The American journal of medicine
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Human insulin preparations administered to patients with diabetes mellitus fail to reproduce the normal physiologic pattern of insulin secretion. Modifications have been made in the amino acid sequence of the insulin molecule with the aim of overcoming the pharmacokinetic shortcomings of human insulins. Such modifications have produced long-acting analogues, with relatively flat time-action profiles, for controlling glycemic levels between meals; and rapid-acting analogues with a fast onset and short duration of action, for controlling postprandial hyperglycemia. ⋯ The rapid-acting and premixed analogues offer better control of postprandial glucose excursions than do regular human insulin, resulting in similar or lower HbA1c levels. Furthermore, the analogues can offer patients greater flexibility and more convenience in administration compared with human insulins. This review provides an overview of the insulin analogues available today and describes their structure, pharmacokinetics, pharmacodynamics, efficacy, and safety.
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In the mid-19th century, Virchow identified hypercoagulability as part of the triad leading to venous thrombosis, but the specific causes of hypercoagulability remained a mystery for another century. The first specific cause to be identified was antithrombin III deficiency. Many other causes of thrombophilia, both genetic and acquired, have been discovered since then. ⋯ Some physicians screen for thrombophilia to aid decision making concerning the duration of anticoagulant therapy. However, several studies have demonstrated that, with the exception of antiphospholipid syndrome, thrombophilia does not significantly increase the risk of recurrent VTE. On the other hand, idiopathic VTE significantly increases the risk of recurrence in patients with or without thrombophilia.
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Diabetes mellitus is a chronic progressive disease that has profound consequences for individuals, families, and society. Despite clear glycemic control targets articulated by the major medical societies, patients and physicians still struggle to meet and maintain these goals, leading to shortfalls in delivery of care. Recent advances in the treatment of type 2 diabetes seek to address these shortfalls: Modern oral hypoglycemic agents may be used with or in place of traditional therapies. ⋯ Using these new classes of therapy, physicians should strive to help patients understand and reach the targets for control that we know to be beneficial for the majority of individuals. Such targets include those for glycosylated hemoglobin (HbA1c), but increasingly we also realize the central importance of maintaining postprandial glucose levels within recommended limits, and it is likely that the recent introduction of a serum marker for this purpose, 1,5-anhydroglucitol, will help improve patient outcomes. By intensifying therapy early during the course of the disease process, using the most effective and acceptable therapies available, and maintaining the lowest and safest HbA1c levels for as long as possible, we will be serving our patients well and living up to our responsibilities as diabetes care physicians.