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Controlling
Hyperglycemia -Type 1: -The DCCT study confirmed the causal relationship between hyperglycemia and diabetic complications in type 1 diabetics.
-A hbgA1c of below 7 appears to be most beneficial as long as
hypoglycemia isn’t a limiting factor.
-Insulin is required for type 1 diabetics who lack insulin production
-A typical starting dose is usually 0.2-0.4 units per kilogram.
Typically a longer acting insulin coupled with a pre-meal short acting
insulin is used to cover the both the hepatic production of glucose with the
long acting and the meal time glucose surge with the shorter acting
-Short acting insulin options include regular insulin and monomeric
insulin which has an onset of action 15 minutes after injection and has a
shorter half-life than regular insulin. Use of these types of insulin in conjunction with a long
acting insulin can help decrease postprandial glucose spikes.
-Long acting insulin preparations include NPH, ultralente and insulin
glargine (Lantus). NPH is given 1
or 2 times per day. NPH can be used
at bedtime alone in type 2 diabetics to control nocturnal hepatic glucose
production. It can also be used in
a bid regimen as basal insulin. Insulin
glargine is given once a day usually at night and has the advantage of having a
less peaking effect. -Type 2:
-Treatment in type two diabetes is different in that the main problem is
typically insulin resistance. Weight loss, diet, and exercise alone can delay both the
onset of diabetes as well as the need for medications.
For those that fail these measures, oral medications and sometimes
insulin is added.
-Medication classes include:
1. Sulfonyureas and
meglitinides: act by increasing
pancreatic insulin secretion. Sometimes
first line agent in type 2 patients who are not overweight.
Meglitinides have a quicker onset of action allowing for more flexibility
with meal times, however they currently much more costly than sulfonyureas.
These insulin secreting oral meds have the complication of hypoglycemia. Patients with persistent hypoglycemia are occasionally found
to be abuseing these meds. A urine
sulfonyurea level can screen for this.
2. Biguanides (Metformin):
Decreases glucose production by the liver and is not associated with
hypoglycemia. It is also beneficial
in that it does not cause weight gain and may lower ldl cholesterol.
It should be avoided in patients with renal insufficiency as lactic
acidosis may ensue. Also those with
overt heart failure should avoid metformin.
3. Thiazolidinediones (rosiglitazone
and pioglitazone): Act by improving
insulin sensitivity at the cellular level.
Liver enzymes need to be monitored.
Also fluid retention, heart failure and weight gain can be complications.
Otherwise they are effective in lowering the hgbA1c and can be used in
combination with the above medciations
4. Alpha-glucosidase
inhibitors (acarbose, miglitol): Act
by interfering with glucose absorption in the small intestine by blocking the
alpha-glucosidase enzyme. Drawbacks
include flatulence and diarrhea. -Patients
who do not reach goal or have side effects from oral medications can be started
on insulin. Combination insulin and drug therapy has shown some benefits
so the two together can be used. Bedtime
insulin along with oral medications can be a beneficial combination in that the
insulin acts to decrease hepatic production of insulin during the night.
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