The general guiding principal of diabetes therapy is to lower glucose levels on a consistent basis to normal or near normal. Keeping glucose levels at or near normal in type 1 diabetics (HgbA1c £ 7.0 percent; normal, 4.0 to 6.0 percent) through intensive insulin therapy as practiced in the Diabetes Control and Complications Trial
(DCCT) dramatically reduces the risk of developing both the microvascular and the macrovascular complications of diabetes. 13
Several preliminary studies affirm the association of good glycemic control with fewer complications in type 2 diabetes. However, more study is needed to define the population of type 2 patients that will receive the most benefit, given the increased risk of hypoglycemia involved with intensive insulin therapy. 14
Intensive insulin therapy (2 h postprandial and an occasional middle of the night check) is indicated for well-motivated patients who administer multiple daily injections, and who can adjust doses and caloric intake appropriately. Target glucose values for therapy should be tailored to the individual. However, generally the goal is to keep blood glucose at 140 mg/dL or less in intensive-therapy candidates and 180 to 200 mg/dL or less in diabetics who do not meet criteria for intensive therapy. Target HgbA1c of 7.0 percent or less in intensive-therapy patients and 8.0 percent or less in non-intensive-therapy patients is a reasonable goal to prevent, delay the onset of, and delay progression of complications. Intensive therapy is generally not indicated for patients with autonomic insufficiency, adrenal or pituitary insufficiency, atherosclerotic coronary or cerebrovascular disease; for patients taking b-blocker medication; for patients with counterregulatory hormone deficiency; for the elderly or small children; for patients with psychiatric disorders; and for unreliable, chronically noncompliant patients.
Euglycemia reduces the chance of developing DKA or HHNS. Lowering blood glucose reduces the clinical signs and symptoms of diabetes, such as polyuria, polydipsia, blurred vision, weight loss, and poor wound healing. Consistently near-normal glucose values reduce the risk of microvascular complications of diabetes (specifically, neuropathy, retinopathy, and nephropathy). Excellent glycemic control is also associated with a more favorable and less atherogenic lipid profile, leading to fewer macrovascular complications.
Glycemic control in type 1 diabetes is accomplished primarily with multiple daily insulin injections, whereas glycemic control in type 2 patients is staged. Stage 1 is diet modification and weight reduction. Stage 2 includes oral hypoglycemics. Stage 3 represents insulin requirement, alone or in addition to oral hypoglycemic agents. Table^i-l presents the various forms of insulin commonly prescribed, time to onset of action, time to peak effect, and their durations of action when given subcutaneously.15 Insulin preparations available today are extremely pure and represent genetically engineered forms of human insulin produced by bacteria or yeast. Immunogenicity is rare. Iable.209-5. presents frequently prescribed oral hypoglycemic agents with their usual dose, half-life, and duration of activity. Caution should be used in prescribing these agents to the elderly or to patients with impaired renal or hepatic function due to serious complications of hypoglycemia. Once the symptoms of acute hyperglycemia are controlled, and underlying causes or exacerbating factors are sought out and treated, initiation of oral hypoglycemic and/or insulin therapy in new-onset type 2 diabetics can usually be left to the primary care provider at 24 to 48-h follow-up if admission was not warranted. Finding new-onset type 1 diabetes in the absence of serious precipitating illness or metabolic disorder is rare. An excellent review on initiating insulin and/or oral hypoglycemic therapy is presented in Applied Therapeutics: The Clinical Use of Drugs, 6th edition.15
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TABLE 209-4 Pharmacology of Commonly Available Insulin Preparations
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Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...