Archive for the ‘WHAT’S HOT IN DIABETES’ Category
As a result of one landmark study, The United Kingdom Prospective Diabetes Study (UKPDS), we now recognize that type 2 diabetes is a progressive disease. Beta-cell function gradually deteriorates over time. Insulin resistance may rise, secondary to hyperglycemia (“glucose toxicity”). Aggressive drug therapy is needed—with newly approved oral agents thatwill address thedual defects of deficient insulin secretion (third generation sulfonylureas, meglitinides) and insulin resistance (thiazo-lidinediones). Metformin acts on a third physiologic component of uncontrolled diabetes: increased hepatic glucose production. We can now limit dietary carbohydrate breakdown by alpha-glucosidase inhibitors. Thus, before insulin is needed, one can often control glycemia by new drug combinations that address specific pathophysiologic alterations in type 2 diabetes. When insulin is required, we now have newly developed products that will address the issue of increased hepatic glucose output during the overnight fasting period. Combinations of oral drugs with insulin are proving to be acceptable strategies. With this multifactorial aggressive approach to hyperglycemia, the UKPDS demonstrated that progression of microvascular events could be delayed in type 2 diabetes.
In spite of all of this, people with type 2 diabetes usually die from cardiovascular events, and they have the same very high risk for myocardial infarction as nondiabetics who have already had a heart attack! The good news is that additional prospective collaborative trials have conclusively shown that major risk reductions in cardiovascular events can be achieved by intensive control of blood pressure, lipid abnormalities, and the pro-thrombotic state characteristic of type 2 diabetes. Thus, combination therapy for hypertension, as in type 1 diabetics, will lower the risk for cardiovascular events and progression of retinopathy and nephropathy. Statin therapy has revolutionized cholesterol-lowering strategies, and studies continue to support this treatment in diabetics of all ages, either gender, and as a primary or secondary prevention approach. Fibrate therapy has been shown to decrease risk for cardiac events in diabetics with low HDL cholesterol, and many studies support the use of low-dose aspirin for the prothrombotic state, which is frequently present.
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