and its risk factors in a large population-based cohort of children with Type 1 diabetes (n = 1,335, mean age at entry was 9.5 years). The mean follow-up period was 4.7 years (plus or minus 3.1 years), yielding 6,928 patient-years of data. Patients were reviewed every 3 months for a period between 1992 and 2002; prospected assessment of severe hypoglycemia (an event leading to loss of consciousness or seizure) and associated clinical factors and outcomes was made. A total of 944 severe events were recorded. The incidence of severe hypoglycemia increased significantly by 29 percent per year for the first 5 years but appeared to plateau over the last 5 years. The overall average HbA1c (glycosylated hemoglobin, a measure of blood glucose over time) significantly decreased (by 0.2 percent per year) over the entire follow-up period. An increased risk of severe hypoglycemia was associated with lower HbA1c, younger age, higher insulin dose, male sex, and lower parental socioeconomic status. Of insulin therapies, only pump treatment was associated with reduced rates of severe hypoglycemia. The authors conclude that severe hypoglycemia remains a major problem for children and adolescents with Type 1 diabetes. 2 figures. 3 tables. 25 references.

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Insulin Glulisine Provides Improved Glycemic Control in Patients With Type 2 Diabetes. Diabetes Care. 27(10): 2363-2368. October 2004.

Insulin glulisine is a new analog of human insulin designed for use as a rapid-acting insulin. This article reports on a study that compared the safety and effectiveness of glulisine with regular human insulin (RHI) in combination with NPH insulin. The authors studied 876 relatively well-controlled patients with type 2 diabetes (mean HbA1c levels 7.55 percent). Patients were treated with glulisine and NPH (n = 435) or RHI and NPH (n = 441) for up to 26 weeks in this randomized, multicenter, open label, parallel group study. Subjects continued to use the same dose of prestudy regimens of oral antidiabetes agents, unless hypoglycemia necessitated a dose change. Results showed a slightly greater reduction from baseline to end point HbA1c in the glulisine group versus RHI. Also at end point, lower postbreakfast and postdinner blood glucose levels were noted. Symptomatic hypoglycemia and weight gain were comparable between the two treatment groups. The authors conclude that twice-daily glulisine associated with NPH can provide small improvements in glycemic control compared with RHI in patients with type 2 diabetes who are already relatively well controlled on insulin alone or insulin plus oral antidiabetes drugs. 2 figures. 1 table. 14 references.

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Insulin Therapy. In: Harmel, A.P. and Mathur, R. Davidson's Diabetes Mellitus: Diagnosis and Treatment. 5th ed. Orlando, FL: W.B. Saunders Company. 2004. p. 109-145.

More types of insulin are becoming available, ranging from the traditional insulins to insulin analogues. This diversity of choice, in terms of onset and duration of action, allows use of exogenous insulin to mimic normal physiology more closely, thereby allowing for improvements in glycemic control with less hypoglycemia. This chapter on insulin therapy is from a textbook that provides readers with current information on the diagnosis and treatment of patients with diabetes, including the latest advances, medications, and research studies. The beginning of the chapter focuses on choosing the concentrations and types of insulin to use. Other characteristics of insulin preparations, such as species source and purity, are discussed later in conjunction with a description of the immunologic responses to insulin therapy. Other topics covered include insulin allergy, insulin resistance, and insulin-induced lipoatrophy. One section also considers initiation of insulin therapy in hospitalized patients. The chapter includes illustrative case reports. 10 figures. 11 tables. 109 references.

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Quick Guide to Medications. Chicago, IL: American Association of Diabetes Educators. 2004. 19 p.

Approximately 90 percent of people with diabetes require oral glucose-lowering medications, insulin injections, or both, to reach blood glucose goals. This lengthy brochure is designed to provide in quick reference format an overview of the oral medications used to manage diabetes mellitus. In addition to oral medications and insulin, the drug therapies for a person with diabetes often include other medications to treat the associated conditions or complications of diabetes. The drugs are considered in separate categories: oral glucose-lowering agents, insulins available in the United States, major classes of agents used to treat high blood pressure, and lipid-lowering therapies. Other charts cover a comparison of human insulins and analogs, guidelines for mixing insulin or prefilling syringes, the use of glucagons injection for severe hypoglycemia, drug-food interactions of diabetes medications, adverse effects of drugs on body systems, drug-disease and drug-drug interactions, and drug therapies for the treatment of dyslipidemia in people with diabetes. The brochure emphasizes that health care professionals must be knowledgeable of the total range of therapies that are available for comprehensive diabetes care, not just the therapies that are used for glycemic control. 2 figures. 6 tables. 1 reference.

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Working Together to Manage Diabetes: Diabetes Medications Supplement. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2004. 10 p.

This booklet consists primarily of charts listing diabetes medications (oral agents used to treat type 2 diabetes), information about different types of insulin, storage guidelines for different types of insulin, measures to control glycemia, medications used to treat high blood cholesterol, and medications to lower high blood pressure. The chart for diabetes medications has eight sections: the name of the agent, the class it belongs in, its primary action, typical dosage, side effects, precautions, critical tests (tests used to monitor any drug side effects), and comments. The chart for medications used to lower hypertension has seven sections: the category of drug, brand names in that category, corresponding generic names, the manufacturer, minimum daily dose, maximum daily dose, and special considerations. There is very little text in the booklet, just a final note that offers three websites for readers seeking additional information about high blood pressure. 7 tables.

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Guide to Combination Therapy in Type 2 Diabetes. Patient Care. 37(4): 16-18, 20, 23-24. April 2003.

Effective glycemic (blood glucose) control can be achieved in patients with type 2 diabetes with combination therapy. This article is a guide to the use of oral agents and oral-insulin combinations for patients with type 2 diabetes. The author stresses that appropriate treatment depends on employing insulin sensitizers and secretagogues in combination with each other and with insulin. The author notes that monotherapy (a single drug) rarely achieves glycemic control in this population. Readers are advised to tailor therapy to each individual patient, choosing specific agents based on the side effect profile and the benefits on the insulin-resistance syndrome. Agents that are effective in reducing fasting hyperglycemia (high blood glucose) include long-acting and intermediate insulins and their analogs, sulfonylureas, biguanides (metformin) and the thiazolidinediones (pioglitazone and rosiglitazone). The thiazolidinediones may play an important role in delaying and even preventing the development of type 2 diabetes. Agents that are effective in reducing postprandial (after a meal) hyperglycemia include the short-acting insulins and their analogs, meglitinides (repaglinide), D-phenylalanine derivatives (nateglinide), alpha glucosidase inhibitors (acarbose and miglitol) and to some extent the thiazolidinediones and biguanides. 1 figure. 3 tables. 21 references.

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Insulin Regimens for Type I Diabetes. In: Sperling, M.A. Type I Diabetes: Etiology and Treatment. Totowa, NJ: Humana Press Inc. 2003. p. 199-213.

The increasing incidence of diabetes worldwide has prompted a rapid growth in the pace of scientific discovery and clinical understanding of this disease. This chapter on insulin regimens for type 1 diabetes is from a book in which well-recognized physicians and researchers review the latest thinking about the causes of type 1 diabetes and the best approaches to treating both its acute and chronic complications. The authors of this chapter review the principles of insulin treatment, types of injectable insulins, insulin regimens, practical aspects of insulin administration, monitoring glucose control, and adjusting insulin treatment during illness or surgery. The authors stress that in order to minimize the complications associated with type 1 diabetes, insulin treatment regimens must mimic the complex secretion of insulin by the beta cells of the healthy pancreas. This task remains a challenging goal. 3 figures. 2 tables. 51 references.

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Insulin Resistance and Pre-Diabetes. Bethesda, MD: National Diabetes Information Clearinghouse (NDIC). 2003. 8 p.

Insulin resistance is a silent condition that increases the changes of developing diabetes and heart disease. This fact sheet describes insulin resistance and pre-diabetes and how readers can make lifestyle changes to help prevent diabetes and other health problems. Topics include the role of insulin; the interplay between insulin resistance, prediabetes and type 2 diabetes; the causes of insulin resistance; symptoms; metabolic syndrome; diagnostic tests used to confirm the presence of diabetes and prediabetes, including fasting blood glucose tests, glucose tolerance test, and insulin measure; strategies to reverse insulin resistance, including physical activity, appropriate weight loss, control of blood pressure, control of cholesterol levels, and stopping smoking; and the drugs that are used to improve response to insulin. One additional section briefly reports on future research projects in this area. The fact sheet concludes with a brief description of the goals and activities of the National Diabetes Information Clearinghouse (NDIC).

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Insulins. In: Patel, A. Diabetes in Focus. 2nd ed. Lewisville, TX: Pharmaceutical Press. 2003. p. 79-102.

Diabetes mellitus is a common chronic disorder and represents a serious health care challenge. The prevalence of diabetes is increasing worldwide and considerable progress has been made in the understanding of diabetes management. This chapter on insulins is from a textbook that details the practical pharmaceutical care that pharmacists can provide for people with diabetes. In this chapter, the author describes how exogenous insulin is given as replacement therapy to compensate for the lack of endogenous insulin in type 1 diabetes and the relative lack of endogenous insulin (due to insulin resistance or a defect in the insulin release mechanism) in type 2 diabetes. Topics include the mechanism of action, the insulin molecule, insulin secretion, insulin receptors, glucose uptake, pharmacokinetics, administration and dosage, adverse effects (hypoglycemia, lipodystrophy, cardiovascular effects, weight gain), and drug interactions. A final section discusses the different types of insulin preparations, insulin formulations, and insulin analogues. 4 figures. 1 table. 21 references.

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Meglitinides. In: Patel, A. Diabetes in Focus. 2nd ed. Lewisville, TX: Pharmaceutical Press. 2003. p. 127-131.

Diabetes mellitus is a common chronic disorder and represents a serious health care challenge. The prevalence of diabetes is increasing worldwide and considerable progress has been made in the understanding of diabetes management. This chapter on drug therapy with meglitinides (a new chemical class of insulin secretagogue drugs) is from a textbook that details the practical pharmaceutical care that pharmacists can provide for people with diabetes. In this chapter, the author reviews the use of two meglitinide analogues, nateglinide and repaglinide, currently licensed in the United Kingdom for use in the management of type 2 diabetes. Nateglinide is licensed for use only in combination with metformin, whereas repaglinide may be used either as monotherapy or in combination with metformin. Topics include mechanism of action, pharmacokinetics, dosage, adverse effects (hypoglycemia, weight gain), drug interactions, and preparations. 1 figure. 4 references.

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Pharmacologic Therapies for Glucose Management. In: Franz, M.J., et al., eds. Core Curriculum for Diabetes Education. 5th ed. (Volume 2) Diabetes Management Therapies. Chicago, IL: American Association of Diabetes Educators (AADE). 2003. p. 93-154.

For the majority of people with diabetes, their treatment includes pharmacologic (drug) intervention. In addition to oral medications or insulin, the pharmacologic therapies for a person with diabetes often include other agents to treat the myriad of associated comorbid conditions or complications of diabetes. This chapter on pharmacologic therapies for glucose management for diabetes is from a handbook of the CORE Curriculum, a publication that helps educators prepare for the Certified Diabetes Educators (CDE) exam, serves as a key reference for the Advanced Diabetes Management credential exam, and provides an authoritative source of information for diabetes education, training, and management. This chapter covers the physiologic effects of insulin; the different types of insulin preparations based upon species, source, type, purity, and concentration; proper administration and storage of insulin; the limitations of insulin mixing; the similarities and differences of potential insulin therapy regimens, including the use of insulin pumps, and indications for specific insulin products; commonly encountered insulin regimens in people with type 1 and type 2 diabetes; the differences between use of insulin in a person with type 1 and type 2 diabetes; the mechanisms of action of sulfonylureas, d-phenylalanine derivatives, meglitinides, biguanides, alpha-glucosidase inhibitors, and thiazolidinediones; the clinical use of these drug families; the use of combination therapy in people with type 2 diabetes; the clinical use of glucagon; and potential drug-disease, drug-drug, and drug-food interactions. The chapter includes an introduction, a list of learning objectives, key definitions (glossary), key educational considerations, self review questions, references, and a post-test (including an answer key). 8 figures. 9 tables. 84 references.

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Pharmacotherapeutic Interventions with Antidiabetic Drugs. In: Patel, A. Diabetes in Focus. 2nd ed. Lewisville, TX: Pharmaceutical Press. 2003. p. 69-78.

Diabetes mellitus is a common chronic disorder and represents a serious health care challenge. The prevalence of diabetes is increasing worldwide and considerable progress has been made in the understanding of diabetes management. This chapter on drug therapy with antidiabetes drugs is from a textbook that details the practical pharmaceutical care that pharmacists can provide for people with diabetes. In this chapter, the author reviews the six classes of drugs with different mechanisms of action that are currently available in the United Kingdom (UK) for the management of hyperglycemia (high blood glucose levels) in people with diabetes. Topics include sulfonylureas and meglitinides, biguanides, thiazolidinediones, alpha-glucosidase inhibitors, and exogenous insulin. A final section considers combination therapy in type 2 diabetes. 2 figures. 13 references.

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Sulfhonylureas. In: Patel, A. Diabetes in Focus. 2nd ed. Lewisville, TX: Pharmaceutical Press. 2003. p. 103-112.

Diabetes mellitus is a common chronic disorder and represents a serious health care challenge. The prevalence of diabetes is increasing worldwide and considerable progress has been made in the understanding of diabetes management. This chapter on drug therapy with sulfonylureas is from a textbook that details the practical pharmaceutical care that pharmacists can provide for people with diabetes. In this chapter, the author reviews the use of sulfonylureas for the management of type 2 diabetes when dietary management alone has failed. Sulfonylureas may be used as monotherapy or in combination with metformin or insulin. Topics include mechanism of action, pharmacokinetics, dosage, adverse effects (hypoglycemia, cardiovascular effects, weight gain), drug interactions, and preparations. 1 figure. 1 table. 12 references.

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Type 2 Diabetes in Youth. In: Franz, M.J., et al., eds. Core Curriculum for Diabetes Education. 5th ed. (Volume 4) Diabetes in the Life Cycle and Program Management. Chicago, IL: American Association of Diabetes Educator (AADE). 2003. p. 63-96.

Type 2 diabetes is increasingly prevalent in children and adolescents. This chapter on type 2 diabetes in youth is from a handbook of the CORE Curriculum, a publication that helps educators prepare for the Certified Diabetes Educators (CDE) exam, serves as a key reference for the Advanced Diabetes Management credential exam, and provides an authoritative source of information for diabetes education, training, and management. This chapter covers the diagnostic criteria for type 2 diabetes in children and adolescents; the screening criteria for this population; the unique characteristics of type 2 diabetes in children and adolescents; insulin resistance and associated clinical findings; the goals of self management training for youth with type 2 diabetes; nutrition therapy and physical activity plans for this population; drug therapy and monitoring recommendations; the psychosocial issues associated with type 2 diabetes in children and adolescents; and the role of the family and caregivers in the treatment of type 2 diabetes in these children and adolescents. The chapter includes an introduction, a list of learning objectives, key definitions (glossary), key educational considerations, self review questions, references, and a post-test (including an answer key). 9 figures. 3 tables. 28 references.

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Art and Science of Insulin-Pump Therapy. In: Leahy, J.L. and Cefalu, W.T., eds. Insulin Therapy. Monticello, NY: Marcel Dekker, Inc. 2002. p. 223-244.

This chapter on insulin pump therapy is from a reference book that explores the pharmacokinetics of insulin and insulin programs. The book focuses on the latest blood glucose self-monitoring equipment and assessment strategies that can achieve optimal glycemic control and thus reduce the occurrence of complications including retinopathy (eye disease), neuropathy (nerve disease), nephropathy (kidney disease) and cardiovascular disease. In this chapter, the author notes that insulin pumps provide the best method of achieving normal blood sugars, based on multiple studies documenting improved control across all population groups, ages, genders, and socioeconomic backgrounds. The author discusses the research studies, the use of insulin pump therapy in adult patients with type 1 diabetes mellitus, insulin pump therapy in pediatric patients, implementing pump therapy, insulin pump therapy in type 2 diabetes, insulin pump therapy during pregnancy, and special considerations, including hypoglycemic unawareness and the problem of renal disease and neuropathies (nerve diseases) such as gastroparesis. 3 figures. 3 tables. 63 references.

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Combination of Insulin and Metformin in the Treatment of Type 2 Diabetes. Diabetes Care. 25(12): 2133-2140. December 2002.

This article reports on a study that investigated the metabolic effects of metformin, as compared with placebo, in patients with type 2 diabetes intensively treated with insulin. A total of 390 patients whose type 2 diabetes was controlled with insulin therapy completed a randomized controlled double blind trial with a planned interim analysis after 16 weeks of treatment. Of the 390 subjects, 37 dropped out (12 in the placebo and 25 in the metformin group). Of those who completed 16 weeks of treatment, metformin use, as compared with placebo, was associated with improved glycemic control, reduced insulin requirements, reduced weight gain, and decreased plasma LDL cholesterol. Risk of hypoglycemia was similar in both groups. The authors conclude that in patients with type 2 diabetes who are intensively treated with insulin, the combination of insulin and metformin results in superior glycemic control compared with insulin therapy alone, while insulin requirements and weight gain are less. 3 figures. 2 tables. 36 references.

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Comparison of Insulin Monotherapy and Combination Therapy with Insulin and Metformin or Insulin and Troglitazone in Type 2 Diabetes. Diabetes Care. 25(10): 1691-1698. October 2002.

This article reports on a study undertaken to evaluate the safety and effectiveness of treatment with insulin alone, insulin plus metformin, or insulin plus troglitazone in individuals with type 2 diabetes. A total of 88 patients with type 2 diabetes using insulin monotherapy were randomly assigned to insulin alone (n = 31), insulin plus metformin (n = 27) or insulin plus troglitazone (n = 30) for 4 months. The insulin dose was increased only in the insulin alone group. Metformin was titrated to a maximum dose of 2,000 milligrams and troglitazone to 600 milligrams. HbA1c (glycosylated hemoglobin, a measure of blood glucose over time) levels decreased in all groups; the lower level occurred in the insulin plus troglitazone group. Body weight increased by 0.5 kilograms in the insulin plus metformin group, whereas the other two groups gained 4.4 kilograms. Triglyceride and VLDL triglyceride levels significantly improved only in the insulin plus troglitazone group. Subjects taking metformin experienced significantly more gastrointestinal side effects and less hypoglycemia. The authors conclude that aggressive insulin therapy significantly improved glycemic control in type 2 diabetes subjects to levels comparable with those achieved by adding metformin to the insulin therapy. Troglitazone was the most effective in lowering HbA1c, total daily insulin dose, and triglyceride levels. However, treatment with insulin plus metformin was advantageous in avoiding weight gain and hypoglycemia. 1 figure. 2 tables. 49 references.

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Diabetes: A Growing Public Health Concern: Either You Have It or You Don't. FDA Consumer. 36(1): 26-33. January-February 2002.

This article reminds readers that diabetes is a definite diagnosis; there is no such thing as 'a little diabetes.' The author stresses that an accurate diagnosis is essential, because while a person can live a long and healthy life with diabetes, ignoring it or not taking it seriously can be deadly. Much of the treatment depends largely on self care practices. Monitoring blood sugar (glucose) levels is a key component in the treatment and management of the disease. People who keep their blood glucose levels within individual target ranges set by their doctors stand a good change of reducing the risk of complications from diabetes. In many cases, intensive lifestyle changes in diet and exercise can actually prevent, reduce or delay the risk of developing one type of the disease. The author reviews diabetes and the metabolism of insulin production and physiology, lists the characteristics of type 1 diabetes, describes type 2 diabetes and gestational diabetes, summarizes the treatment goals for controlling diabetes, discusses insulin therapy and oral medications, and explains the use of organ transplants (pancreas and kidney). The article concludes with the contact information for four resource organizations, including their web sites. One sidebar summarizes recent advances in diabetes monitoring and treatment devices; two charts summarize insulin and oral drugs available. 5 figures. 2 tables.

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Evolution of Diabetes Knowledge in Relation to the Theory of Scientific Revolutions. Diabetes Educator. 28(5): 688, 691-694,696. September-October 2002.

Thomas Kuhn describes the advancement of scientific knowledge as going through periods of stability, which he calls normal science, punctuated by rare periods of revolution in which new, incompatible knowledge is discovered. This article examines the evolution of knowledge of diabetes mellitus in relationship to Kuhn's theory of scientific revolutions. Topics include the early history of diabetes, the pancreas as the origin of diabetes, extracting insulin for the treatment of diabetes, the progression of the development of insulin, control of blood glucose, oral drug therapy, defining type 1 diabetes, and defining type 2 diabetes. The author concludes that indeed the evolution of diabetes knowledge in relationship to the theory of scientific revolutions has revealed that much of the progress in the quest for understanding diabetes has evolved in the fashion described by Kuhn. Major advances in knowledge of diabetes and its treatment have emerged serendipitously through tradition-bound research. 20 references.

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Hormone Replacement Therapy, Insulin Sensitivity, and Abdominal Obesity in Postmenopausal Women. Diabetes Care. 25(1): 127-133. January 2002.

This article reports on a study undertaken to determine whether insulin sensitivity differs between postmenopausal women taking estradiol, women on estrogen plus progesterone hormone replacement therapy (HRT), and women not on HRT and whether differences are explained by the differences in total or abdominal adiposity and fat deposition in the muscle. The authors studied 28 obese, sedentary postmenopausal Caucasian women. Women taking oral estrogen (n = 6) were matched for age, weight, and body mass index (BMI) with women not on HRT (n = 6). Eight women taking oral estrogen plus progesterone were matched with eight different women not on HRT for age, weight, and BMI. Maximal aerobic capacity, percentage of fat, total body fat mass, and fat-free mass (FFM) were similar between groups. Visceral fat, subcutaneous abdominal fat, sagittal diameter, and mid thigh low density lean tissue (intramuscular fat) did not differ by hormone status. Basal carbohydrate and fat utilization was not different among groups. Fasting plasma glucose and insulin did not differ by hormone use. Glucose utilization (M) was measured; postmenopausal women taking oral estrogen had a 31 percent lower M than women not on HRT. M was 26 percent lower in women taking estrogen plus progesterone than women not on HRT. M per I, the amount of glucose metabolized per unit of plasma insulin (I), an index of insulin sensitivity, was 36 percent lower in women taking estrogen compared with matched women not on HRT and 28 percent lower in women taking estrogen plus progesterone compared with matched women not on HRT. The authors conclude that postmenopausal women taking oral estrogen or those taking a combination of estrogen and HRT are more insulin-resistant than women not on HRT, even when women are of comparable total and abdominal adiposity. 1 figure. 3 tables. 49 references.

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Implications of the United Kingdom Prospective Diabetes Study. Diabetes Care. 25(Supplement 1): S28-S32. January 2002.

This article presents the American Diabetes Association position statement on the implications of the United Kingdom Prospective Diabetes Study (UKPDS). This study recruited 5,102 patients with newly diagnosed type 2 diabetes in 23 centers within the United Kingdom, between 1977 and 1991. Patients were followed for an average of 10 years to determine whether intensive use of pharmacological (drug) therapy to lower blood glucose levels would result in clinical benefits (e.g., reduced cardiovascular and microvascular complications) and whether the use of various sulfonylurea drugs, the biguanide drug metformin, or insulin have specific therapeutic advantages or disadvantages. This article summarizes the main results and conclusions of the UKPDS. The results have provided strong support for the American Diabetes Association's position that vigorous treatment of diabetes can decrease the morbidity (related illness) and mortality (death) of the disease by decreasing its chronic complications. The results show that lowering blood glucose reduces the incidence of microvascular complications in type 2 diabetes as it does in type 1 diabetes. In addition, lowering blood pressure reduces the incidence of cardiovascular complications as it does in nondiabetic individuals, and also leads to further reduction in the severity of microvascular complications. 10 references.

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Insulin Management of Hospitalized Diabetic Patients. In: Leahy, J.L. and Cefalu, W.T., eds. Insulin Therapy. Monticello, NY: Marcel Dekker, Inc. 2002. p. 153-172.

Adults with diabetes mellitus are admitted to the hospital more frequently than adults who don't have diabetes, often for prolonged periods. Particularly common are admissions for hyperglycemic emergencies, local or systemic infections, unstable angina or myocardial infarction (heart attack), stroke, and orthopedic injuries. This chapter on insulin management of hospitalized diabetes patients is from a reference book that explores the pharmacokinetics of insulin and insulin programs. The book focuses on the latest blood glucose self-monitoring equipment and assessment strategies that can achieve optimal glycemic control and thus reduce the occurrence of complications including retinopathy (eye disease), neuropathy (nerve disease), nephropathy (kidney disease) and cardiovascular disease. In this chapter, the authors discuss the importance of identifying patients with diabetes, classification (type of diabetes), nutritional status and required caloric support for the patient, inpatient blood glucose monitoring, glycemic goals, the use of sliding scales, insulin algorithms, inpatient insulin programs, the use of intravenous insulin infusions, caring for patients receiving enteral nutrition, caring for patients receiving parenteral nutrition, and preoperative care. The authors conclude by reiterating that optimal care of hospitalized patients with diabetes cannot, and should not, ignore control of their glycemia. 4 tables. 22 references.

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Insulin Therapy and Hypoglycemia. In: Leahy, J.L. and Cefalu, W.T., eds. Insulin Therapy. Monticello, NY: Marcel Dekker, Inc. 2002. p. 193-222.

Those wishing to decrease the risk of microvascular complications of diabetes through tight glycemic (blood glucose) control inevitably face an increased risk of hypoglycemia (low blood glucose levels), often without warning symptoms and potentially with severe consequences. This chapter on insulin therapy and hypoglycemia is from a reference book that explores the pharmacokinetics of insulin and insulin programs. The book focuses on the latest blood glucose self-monitoring equipment and assessment strategies that can achieve optimal glycemic control and thus reduce the occurrence of complications including retinopathy (eye disease), neuropathy (nerve disease), nephropathy (kidney disease) and cardiovascular disease. In this chapter, the author discusses the importance of hypoglycemia in type 1 diabetes mellitus, the Diabetes Control and Complications Trial (DCCT), recognizing hypoglycemia and hypoglycemia unawareness, brain vulnerability to hypoglycemia, hypoglycemia and sudden death, hypoglycemia in type 2 diabetes mellitus, hypoglycemia and the elderly, reversible hypoglycemia disorders, managing patients with hypoglycemia on insulin therapy, treatment of hypoglycemia, monitoring diabetes to adjust insulin therapy, and insulin therapy regimens and hypoglycemia. The author concludes that modern insulin therapy is tailored toward avoidance of hypoglycemia. Insulin-therapy strategies are recommended that mimic physiological insulin secretion using a basal-bolus approach. This is accomplished partly through use of insulin preparations that more accurately mimic the way beta cells secrete insulin. 7 figures. 11 tables. 67 references.

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Insulin Therapy in Children. In: Leahy, J.L. and Cefalu, W.T., eds. Insulin Therapy. Monticello, NY: Marcel Dekker, Inc. 2002. p. 127-138.

This chapter on insulin therapy in children is from a reference book that explores the pharmacokinetics of insulin and insulin programs. The book focuses on the latest blood glucose self-monitoring equipment and assessment strategies that can achieve optimal glycemic control and thus reduce the occurrence of complications including retinopathy (eye disease), neuropathy (nerve disease), nephropathy (kidney disease) and cardiovascular disease. In this chapter, the authors note that the combination of severe insulin deficiency and the physical and psychoemotional changes that accompany normal growth and development make day-to-day management of pediatric patients especially difficult. The authors discuss the goals of treatment, insulin regimens, new insulin preparations, adjusting insulin doses, matching insulin to food intake, exercise, outpatient care, hypoglycemia, and sick day rules. One case study is included. 18 references.

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Insulin Therapy in Pregnancy. In: Leahy, J.L. and Cefalu, W.T., eds. Insulin Therapy. Monticello, NY: Marcel Dekker, Inc. 2002. p. 139-151.

This chapter on insulin therapy in pregnancy is from a reference book that explores the pharmacokinetics of insulin and insulin programs. The book focuses on the latest blood glucose self-monitoring equipment and assessment strategies that can achieve optimal glycemic control and thus reduce the occurrence of complications including retinopathy (eye disease), neuropathy (nerve disease), nephropathy (kidney disease) and cardiovascular disease. In this chapter, the author presents a review intended to help clinicians understand the increasing insulin requirements of pregnancy and to design treatment protocols to achieve and maintain normoglycemia throughout pregnancy. Topics include glucose toxicity and the role of postprandial hyperglycemia, how diabetogenic forces of normal pregnancy increase the insulin requirements, the rationale for the use of human insulin during pregnancy, insulin requirements, dietary prescription, blood glucose monitoring, glycosylated hemoglobin determinations, insulin and glucose treatment during labor, postpartum, and neonatal care. 5 tables. 20 references.

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Insulin Therapy in Type 2 Diabetes Mellitus. In: Leahy, J.L. and Cefalu, W.T., eds. Insulin Therapy. Monticello, NY: Marcel Dekker, Inc. 2002. p. 113-125.

This chapter on insulin therapy in type 2 diabetes is from a reference book that explores the pharmacokinetics of insulin and insulin programs. The book focuses on the latest blood glucose self-monitoring equipment and assessment strategies that can achieve optimal glycemic control and thus reduce the occurrence of complications including retinopathy (eye disease), neuropathy (nerve disease), nephropathy (kidney disease) and cardiovascular disease. In this chapter, the authors discuss indications for insulin therapy in type 2 diabetes, patients' and physicians' concerns about insulin therapy in type 2 diabetes, the benefits of insulin therapy, combination therapy with oral agents and insulin, intensified insulin regimens, and the role of insulin in type 2 diabetes treatment progression. The authors conclude that the combination of insulin with oral agents will remain an important first step in this form of diabetes, but many patients will progress to basal-prandial insulin regimens similar to those used in type 1 diabetes. 4 tables. 23 references.

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Insulin Therapy. In: Edelman, S.V. and Henry, R.R. Diagnosis and Management of Type 2 Diabetes. Caddo, OK: Professional Communications, Inc. 2002. p. 121-148.

This chapter on the use of insulin therapy is from a handbook for primary care providers that offers a concise overview of the diagnosis and management of type 2 diabetes. Insulin therapy most commonly is reserved for patients who have failed an adequate trial of diet, exercise, and oral antidiabetes agents. However, institution of insulin therapy is commonly delayed inappropriately in patients failing oral antidiabetes agents. The authors encourage early use of insulin soon after it is evident that oral antidiabetes agents are failing. The authors focus on the different insulin regimens commonly used to normalize glucose levels and glycosylated hemoglobin (HbA1c, a measure of blood glucose levels over time) in patients with type 2 diabetes mellitus. Topics include selecting an insulin preparation, the application of intensive insulin therapy, combination therapy, multiple injection regimens, insulin pump therapy, alternative insulin delivery systems, complications of insulin therapy, and the use of islet cell transplantation. 2 figures. 5 tables. 5 references.

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Insulin Therapy. Monticello, NY: Marcel Dekker, Inc. 2002. 272 p.

Evaluating strategies for the management of type 1 and type 2 diabetes, this reference book explores the pharmacokinetics of insulin and insulin programs. The book focuses on the latest blood glucose self-monitoring equipment and assessment strategies that can achieve optimal glycemic control and thus reduce the occurrence of complications including retinopathy (eye disease), neuropathy (nerve disease), nephropathy (kidney disease) and cardiovascular disease. The book offers fifteen chapters in three sections: background, patient populations, and prevention and therapy. Topics include the rationale for and strategies to achieve glycemic control; goals of treatment; insulin syringes, pens, and glucose-monitoring equipment and techniques; nutrition assessment and therapy; the physiology of glucose homeostasis and insulin secretion; insulin pharmacokinetics; intensive insulin therapy in type 1 diabetes mellitus; insulin therapy in type 2 diabetes mellitus; insulin therapy in children; insulin therapy in pregnancy; insulin management of hospitalized diabetic patients; hyperglycemic emergencies, including diabetic ketoacidosis and nonketotic hyperosmolar syndrome; insulin therapy and hypoglycemia; the art and science of insulin pump therapy; and noninvasive insulin-delivery systems. Each chapter includes references and the text concludes with a subject index.

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Intensive Insulin Therapy in Type 1 Diabetes Mellitus. In: Leahy, J.L. and Cefalu, W.T., eds. Insulin Therapy. Monticello, NY: Marcel Dekker, Inc. 2002. p. 87-112.

This chapter on intensive insulin therapy in type 1 diabetes is from a reference book that explores the pharmacokinetics of insulin and insulin programs. The book focuses on the latest blood glucose self-monitoring equipment and assessment strategies that can achieve optimal glycemic control and thus reduce the occurrence of complications including retinopathy (eye disease), neuropathy (nerve disease), nephropathy (kidney disease) and cardiovascular disease. In this chapter, the author demystifies insulin therapy in type 1 diabetes by providing a conceptual framework for what to do and how to do it. The author cautions that this is not always an easy task. Often the entire patient care team (physician, registered dietitian, diabetes educator) is necessary to analyze diet and lifestyle practices and look for clues to day-to-day variations in glycemia. The author stresses that insulin programs should be used that are based on the unique diet, exercise, and work habits of each patient. Patients may go through a difficult time for awhile, trying to cope with all the things asked of them with an intensive treatment program. However, over the long term, they will have a better understanding of their diabetes and how to manage it, and a greater chance for a life unencumbered by hypoglycemia and end-organ complications. 3 figures. 5 tables. 28 references.

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Non-alcoholic Fatty Liver Disease. Journal of Gastroenterology and Hepatology. 17 (Supplement): S186-S190. February 2002.

This review article considers nonalcoholic fatty liver disease (NAFLD), a chronic liver disease that affects a high proportion of the world's population. Insulin resistance and oxidative stress play a critical role in the pathogenesis (development) of NAFLD. Clinical, biochemical and imaging studies are of value in the diagnostic evaluation of patients with NAFLD, but liver biopsy remains the most sensitive and specific means of providing important diagnostic and prognostic information. Simple steatosis (fatty liver) has the best prognosis within the spectrum of NAFLD, but NAFLD has the potential to progress to steatohepatitis, fibrosis, and even cirrhosis (liver scarring). No effective medical therapy is currently available for all patients with NAFLD. In patients with diabetes mellitus and hyperlipidemia (high levels of blood fats), appropriate metabolic control is always recommended, but rarely effective in resolving the liver disease. Weight reduction, when achieved and sustained, may improve the liver disease, although the results with weight loss have been inconsistent. Drug therapy aimed at the underlying liver disease holds promise. Several medications with different mechanisms of action and potential benefit are currently being evaluated in clinical trials. Liver transplantation is a life-extending treatment choice for patients with end stage NAFLD, but NAFLD may recur after liver transplantation. 43 references.

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Nonalcoholic Fatty Liver Disease. New England Journal of Medicine. 346(16): 1221-1231. April 18, 2002.

Nonalcoholic fatty liver disease (NAFL) is an increasingly recognized condition that may progress to end stage liver disease. This review article considers the epidemiology, clinical manifestations (symptoms), pathogenesis (development), diagnosis, natural history, and management of NAFL. Insulin resistance and oxidative stress have critical roles in the pathogenesis of NAFL. Liver biopsy remains the most sensitive and specific means of providing important prognostic information. Simple steatosis may have the best prognosis within the spectrum of NALF, but it has the potential to progress to Steatohepatitis, fibrosis, and even cirrhosis (scarring of the liver). No effective medical therapy is currently available for all patients with nonalcoholic fatty liver disease. Weight reduction, when achieved and sustained, may improve the liver disease. Drug therapy aimed at the underlying liver disease holds promise, however, questions remain regarding the use of drug therapy and the effect of recommended dietary measures. Liver transplantation is a therapeutic alternative for some patients with decompensated, end stage NALF disease, but NALF may recur or develop after liver transplantation. 5 figures. 3 tables. 95 references.

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Noninvasive Insulin-Delivery Systems: Options and Progress to Date. In: Leahy, J.L. and Cefalu, W.T., eds. Insulin Therapy. Monticello, NY: Marcel Dekker, Inc. 2002. p. 245-260.

This chapter on noninvasive insulin-delivery systems is from a reference book that explores the pharmacokinetics of insulin and insulin programs. The book focuses on the latest blood glucose self-monitoring equipment and assessment strategies that can achieve optimal glycemic control and thus reduce the occurrence of complications including retinopathy (eye disease), neuropathy (nerve disease), nephropathy (kidney disease) and cardiovascular disease. In this chapter, the author brings readers up to date on the noninvasive insulin-delivery systems currently available and those currently under study. The author first reviews the history of insulin development, then details the search for a practical noninvasive insulin-delivery system. Topics include jet injectors, transdermal delivery by iontophoresis, low-frequency ultrasound, transfersomes, intranasal delivery, oral insulin, and pulmonary delivery. The author concludes that although research studies are still active, the evidence to date suggests that pulmonary insulin delivery (inhaled) may offer the potential to improve compliance and thereby help reduce the number of complications associated with diabetes. 2 figures. 2 tables. 57 references.

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Oral Agents. In: Edelman, S.V. and Henry, R.R. Diagnosis and Management of Type 2 Diabetes. Caddo, OK: Professional Communications, Inc. 2002. p. 69-120.

This chapter on the use of oral hypoglycemic agents is from a handbook for primary care providers that offers a concise overview of the diagnosis and management of type 2 diabetes. The majority of patients with type 2 diabetes have less than ideal metabolic control despite the medical community's understanding of the underlying pathophysiologic mechanisms of hyperglycemia (high blood glucose) and the availability of a wide variety of new treatment options. The authors contend that failure to achieve glycemic (blood glucose) goals is related in part to a misconception by patients and caregivers that type 2 diabetes is a mild disease, and not as serious as type 1 diabetes. Drug therapy with oral antidiabetes agents is required when dietary modification and exercise therapy do not result in normalization or near normalization of metabolic abnormalities. Topics include the pathophysiologic basis of pharmacologic therapy, the importance of controlling postprandial (after a meal) hyperglycemia, intensive therapy in type 2 diabetes, diabetes prevention study results, oral antidiabetes agents, thiazolidinediones (including rosiglitazone, pioglitazone), metformin (Glucophage), alpha-glucosidase inhibitors, sulfonylureas, meglitinides, monotherapy with oral antidiabetes agents, combination therapy with oral antidiabetes agents, taking patients with type 2 diabetes off insulin, and drugs under development. 5 figures. 4 tables. 31 references.

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Practical Insulin: A Handbook for Prescribers. Alexandria, VA: American Diabetes Association. 2002. 59 p.

The medical practice of many physicians now includes handling ever-increasing numbers of patients with diabetes. Insulin therapy is a medical necessity for all patients with type 1 diabetes and the many patients with type 2 diabetes who cannot reach their glycemic (levels of blood glucose) without insulin therapy. This handbook offers solutions to the many common challenges involved in prescribing insulin, from choosing insulin regimens, to dealing with patient reluctance to start insulin therapy, to minimize the weight gain that often accompanies improved glycemic control. Specific topics include patient selection, insulin choices, the different types of insulin and their character, mixing insulins, insulin regimens (for type 1 and for type 2 patients), troubleshooting, patient SMBG (self monitoring of blood glucose) records, and patient education. The handbook also includes numerous appendices: endogenous insulin action, insulin storage, insulin potency, additives, insulin delivery, insulin pump, and determining insulin-to-CHO (carbohydrates) ratio. The author notes that there are no standards for how to best use insulin therapy; individual patient strategies must be implemented. 11 figures. 11 tables.

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Repaglinide Versus Metformin in Combination with Bedtime NPH Insulin in Patients with Type 2 Diabetes Established on Insulin/Metformin Combination Therapy. Diabetes Care. 25(10): 1685-1690. October 2002.

This article reports on a study undertaken to compare the effect on glycemic control and weight gain of repaglinide versus metformin combined with bedtime NPH insulin in patients with type 2 diabetes. A total of 80 subjects treated with 850 or 1,000 milligrams metformin (3 times daily) combined with bedtime NPH insulin were randomized to 13 weeks of open label treatment with 4 milligrams repaglinide (3 times daily, n = 39) or metformin (dose unchanged, n = 41). Insulin dose was titrated at the clinician's discretion, aiming for a fasting blood glucose less than 6.0 mmol per liter. Baseline age, diabetes duration, insulin requirement, weight, and glycosylated hemoglobin (HbA1c, a measure of blood glucose over time) were similar. Glycemic control improved (nonsignificantly) with insulin and metformin but deteriorated with insulin and repaglinide. Weight gain was less with insulin and metformin. Diabetes Treatment Satisfaction Questionnaire Score increased with insulin and metformin, but decreased with insulin and repaglinide. The authors conclude that, combined with bedtime NPH insulin, metformin provides superior glycemic control to repaglinide with less weight gain and improved diabetes treatment satisfaction. 3 figures. 1 table. 20 references.

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Treatment Options for Type 2 Diabetes: Finding What's Best for You. Diabetes Self-Management. 19(3): 6, 8-10, 13. May-June 2002.

This article describes the expanding treatment options for people with type 2 diabetes. New medicines, as well as new ways of approaching treatment, can have a dramatic impact on management and the all-important goals of keeping blood glucose levels in control and preventing complications. The author notes that the first line of treatment for type 2 diabetes is still diet and exercise, but experts acknowledge that lifestyle efforts alone are not generally effective for the long term. The author describes oral drugs introduced to boost insulin production (sulfonylureas), alpha-glucosidase inhibitors (to slow processing of carbohydrates in the intestines), drugs to address insulin sensitivity, new drugs currently at the research stages, and newer insulin formulations. The article concludes with a section offering suggestions for readers trying to make good decisions about their own drug therapy as a member of their own health care team. One chart summarizes diabetes pills and insulins, listing generic names, brand names, and the use of each. 1 table.

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Autoimmune Diabetes Not Requiring Insulin at Diagnosis (Latent Autoimmune Diabetes of the Adult): Definition, Characterization, and Potential Prevention. Diabetes Care. 24(8): 1460-1467. August 2001.

This review article provides an overview of latent autoimmune diabetes of the adult (LADA). Type 1 diabetes is caused by the immune mediated destruction of islet insulin secreting beta cells. This chronic destructive process is associated with both cellular and humoral immune changes in the peripheral blood that can be detected months or even years before the onset of clinical diabetes. Throughout this prediabetic period, metabolic changes, including altered glucose tolerance and reduced insulin secretion, deteriorate at variable rates and eventually result in clinical diabetes. A fraction of people with humoral immunological changes have clinical diabetes that initially is not insulin requiring. The onset of diabetes in these patients is usually in adult life, and because their diabetes is at least initially not insulin requiring, they appear clinically to be affected by type 2 diabetes. Such patients probably have the same disease process as patients with type 1 diabetes in that they have similar HLA genetic susceptibility as well as autoantibodies to islet antigens, low insulin secretion, and a higher rate of progression to insulin dependency. These patients are defined as being affected by an autoimmune type of diabetes not requiring insulin at diagnosis. Special attention should be paid to diagnose such patients because therapy may influence the speed of progression toward insulin dependency, and in this respect, efforts should be made to protect residual C peptide secretion. Although people with LADA represent a sizeable number of patients with diabetes, there is no established intervention for them. There are no clinical data so far to indicate that there is one specific treatment that is superior for LADA patients, so LADA is treated like type 2 diabetes using diet and drug therapy. LADA can serve as a model for designing new strategies for prevention of type 1 diabetes but also as a target group for prevention in its own right. 2 figures. 2 tables. 68 references. (AA-M).

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Basal Insulin Therapy in Type 2 Diabetes: 28-Week Comparison of Insulin Glargine (HOE 901) and NPH Insulin. Diabetes Care. 24(4): 631-636. April 2001.

This review article describes a study that determined the safety and efficacy of the long acting analog insulin glargine compared with NPH insulin in patients with type 2 diabetes who were not taking oral agents and who had previously been treated with insulin alone. The study population consisted of 518 people with type 2 diabetes who were receiving NPH insulin with or without regular insulin for postprandial control. Of these, 259 were randomized to receive insulin glargine once daily, and the remaining 259 received NPH insulin once or twice daily for 28 weeks in an open label, multicenter trial. Doses were adjusted to obtain target fasting glucose less than 6.7 mmol per liter. At study endpoint, the median total daily insulin dose in both treatment groups was 0.75 IU per kilogram. The study found that the treatment groups showed similar improvements in glycosylated hemoglobin (HbA1c) from baseline to endpoint on intent to treat analysis. The mean change in HbA1c from baseline to endpoint was similar in the insulin glargine group and the NPH group after patients began with an average baseline HbA1c of approximately 8.5 percent. The treatments were associated with similar reductions in fasting glucose levels. Overall, mild symptomatic hypoglycemia was similar in insulin glargine subjects and NPH insulin subjects. However, nocturnal hypoglycemia in the insulin glargine group was reduced by 25 percent during the treatment period after the dose titration phase. Subjects in the insulin glargine group experienced less weight gain than those in the NPH group. The article concludes that, in patients with type 2 diabetes, once daily bedtime insulin glargine is as effective as once or twice daily NPH in improving and maintaining glycemic control. In addition, insulin glargine demonstrates a lower risk of nocturnal hypoglycemia and less weight gain compared with NPH insulin. 1 appendix. 2 figures. 1 table. 18 references. (AA-M).

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Diabetes and Hypertension. In: Johnstone, M.T. and Veves, A. Diabetes and Cardiovascular Disease. Totowa, NJ: The Humana Press, Inc. 2001. p. 123-129.

With over ten million diagnosed patients and another five million undiagnosed, diabetes mellitus and its complications is a major public health problem that will assume epidemic proportions as the population grows older. This chapter on diabetes and hypertension is from a textbook that offers physicians practical knowledge about cardiovascular disease and diabetes. This chapter is in Part I, which focuses on pathophysiology, including the mechanisms and risk factors for diabetic cardiovascular disease. The author notes that many factors contribute to increased cardiovascular disease (CVD) in persons with diabetes. These factors include hypertension (high blood pressure), dyslipidemia (disordered levels of fats in the blood), platelet hyperactivity, endothelial (the cells lining the body cavity and cardiovascular system) abnormalities, as well as hyperglycemia (high blood glucose), microalbuminuria (protein in the urine), and hyperinsulinemia (high levels of insulin in the blood). The author discusses characteristics of hypertension in people with diabetes and then focuses on treatment goals in this population. The goal of hypertension treatment in persons with diabetes is to prevent hypertension-associated death and disability. The level of blood pressure and the diagnosis of hypertension should be based on multiple blood pressure measurements obtained in a standardized fashion on at least three occasions. Because of the tendency to orthostatic hypotension (abnormally low blood pressure upon standing), standing blood pressures should be measured at each office visit. Pharmacologic (drug) therapy should be initiated when lifestyle modifications do not lower blood pressure to less than 130 over 85 mmHg in people with diabetes. Combination therapy is usually necessary for adequate blood pressure control; therapy should include an ACE inhibitor for maximal benefits in protecting against cardiovascular disease as well as renal (kidney) disease. 1 figure. 1 table. 30 references.

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Diabetes and the Elderly. Clinical Diabetes. 19(4): 176. 2001.

This patient education handout (designed to be photocopied and distributed to patients by their physicians) reviews diabetes and the elderly. In diabetes, the body either does not make enough insulin or does not respond to the insulin it makes in the usual way. Complications of untreated diabetes include blindness, kidney disease, nerve disease, infections, heart disease, and strokes. Most elderly people with diabetes have type 2. Initially, type 2 diabetes may be controlled by changing diet and exercise habits. However, drug therapy, either pills or insulin, may eventually be needed. The handout reviews five different types of medications and their use in elderly patients: alpha glucosidase inhibitors (Precose and Glyset); sulfonylureas (e.g., Glucotrol, Micronase, Glynase, Diabeta); other insulin secretatagogues (Prandin and Starlix); glucophage; and thiazolidinediones (Avandia, Actos).

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Improving Diabetes Care in the Hospital Using Guideline-Directed Orders. Diabetes Spectrum. 14(4): 226-233. October, 2001.

Improving glycemic (levels of blood glucose, or sugar) control for inpatients with diabetes remains a formidable challenge. While the use of inadequate and nonphysiological insulin regimens is widespread, there are many potential barriers to improving physician and nursing hospital practices in this area. This article describes an integrated program that utilizes subcutaneous and intravenous insulin order forms incorporating guidelines that encourage more appropriate insulin therapy in the hospital. This approach has resulted in a significant decrease in one factor associated with suboptimal insulin use for inpatients: reliance of sliding-scale, short-acting insulin alone for blood glucose control. The effectiveness of these orders improved and resistance to change was overcome after ongoing education and protocol revisions based on feedback from physicians, nurses, and pharmacists. 5 figures. 18 references.

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Insulin Analogues. Current Opinion in Endocrinology and Diabetes. 8(2): 95-100. April 2001.

This article presents some of the well documented findings concerning insulin analogues. These agents have been developed to provide more physiologic insulin replacement after subcutaneous injection than human insulin. Lispro insulin, the first rapid-acting insulin, was approved in 1998 for the treatment of diabetes. Numerous clinical trials have demonstrated the efficacy of lispro in reducing postprandial glucose elevations. More recently insulin aspart, a similar analogue, has become available. The two are of significant advantage in many patients with diabetes and produce reductions in postprandial hyperglycemia as well as in hypoglycemia risk. A comparison of available pharmacokinetic data suggests that aspart may have a longer half life than lispro insulin. If true, theoretically, it could prove advantageous in certain clinical scenarios and problematic in others, but it would provide more options in attempting to achieve precise physiologic replacement of insulin. Insulin glargine is a long acting insulin analogue, first marketed in Europe in 2000. It provides a peakless profile of activity with 24 hour action. Glargine reduces nocturnal hypoglycemia with more consistent and greater control of fasting glucose than available intermediate acting insulins. The availability of insulin analogues designed to produce novel patterns of activity provides new options for the treatment of diabetes to normalize glycemia and minimize the risk of hypoglycemia. 1 figure. 17 references. (AA-M).

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Insulin Glargine: The New Kid on the Block. Diabetes Self-Management. 18(5): 12-17. September-October 2001.

Insulin glargine (brand name Lantus) is a newly available long acting insulin preparation that may well turn out to improve diabetes treatment significantly. Insulin glargine enters the bloodstream gradually and predictably and has an activity profile without a peak, which could make it an ideal long acting insulin. This article describes glargine and considers whether its properties actually translate into better blood glucose (sugar) control in the real world setting. The author first reviews the other long acting insulins on the market, including NPH, Lente and Ultralente, and explains why long acting insulins are used. The author then explains that insulin glargine is an insulin analog, an artificially produced form of insulin in which the insulin molecule has been altered to produce a more desirable effect. Once injected into the skin, glargine forms a precipitate, which is absorbed very slowly and evenly into the bloodstream, with little variability and with no peak activity level. The author then summarizes the research on insulin glargine in both type 1 and type 2 diabetes. The author concludes with a brief section designed to help readers determine if insulin glargine may be appropriate in their own situation. Insulin glargine may be appropriate for patients whose blood glucose levels are too high, despite the best efforts to control it with diet, exercise, and oral agents; for patients who are currently using an intermediate acting insulin (such as NPH) once a day and want 24 hour basal coverage; and for patients who would rather take one injection of glargine rather than two injections of NPH. The author calls for additional clinical studies and for caution in changing insulins; patients are encouraged to work closely with their health care provider to monitor their own response to any change in drug regimen.

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Intensive Insulin Therapy in Critically Ill Patients. New England Journal of Medicine. 345(19): 1359-1367. November 8, 2001.

Hyperglycemia (high levels of blood glucose or sugar) and insulin resistance are common in critically ill patients, even if they have not previously had diabetes. Whether the normalization of blood glucose levels with insulin therapy improves the prognosis for such patients is not known. This article reports on a study undertaken to investigate the use of intensive insulin therapy in critically ill patients. The authors studied adult patients admitted to a surgical intensive care unit (ICU) who were receiving mechanical ventilation. On admission, patients were randomly assigned to receive intensive insulin therapy (maintenance of blood glucose at a level between 80 and 110 milligrams per deciliter) or conventional treatment (infusion of insulin only if the blood glucose level exceeded 215 milligrams per deciliter and maintenance of glucose at a level between 180 and 200 milligrams per deciliter). At 12 months, with a total of 1,548 patients enrolled, intensive insulin therapy reduced mortality during intensive care from 8.0 percent with conventional treatment to 4.6 percent. The benefit of intensive insulin therapy was attributable to its effect on mortality (death) among patients who remained in the ICU for more than five days. The greatest reduction in mortality involved deaths due to multiple organ failure with a proven septic (infectious) focus. Intensive insulin therapy also reduced overall in hospital mortality by 34 percent, bloodstream infections by 46 percent, acute renal (kidney) failure requiring dialysis or hemofiltration by 41 percent, the median number of red cell transfusions by 50 percent, and critical illness polyneuropathy by 44 percent. Patients receiving intensive insulin therapy were also less likely to require prolonged mechanical ventilation and intensive care. 2 figures. 4 tables. 47 references.

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Oral Diabetes Medicines. Cleveland, OH: Diabetes Association of Greater Cleveland. 2001. 2 p.

Keeping blood glucose (sugar) levels in the appropriate range is one of the main goals of diabetes management. Everyone with type 2 diabetes should follow a meal plan and exercise program. In addition, if the blood glucose levels are higher than recommended, the physician may add medication to help lower the blood glucose. This fact sheet describes oral diabetes medicines that may be used for this purpose. The fact sheet discusses how the drugs work, why some people need to add insulin to their drug therapy for type 2 diabetes, and things to remember when taking an oral diabetes medication. The reverse side of the fact sheet offers a chart of six categories of oral diabetes medications; for each the chart notes the drug class and brand names, how it works, the advantages, and potential side effects. The fact sheet concludes with the contact information for the Diabetes Association of Greater Cleveland (www.dagc.org). 1 table. 1 reference.

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Pharmacologic Therapies. In: Franz, M.J., et al, eds. Core Curriculum for Diabetes Education. 4th ed.: (Volume 2) Diabetes Management Therapies. Chicago, IL: American Association of Diabetes Educators (AADE). 2001. p. 89-150.

For the majority of people with diabetes, disease management strategies will include pharmacological (drug) intervention. Approximately 90 percent of people with diabetes require oral antidiabetes medications, insulin injections, or both, to reach glucose goals. This chapter on drug therapy is from a book in a series of four texts that make up a Core Curriculum, designed primarily to help educators prepare for the Certified Diabetes Educator (CDE) exam. Topics include the physiologic effects of insulin; different types of insulin preparations; proper administration and storage of insulin; limitations of insulin mixing; the similarities and differences of potential insulin therapy regimens, including the use of insulin pumps, and indications for specific insulin products; the mechanisms of action and clinical use of sulfonylureas, meglitinides, biguanides, alphaglucosidase inhibitors, and thiazolidinediones; the use of combination therapy in patients with type 2 diabetes; the clinical use of glucagon; drug related effects on diabetes; potential drug and food interactions; and suggestions that the diabetes educator may offer to help patients prevent, minimize, or be prepared for a drug-related problem. The chapter lists the learning objectives for that chapter, presents information in outline and bulleted format, summarizes the key educational considerations, offers self review questions and questions for discussion, presents an illustrative case report, and concludes with a list of references. A post-test and the answers to the post-test questions are appended to the chapter. 9 figures. 8 tables. 82 references.

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Pharmacy Update: Clinical Importance of Postprandial Hyperglycemia. Diabetes Educator. 27(5): 624-637. September-October, 2001.

The role of elevated postprandial (after a meal) blood glucose levels in the etiology (cause) of diabetes related complications is of great concern. Interventions to manage both fasting and postprandial glucose levels are needed to reduce diabetes complications. This article helps diabetes educators understand these issues and the pharmaceuticals (drugs) available to help patients control hyperglycemia (high levels of blood glucose). One table summarizes the harmful effects of sustained hyperglycemia. Glycosylated hemoglobin (HbA1c, a measure of average blood glucose levels) measurements can be used to monitor both postprandial hyperglycemia (PPHG) as well as fasting plasma glucose (FPG) levels. Drugs discussed include insulin lispro (Humalog),, insulin aspart (Novolog), acarbose (Precose), miglitol (Glyset), repaglinide (Prandin), natiglinide (Starlix), and tolbutamide (Orinase). The authors stress that the most efficient way to manage PPHG is to prevent it rather than to try to improve glucose disposal. Health care providers now have the medications that, when used in combination with self monitoring (SMBG), diet, and exercise, can near normalize blood glucose values, both fasting and after meals. Treatment programs for all appropriate diabetes patients should be intensified to bring HbA1c levels to less than 7 percent. 2 tables. 26 references.

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Postchallenge Hyperglycemia in a National Sample of U.S. Adults with Type 2 Diabetes. Diabetes Care. 24(10): 1734-1738. October 2001.

Postchallenge hyperglycemia (PCH, high levels of blood glucose, or sugar) is known to contribute to less than optimal glycemic control in adults with non insulin-requiring type 2 diabetes. This article reports on a study undertaken to estimate the prevalence of PCH among individuals with diabetes. The authors conducted a cross sectional analysis of data from the Third National Health and Nutrition Examination Survey (NHANES III, 1988 to 1994) in adults aged 40 to 74 years with diabetes who were not using insulin (i.e., they used oral hypoglycemic drugs or received no drug therapy). Each respondent underwent a standard 75 gram oral glucose tolerance test. PCH was defined as a 2 hour glucose level greater than 200 milligrams per deciliter. Overall, PCD was present in 74 percent of those with diagnosed diabetes. Although it was present in virtually all (99 percent) of the adults with diabetes that was not under optimal control, PCD was also common (39 percent) in those patients whose diabetes was under optimal control. Likewise, in those patients receiving sulfonylurea drugs, PCH was present in 99 percent of those under suboptimal control and in 63 percent of those under good control. Similar patterns were observed in those with undiagnosed diabetes. The authors conclude that their data suggest PCH is common among adults with diabetes in the United States, even in the setting of 'optimal' glycemic control and sulfonylurea use. Interventions designed to lower postprandial (after a meal) glucose excursions may help improve overall glycemic control in the general population of U.S. adults with diabetes. 2 figures. 2 tables. 27 references.

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Preventing Cardiovascular Complications of Type 2 Diabetes: Focus on Lipid Management. Clinical Diabetes. 19(3): 113-120. June 2001.

This review article focuses on the prevention of cardiovascular complications of type 2 diabetes. Diabetes is a well recognized independent risk factor for cardiovascular disease (CVD) in both men and women. Most adults who have diabetes have one or more lipid abnormalities. The presence of increased triglyceride and decreased high density lipoprotein (HDL) levels is the best predictor of CVD in people with type 2 diabetes. A clustering of risk factors, which has been termed the metabolic syndrome, occurs commonly in type 2 diabetes and simultaneously affects the development of CVD and diabetes. The main feature of the metabolic syndrome is insulin resistance. This condition appears to induce other metabolic disturbances included in the metabolic syndrome: atherogenic dyslipidemia, impaired glucose tolerance, and hypertension. Thus, intensive treatment of dyslipidemia, high blood pressure, and hyperglycemia is considered essential in the treatment of diabetes. According to current American Diabetes Association (ADA) recommendations, the major emphasis for treating diabetic dyslipidemia should be placed on lowering low density lipoprotein (LDL) cholesterol levels to less than 100 milligrams (mg) per deciliter (dl). Diet and exercise are the foundation of therapy for all people with dyslipidemia. Pharmacological tools are available to treat all lipid abnormalities in people who are at very high risk for CVD. Drug therapy should follow when a 3 to 6 month trial of lifestyle modifications alone fails to lower LDL cholesterol levels adequately. The ADA recommends initiation of a lipid lowering agent in people who have diabetes but no preexisting CVD if LDL cholesterol level remains at 130 mg per dl or more despite a modified diet and exercise. People who have diabetes and established CVD or a very high LDL cholesterol level at diagnosis should receive pharmacological therapy at the same time as lifestyle modifications. Statins are the drug of first choice for reducing LDL levels. Fibric acids are the drugs of first choice for treating elevated triglyceride levels. Combination therapy with statins and fibric acids may be required if aggressive statin therapy does not achieve lipid and lipoprotein goals. Bile acid binding resins may be used in combination with a fibric acid derivative as a third line choice for high LDL levels. 4 tables. 43 references.

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Recent Developments in the Pharmacological Reduction of Blood Glucose in Patients with Type 2 Diabetes. Clinical Diabetes. 19(4): 153-159. 2001.

The pharmacological management (drug therapy) of patients with type 2 diabetes has changed dramatically in the past few years with the introduction of many new medications, including alpha glucosidase inhibitors, a biguanide, the thiazolidinediones, insulin analogs, meglitinides, and d phenylalanine derivatives. These new agents have dramatically increased the number of options available to providers and patients. Combination therapy has become commonplace for the management of hyperglycemia in patients with type 2 diabetes. This article briefly reviews some of the more recent pharmacological advances in diabetes care. The glyburide and metformin combination and the extended release metformin formulation may be useful for many patients because of their ease of compliance. The introduction of the combination format also brings into focus the importance of treating type 2 diabetes as a dual defect disease. The new insulin secretagogue nateglinide is an oral medication that essentially normalizes first phase insulin response, thus controlling postprandial (after a meal) hyperglycemic (high blood glucose) excursions without causing a high rate of hypoglycemia (low blood glucose). Finally, two new insulin products, aspart and glargine, offer distinct characteristics that will make them optimal choices in certain situations. Aspart, a rapid acting analog, is useful in controlling postprandial hyperglycemic excursions, whereas glargine offers the first true basal analog. A single injection of glargine provides continuous infusion of insulin into the bloodstream for a 24 hour period. 2 tables. 25 references.

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Type 2 Diabetes Mellitus in Children: Primary Care and Public Health Considerations. JAMA. Journal of the American Medical Association. 286(12): 1427-1430. September 26, 2001.

A variety of environmental factors, including poor dietary quality, inadequate physical activity, and sedentary lifestyles, have converged in the past two decades to produce an unprecedented epidemic of childhood obesity and its most serious complication, type 2 diabetes mellitus. This article considers the implications of this epidemic, examines the pathophysiology of type 2 diabetes mellitus in children, and reviews prevention and treatment strategies. All types of diabetes increase the risk for microvascular and macrovascular disease, including myocardial infarction (heart attack), stroke, renal (kidney) failure, blindness, and neuropathy; evidence is accumulating to show that risks for developing these complications may be greater in type 2 diabetes. The authors note that, as a result of this epidemic, the prospect of coronary heart disease becoming a disease of young adulthood must be faced. Treatment focuses on weight loss, dietary composition, physical activity, and drug therapy. This impending crisis demands a concerted public health campaign, calling on biomedical researchers to identify novel treatments for obesity and insulin resistance, public health agencies to device community based prevention strategies, public schools to promote physical activity and fitness, the commercial food industry to market healthful foods to children, and parents to model and support healthful lifestyle choices. The primary care clinician must also play an active role in both the primary prevention of obesity and the timely diagnosis and treatment of type 2 diabetes mellitus in children. A patient education handout on this topic is available in the same issue. 37 references.

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Type 2 Diabetes: New Drugs: Optimal Treatment Strategies. Consultant. 41(4): 581-583, 587-589. April 1, 2001.

This review article focuses on medications recently approved for the treatment of type 2 diabetes, including meglitinides, the thiazolidinediones, new insulin formulations, and the first sulfonylurea-metformin combination tablet. The article begins by considering the chronology of the defects in the natural history of type 2 diabetes and what this implies for the design of maximally effective and individualized treatment approaches. This is followed by a description of some of the new drugs available to manage type 2 diabetes. Used singly or in combination, these agents can be used selectively to act at the level of the pancreatic beta cell defect, increase peripheral insulin sensitivity, reduce hepatic gluconeogenesis, or accomplish any combination of these effects. The insulin secretagogues, repaglinide and nateglinide, are effective agents for patients with mildly elevated fasting glucose levels, poor glycemic control, and postprandial hyperglycemia. The alpha glucosidase inhibitors can also be useful when postprandial hyperglycemia is the major glycemic abnormality. The thiazolidinediones, rosiglitazone and pioglitazone, are peripheral insulin sensitizers that can also improve endothelial function and may preserve beta cell capacity. To date, they have proved to be free from hepatic toxicity. Given the inability to sustain glycemic control with monotherapy, combination regimens should be more widely employed. Glyburide and metformin can be given in a fixed dose combination tablet. Insulin aspart and lispro, two short acting insulins, can be given immediately before meals. Insulin glargine is a long acting insulin with true basal properties. 3 tables. 7 references. (AA-M).

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Blunting After-Meal Glucose Spikes. Diabetes Self-Management. 17(6): 21-22, 25-26. November-December 2000.

This article discusses the problem of high blood glucose following meals. The article reviews recent studies that point to the importance of controlling postprandial blood glucose and addresses the issue of increasing the number of episodes of hypoglycemia in people with tight diabetes control. In addition, the article describes some new drugs that can help people who have diabetes make or replace insulin right after meals. Three kinds of drugs that directly target after meal blood glucose levels are rapid acting insulin (Humalog and Novolog), alpha glucosidase inhibitors (Precose and Glyset), and meglitinides (Prandin). Rapid acting insulin reaches the bloodstream in less than 15 minutes. Therefore, it can be taken right before or even immediately after a meal. Lispro insulin became available in 1996, and a second rapid acting insulin, called insulin aspart (Novolog), was approved by the Food and Drug Administration in June 2000. These drugs work so quickly because they are synthetic forms of insulin that have the same function as natural insulin without quite the same chemical structure. The drugs in the alpha glucosidase inhibitor class, acarbose and miglitol, slow the breakdown of dietary starches and certain sugars into glucose. When taken with meals, these drugs keep blood glucose levels from rising too quickly afterward. However, for many people with type 2 diabetes, an alpha glucosidase inhibitor needs to be combined with a sulfonylurea, metformin, or insulin to control overall blood glucose. The meglitinides are a class of pill for type 2 diabetes that stimulates the pancreas to release more insulin immediately after a meal. Repaglinide is the first drug in this class. A second meglitinide, known as nateglinide, is under review at the Food and Drug Administration. This drug mimics the body's natural response to food and reduces blood glucose spikes. The new drugs make it easier for doctors to customize drug therapy for patients with diabetes.

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Diabetes Facts. In: Gehling, E. Family and Friends' Guide to Diabetes: Everything You Need to Know. New York, NY: Wiley and Sons, Inc. 2000. p. 5-45.

This book chapter uses a question and answer format to provide the family and friends of people who have diabetes with information on the disease so that they can be understanding and supportive to those who have diabetes. The chapter begins by explaining what diabetes is and what a normal blood glucose level is. This is followed by a description of type 1, type 2, and gestational diabetes and a discussion of the causes of these types of diabetes. Probable causes of type 1 diabetes include immune response, environmental and viral factors, genetics, and unknown reasons. Type 2 diabetes seems to be caused by age, genetics, lifestyle factors, obesity, and environmental factors. The cause of gestational diabetes, which occurs only during pregnancy, is unknown. Other topics include diagnosing and treating diabetes. Treatment options include following a healthful meal plan, developing healthy lifestyle habits, performing blood glucose checks, injecting insulin, taking oral hypoglycemic medications, using an insulin pump, monitoring blood glucose levels, and understanding complications. In addition, the chapter dispels common myths about diabetes, identifies complications that may develop in people who have poorly controlled diabetes, and describes the tests that doctors commonly order for patients who have diabetes. The chapter includes a self assessment quiz that readers can use to determine their risk for developing diabetes.

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Effects of Nicotinamide and Intravenous Insulin Therapy in Newly Diagnosed Type 1 Diabetes. Diabetes Care. 23(3): 360-364. March 2000.

This article describes a study that investigated the effect of intravenous insulin therapy combined with nicotinamide in the metabolic control and beta cell function of newly diagnosed type 1 diabetic subjects in comparison with intensive insulin therapy and nicotinamide alone. A total of 34 newly diagnosed type 1 diabetes patients were included in the pilot study. After the correction of initial metabolic disturbances, subjects were randomly assigned to one of three groups within 72 hours after admission. Twelve patients were assigned to the intensive insulin therapy plus placebo group, 11 to the intensive insulin therapy plus nicotinamide group, and 11 to the 72-hour intravenous insulin followed by intensive insulin therapy plus nicotinamide group. The subjects were monitored for 12 months. GAD antibodies, tyrosine phosphatase antibodies, and insulin autoantibodies were measured. C-peptide was measured basally and after 2, 4, 6, 8, and 10 minutes of 1 mg intravenous glucagon. Glycosylated hemoglobin (HbA1c), glucagon, and antibody measurements were determined initially and at 1, 3, 6, 9, and 12 months. The study found that HbA1c values declined to normal after treatment was initiated in all groups and remained not significantly different during the follow-up period. No differences were found between experimental and placebo groups in terms of beta cell function, considering basal or glucagon-stimulated C peptide values during the follow-up period. After pooling data from the experimental groups and comparing it with data from the placebo group, the results remained unchanged. At diagnosis, GAD positivity was observed in 10 of 12, 8 to 11, and 10 of 11 subjects in the placebo group, nicotinamide group, and the other experimental group, respectively. In addition, IA2 positivity was observed in 3 of 12, 4 of 11, and 4 of 11 subjects in the placebo group, nicotinamide group, and other experimental group, respectively. Antibody titers displayed a similar behavior in all groups during the follow-up period. The article concludes that the pilot study failed to demonstrate that the addition of 72-hour intravenous insulin and nicotinamide to the conventional intensive insulin therapy produced any beneficial effect in newly diagnosed type 1 diabetic subjects in terms of beta cell function and metabolic control. 3 figures. 1 table. 22 references. (AA-M).

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Inside Look at Managing Diabetes. South Deerfield, MA: Channing L. Bete Co., Inc. 2000. 15 p.

This booklet provides an overview of diabetes management. The booklet begins by explaining how glucose gets into cells in a person who is healthy. This is followed by a description of type 1, type 2, and gestational diabetes. Risk factors for each type of diabetes are identified. The booklet then discusses the laboratory tests that can confirm a diagnosis of diabetes, including the fasting plasma glucose test, the random plasma glucose test, and the oral glucose tolerance test. Other topics include the effects of damage to the heart and large blood vessels and impact of damage to the small blood vessels. Small blood vessel damage can lead to eye and kidney disease, reduced circulation to the feet and legs, and nerve damage. In addition, the booklet presents steps that people who have diabetes can take to improve their quality of life, including following a healthy meal plan, engaging in regular physical activity, controlling their weight, performing regular self tests of blood glucose, and testing for ketones. The booklet concludes with information on the use of insulin and diabetes pills to manage the disease and other ways to determine the effectiveness of a treatment and self care plan.

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Insulin Pump Therapy: A Practical Tool for Treating Persons with Type 1 and Insulin Requiring Type 2 Diabetes. In: Leahy, J.L.; Clark, N.G.; Cefalu, W.T. Medical Management of Diabetes Mellitus. Monticello, NY: Marcel Dekker, Inc. 2000. p. 309-323.

Insulin pump therapy (continuous subcutaneous insulin infusion or CSII) is not for everyone. However, many persons with type 1 or type 2 diabetes could improve their glucose control with an insulin pump, while enjoying a much more flexible lifestyle. This chapter on insulin pump therapy is from a textbook for practicing providers and for physicians in training that offers a comprehensive, up-to-date overview of diabetes mellitus. The text outlines the most effective diagnostic and therapeutic approaches to clinical problems, rather than try to be encyclopedic in coverage. In this chapter, the author reviews insulin pump therapy in insulin-requiring patients with type 2 diabetes, general patient candidacy for insulin pump therapy, the disadvantages of insulin pump therapy, the equipment itself and how it works, initiating insulin pump therapy, verifying the basal and bolus rates, determining bolus rates, and special precautions and every day management. The chapter includes a case presentation and discussion. 3 figures. 5 tables. 4 references.

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Insulin Resistance and Hyperinsulinemia: Recognizing the Risk and Reversing the Process. Physician Assistant. 24(9): 23-24, 26, 29-30, 33-36, 38-39. September 2000.

This article reviews the pathophysiology, risk factors, and dietary therapy for hyperinsulinemia (HI) and discusses the link between HI and vascular disease. Insulin resistance (IR) with concomitant HI is a significant risk factor for the development of type 2 diabetes and coronary heart disease. A person develops IR/HI when the insulin response to nutrients becomes chronically elevated. IR/HI is caused by a complexity of genetic and environmental influences. Early identification is important because of the microvascular and macrovascular damage the body experiences prior to the onset of hyperglycemia. Understanding the pathophysiology of IR/HI, the metabolism of nutrients, and the optimal therapeutic diet can help clinicians reverse the primary metabolic disturbance and prevent progression to diabetes, heart disease, and end organ damage. Nutritional therapy should be initiated prior to or in conjunction with pharmacotherapy. Based on physiologic, epidemiologic, and clinical evidence, the low fat, high carbohydrate diet is not appropriate for the IR/HI patient. The most appropriate diet for people who have IR/HI is adequate protein, moderate complex carbohydrate, minimal refined carbohydrate, and healthy fats. Micronutrients are also important in optimizing the health of a patient who has IR/HI. Exercise is also an important key to insulin sensitivity; therefore, exercise, together with a low to no starch diet will cause a dramatic increase in fat utilization for energy. Although diet therapy is needed to reverse the metabolic disturbance associated with IR/HI, pharmacotherapies may be needed to treat the associated risk factors that often accompany IR/HI. 2 figures. 6 tables. 60 references. (AA-M).

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Insulin Resistance. In: Leahy, J.L.; Clark, N.G.; Cefalu, W.T. Medical Management of Diabetes Mellitus. Monticello, NY: Marcel Dekker, Inc. 2000. p. 57-75.

Insulin resistance is a clinical state in which a normal or elevated insulin level produces an impaired biological response. This chapter on insulin resistance is from a textbook for practicing providers and for physicians in training that offers a comprehensive, up-to-date overview of diabetes mellitus. The text outlines the most effective diagnostic and therapeutic approaches to clinical problems, rather than try to be encyclopedic in coverage. In this chapter, the author discusses the history of understanding insulin resistance, insulin resistance in the natural history of type 2 diabetes, cellular events of insulin action, clinical conditions associated with insulin resistance, how insulin resistance is measured, and patient selection for treatment (for primary prevention of diabetes). Conditions associated with insulin resistance include obesity, lipid abnormalities, endothelial function, atherosclerosis, hypertension (high blood pressure), and prothrombotic activity. The author concludes that whether treatment of insulin resistance with pharmacological agents outside the diabetic state is to be recommended will depend on the outcome of the current research trials. 4 figures. 1 table. 28 references.

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Insulin Therapy. In: Leahy, J.L.; Clark, N.G.; Cefalu, W.T. Medical Management of Diabetes Mellitus. Monticello, NY: Marcel Dekker, Inc. 2000. p. 285-308.

This chapter on insulin therapy is from a textbook for practicing providers and for physicians in training that offers a comprehensive, up-to-date overview of diabetes mellitus. The text outlines the most effective diagnostic and therapeutic approaches to clinical problems, rather than try to be encyclopedic in coverage. In this chapter, the author encourages physicians to become familiar in the use of insulin protocols that are best able to achieve optimal glycemic control and thus reduce complications. This approach includes educating patients in self-management of their diabetes. The author discusses insulin pharmacology, insulin preparations, factors that influence subcutaneous insulin absorption, insulin delivery systems, insulin programs, intensive insulin therapy, and adverse events from insulin therapy, including hypoglycemia, worsening retinopathy, weight gain, insulin allergy, and lipodystrophy and lipoatrophy. 1 figure. 7 tables. 18 references.

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Is Snacking Still a Must?. Diabetes Self-Management. 17(1): 80-82, 84. January-February 2000.

This article considers the issue of whether people who have diabetes need to eat snacks. When diabetes drug therapy was limited to regular and N.H. insulin and first-generation sulfonylureas, people who had diabetes were routinely instructed to eat three meals and three snacks a day to prevent hypoglycemia. Today, there are more drug options available, so people who have diabetes may not need to eat snacks to prevent hypoglycemia. The relatively new oral medication repaglinide can cause hypoglycemia but can also eliminate the need for snacks. For people who use insulin, the quick-acting insulin lispro is an alternative to regular insulin. In addition to advances in drug and insulin treatment, improvements in the technology of blood glucose monitoring mean low blood sugar can be detected and treated in a timely manner. Incorporating these options into a diabetes self care regimen involves matching one's eating habits and lifestyle with diabetes medications. People who do not need to eat snacks to prevent low blood sugar should decide to include or not include them in their food plan on the basis of want. People who decide to include snacks in their meal plan should remember that there is no ideal snack. Some are more nutritious than others, some are more appropriate in certain situations, and some are more convenient than others. Advice about the inclusion of fruit and protein in snacks must be individualized. The article presents case examples to illustrate some of the points made in the article. In addition, the article presents questionnaires readers can use to decide whether to include snacks in a meal plan and how to fit medications into daily life.

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Medications for the Treatment of Diabetes. Alexandria, VA: American Diabetes Association. 2000. 190 p.

This book presents an overview of the medications used to treat patients who have type 1 or type 2 diabetes and provides an individual summary of each class of drug and its role in the treatment of diabetes. Chapter one discusses the use of insulin for type 1 diabetes. Topics include insulin sources; insulin pharmacology; insulin storage, mixing, and administration; insulin dosing regimens; insulin use in diabetic ketoacidosis, parenteral nutrition, and pump therapy and among pregnant women, infants, and children; and the role of glucagon in type 1 diabetes. Chapter two reviews the use of insulins, sulfonylureas, thiazolidinediones, meglitinides, biguanides, and alpha glucosidase inhibitors in the treatment of type 2 diabetes. These classes of medications are discussed in terms of mechanisms of action, efficacy of monotherapy and combination therapy, effects on lipid profiles, common side effects, contraindications for use, and patient adherence to the regimens. Chapters three through seven discuss sulfonylureas, alpha glucosidase inhibitors, glitazones, meglitinide products, and biguanides in terms of pharmacology, indications for use, dosing considerations, special populations, contraindications, warnings, precautions, adverse effects, drug interactions, and clinical effects. Chapter eight focuses on insulin use in type 2 diabetes and gestational diabetes. Topics include indications for use, rationale and strategies for oral agent insulin therapy, insulin monotherapy in type 2 diabetes, and intensive insulin therapy. Chapters nine and 10 examine the treatment of hypertension and hyperlipidemia in patients who have diabetes, focusing on the goals of treatment, nonpharmacological interventions, and pharmacological treatments. The final chapter describes some medications currently being studied that will possibly be approved to treat diabetes or its complications. 6 figures. 31 tables. Numerous references.

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Medicines for People with Diabetes. [Medicamentos para las Personas con Diabetes]. Bethesda, MD: National Diabetes Information Clearinghouse (NDIC). 2000. 32 p.

This booklet, written in question and answer format, provides information about medicines for people with diabetes. The booklet points out that diabetes medicines that lower blood sugar never take the place of healthy eating and exercise. Topics include whether or not a person needs to take diabetes medicine, reasons for taking medicines with type 1 or type 2 diabetes, types of diabetes pills (sulfonylureas, biguanides, alpha-glucosidase inhibitors, meglitinides, and thiazolidinediones), insulin, taking more than one diabetes medicine at a time, and information about low blood sugar. The booklet also includes questions to ask a doctor about personal diabetes medicines, a form for recording information about medicines, and information concerning the effectiveness of diabetes medication. People should not change or stop taking their diabetes medicines without first consulting their doctors. The booklet concludes with information about finding diabetes teachers, recognized diabetes education programs, and dietitians. Contact information for the National Diabetes Information Clearinghouse (NDIC) is provided. The booklet is written in nontechnical language (at the fourth to sixth grade reading level) and is illustrated with simple line drawings. (AA-M).

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Oral Agent Use in Type 2 Diabetes: Nutritional Implications. Topics in Clinical Nutrition. 15(4): 41-56. September 2000.

This article considers the nutritional implications of oral medication use in type 2 diabetes. The scope of practice for registered dietitians working in diabetes care and education has changed dramatically in the past few years. To implement an effective plan of medical nutrition therapy for the person who has diabetes, the dietitian must have a good knowledge of the effects of diabetes medications in relation to food, exercise, weight, and blood glucose and lipid levels. The development of new oral agents to treat type 2 diabetes has been unprecedented in the past 5 years, with four new classes of agents being introduced. Before discussing these oral agents, the article explains the pathophysiology of type 2 diabetes and examines the goals for glycemic control, lipid levels, blood pressure, weight, and exercise. The review of oral agents focuses on sulfonylureas, meglitinide, biguanides, alpha glucosidase inhibitors, and thiazolidinediones. Each agent is discussed in terms of its mode of action and nutritional implications. In addition, the article comments on the practice of combination therapy. 6 tables. 33 references. (AA-M).

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Polycystic Ovary Syndrome: Sister to Type 2. Diabetes Forecast. 53(6): 114-116. June 2000.

This article discusses a condition known as polycystic ovary syndrome (PCOS). In women who have PCOS, the ova mature in the ovary but are not released. This failure to ovulate results in decreased frequency of menstrual periods and causes cysts to develop in the ovaries. PCOS also causes elevated blood levels of male sex hormones such as testosterone. This condition is the most common cause of infertility among women in the United States. Type 2 diabetes and PCOS have insulin resistance as a common feature. Most women who have PCOS have insulin resistance, and women who have PCOS are at risk for type 2 diabetes and other disorders such as high blood pressure, abnormal lipids, and heart disease. Although not all women who have insulin resistance will develop type 2 diabetes, they may have elevated insulin levels in the blood. This condition, known as hyperinsulinemia, appears to have a role in the development of PCOS and may impede ovulation and contribute to infertility. Treatments for type 2 diabetes and obesity can also be used for PCOS. The first line of treatment for all three problems is diet and exercise. Drugs that improve sensitivity to insulin, such as metformin, pioglitazone, and rosiglitazone, may be needed. The article recommends that women who have irregular menstrual periods or have excess hair growth inform their doctor because of the interrelated nature of type 2 diabetes, infertility, excess hair growth, high blood pressure, and abnormal lipids.

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T Cell Mutiny. JDF International Countdown. 21(1): 34-36, 38-39. Winter 2000.

This article reviews scientific efforts aimed at intervening in the process by which the immune system attacks and destroys insulin producing beta cells of the pancreas. The mechanism by which the immune system attacks and destroys these cells involves certain white blood cells called T lymphocytes. These cells infiltrate the pancreatic islets and secrete cytokines that set about destroying the beta cells. A current hypothesis is that autoimmune diseases such as diabetes result when the balance of power between autoreactive T cells and autoregulatory T cells shifts in favor of the autoreactive T cells. Although the cause of this shift is unknown, it is known that people who develop type 1 diabetes have a genetic predisposition to the disease. However, many investigators believe that something must happen in the environment to trigger it. Possible triggers include an invading virus and the loss of oral tolerance. The realization that type 1 diabetes is an autoimmune disease led scientists to test whether immunosuppressive agents could preserve functioning of remaining beta cells in people who still had some functioning beta cells. Studies revealed limited success, so scientists shifted their efforts toward earlier intervention. One promising effort is the use of low dose insulin injections before the onset of type 1 diabetes. Another approach has been to give insulin orally to produce oral tolerance. Both strategies have evolved into a large multicenter clinical trial known as the Diabetes Prevention Trial-Type 1. Another relatively benign approach to intervention involves using high doses of the B vitamin nicotinamide. Other research efforts are focusing on the beta cell protein glutamic acid decarboxylase (GAD). Findings from a study of GAD suggest that the immune response to GAD might completely block diabetes in prediabetic people as well as people who have type 1 diabetes who receive islet cell transplants. Emerging strategies for preventing autoimmune recurrence in islet cell transplantation include bone marrow chimerism, antibodies that block the function of T cells, and gene therapy.

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Understanding Type 1 Diabetes. [Como Comprendor la Diabetes de Tipo 1]. Atlanta, GA: Pritchett and Hull Associates, Inc. 2000. 2 p.

This fact sheet helps readers understand type 1 diabetes, in which the pancreas makes no insulin. The result is that glucose cannot get into the cells, so it builds up in the blood, resulting in high blood glucose levels (hyperglycemia). The fact sheet describes the blood glucose levels considered to be diagnostic, the complications of diabetes, and treatment options, including insulin use, diet therapy, physical exercise and activity, drug therapy, and blood glucose monitoring (SMBG). The fact sheet is written in nontechnical language, is illustrated with simple line drawings, and is available in English or Spanish. Space is provided for the reader to record his or her healthy blood glucose goals. 4 figures.

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Understanding Type 2 Diabetes. [Como Comprender la Diabetes de Tipo 2]. Atlanta, GA: Pritchett and Hull Associates, Inc. 2000. 2 p.

This fact sheet helps readers understand type 2 diabetes, in which the cells of the body cannot use insulin the way they should. The result is that glucose cannot get into the cells, so it builds up in the blood, resulting in high blood glucose levels (hyperglycemia). The fact sheet describes the blood glucose levels considered to be diagnostic, the complications of diabetes, and treatment options, including insulin use, diet therapy, physical exercise and activity, drug therapy, and blood glucose monitoring (SMBG). The fact sheet is written in nontechnical language, is illustrated with simple line drawings, and is available in English or Spanish. 4 figures.

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