Insulin Journal
VOLUME 3, NUMBER 3
Editorial
Since publication of our last issue of Insulin, the American Diabetes Association Scientific Sessions were held in San Francisco, California. The results of 3 landmark studies (Action in Diabetes and Vascular Disease [ADVANCE], Action to Control Cardiovascular Risk in Diabetes [ACCORD], and Veterans Affairs Diabetes Trial [VADT]) were revealed, all of which focused on the role of glucose control and its influence on macrovascular disease in type 2 diabetes mellitus (DM). Although all 3 studies concluded that tight glucose control did not significantly reduce major coronary events, they reminded us about the importance of treating our patients individually and as safely as possible. The bottom line is to diagnose early, initiate treatment for glucose and cardiovascular risk factors in a timely manner, and avoid hypoglycemia and excessive weight gain.
In this issue of Insulin, we address several important issues as they relate to the management of patients with DM, using an individualized approach to reduce not only the long-term macrovascular and microvascular complications of DM, but also the forgotten acute conditions that affect morbidity and mortality. Inpatient management of patients with DM has been one of the age-old problems of diabetes care and has become an important treatment issue.
Tight glycemic control was accepted as the standard of care even before publication of the Diabetes Control and Complications Trial (DCCT) because of the strong outcomes data collected from the infants of mothers with DM with varying degrees of control. Now that more women with type 2 DM are becoming pregnant, identification of the causes of pregnancy loss in this growing segment of our population is becoming increasingly important.
We also look at the influence of endothelial dysfunction, vascular inflammation, and oxidative stress on the complications of DM. Correction of these well-documented abnormalities to normal or near-normal levels is believed to be very important in stabilizing the internal metabolic and vascular milieu to minimize acute and chronic complications.
We carefully plan the issues of Insulin to address not only topics on clinical management but also important scientific information as it becomes available. It is hoped that these articles are helpful to you, the readers of Insulin—health care professionals working at multiple levels to improve the management of patients with DM—as they relate to your understanding of the disease and its complications. We hope you enjoy this issue.
I think most clinicians would agree that there has been widespread acceptance of the use of basal insulin in the primary care community. In recent months, I have rarely encountered primary care practitioners who are uncomfortable with initiation and titration of basal insulin. Most practitioners understand and accept its utility in the diabetes treatment paradigm. When I do find confusion relating to basal insulin, I have been impressed that it relates most often to uncertainty about which product to use.
Inpatient Insulin Therapy (CME)
This article reviews the risks associated with hyperglycemia in hospitalized patients, the biologic rationale for using insulin to prevent increases in glucose levels, and strategies for managing hyperglycemia in the hospital setting.
Pregnancy Loss and Neonatal Death in Women with Type 1 or Type 2 Diabetes Mellitus
In women with type 1 DM, the perinatal mortality rate decreased substantially in most western countries by the early 1980s and has remained stable over the past 25 years. The decrease in perinatal mortality was achieved predominantly by a reduction in the number of late intrauterine deaths and stillbirths. Currently, the major causes of pregnancy loss in type 1 DM are major congenital anomalies and complications of prematurity. Pregnancy in type 2 DM has been recognized as a problem in developing countries since the late 1980s, but is now emerging as a significant problem in western countries, particularly in disadvantaged communities.
Reducing Oxidative Stress in Patients with Type 2 Diabetes Mellitus: A Primary Care Call to Action
The effects of chronic hyperglycemia, hyperlipidemia, and hypertension in patients with diabetes mellitus places these individuals at high risk for microvascular and macrovascular complications. Approximately 80% of patients with type 2 DM will succumb to cardiovascular complications such as stroke, peripheral arterial disease, and heart disease. Given the important role of oxidative stress in the development of complications of type 2 DM, physicians should consider methods to reduce oxidative stress that may occur during both acute (postprandial) and chronic hyperglycemia.
Insulin and Endothelial Function: A Brief Review
Since its discovery, insulin has maintained a key position for its principal effects on glucose metabolism. Within the past several decades, we have witnessed a major surge in our ability to decipher insulin's actions beyond glucose metabolism. One of the key effects of insulin in the vasculature has been its interaction with the endothelium; epidemiologic evidence indicates a potential link between insulin and cardiovascular morbidity and mortality. The prevailing dogma holds that insulin and the endothelium maintain a delicate relationship that is essential for normal functioning of the organ lining the blood vessels of the body. Dysfunction of the endothelium is observed in insulin-resistant states, including obesity, glucose intolerance, and type 2 diabetes mellitus.
Insulin Therapy: The Question This Issue
What is a good formula for initiating insulin therapy in a newly diagnosed type 1 diabetic?
"Diabetes Tactics" Case Studies
This month's "Diabetes Tactics" case discusses achieving optimal glycemic control in a pregnant woman with type 2 diabetes and polycystic ovary syndrome.
Responses to April 2008 Case Study
This was the case of a 58-year-old, obese man with type 2 diabetes mellitus, uncontrolled cardiovascular risk factors, and recently diagnosed, nonobstructive coronary disease.
Managing Type 1 Diabetes for Pregnancy
If you have type 1 diabetes and are thinking about becoming pregnant, there are important steps you should take now to make sure you will have a healthy baby. Even if you have good control of your blood glucose when you become pregnant, pregnancy is a high-risk situation for both you and your baby.
A 28-year-old woman with a 25-year history of type 1 diabetes mellitus (DM) comes to your office with her husband for preconception counseling.
