The American journal of medicine
-
Randomized Controlled Trial Clinical Trial
Addition of pioglitazone or bedtime insulin to maximal doses of sulfonylurea and metformin in type 2 diabetes patients with poor glucose control: a prospective, randomized trial.
To compare the efficacy of adding pioglitazone or bedtime isophane (NPH) insulin to maximal doses of metformin and an insulin secretagogue in patients with poor glucose control. ⋯ Adding pioglitazone or bedtime insulin for 16 weeks improved glycemic control in type 2 diabetic patients with secondary oral agent failure. Pioglitazone was associated with less hypoglycemia and improved HDL cholesterol levels.
-
To evaluate the short-term outcome of patients who underwent carotid stenting with the routine use of cerebral protection devices. ⋯ In this uncontrolled study, routine cerebral protection during carotid artery stenting was technically feasible and clinically safe. The incidence of major neurologic complications in this study was lower than in previous reports of carotid artery stenting without cerebral protection.
-
Recognition of the basal and postprandial components of hyperglycemia, in tandem with the development of new insulins and other clinical research, has led to a reassessment of type 2 diabetes mellitus treatment. In the future, insulin will be used earlier, treatment will intensify as the disease progresses, and combination therapy will be routine. Hyperglycemia can be controlled initially with sulfonylureas and metformin, agents that mainly improve control of fasting and preprandial glucose. ⋯ Although the traditional approach has been to introduce insulin therapy only after very high glucose values have persisted, despite prolonged use of oral agents alone, a more desirable strategy would be to prevent patients from ever experiencing the loss of glycemic control associated with hemoglobin A(1c) (HbA(1c)) elevations >7%. This goal could be achieved by diagnosing type 2 diabetes earlier in its course and by adding basal insulin to oral therapy much earlier. To maintain the recommended <7% HbA(1c) target level of control, treatments that target postprandial hyperglycemia will have to be added to basal insulin later on, as endogenous insulin continues to decline.
-
The burden of type 2 diabetes mellitus will become even greater in coming decades as more young people present with the disease and patients live longer with the devastating complications of chronic hyperglycemia. Conventional and largely ineffectual treatment strategies consisting of lifestyle measures and long-term oral therapy are being challenged by studies showing that the early addition of insulin to oral agents can significantly improve glycemic control in patients with type 2 diabetes. ⋯ This simple treat-to-target strategy may be readily adopted in general practice through a widely translatable algorithm moving from oral pharmacotherapy to early addition of basal insulin glargine if glycemic targets are not met. The once-daily flexible dosing of insulin glargine and its smooth, flat profile, associated with fewer episodes of nocturnal hypoglycemia, make it among the safest and most practical tools to date for transforming the paradigm of type 2 diabetes management.
-
Review
Treatment of patients with severe insulin deficiency; what we have learned over the past 2 years.
The initial injection in 1922 of a pancreatic extract, or insulin as it came to be known, into a patient with diabetes mellitus has since been followed by the successive introduction of longer-acting insulins, more highly purified insulins, and insulins that have been modified to more closely match insulin activity to patients' physiologic requirements. The recently introduced rapid-acting insulin analogues lispro and aspart and the long-acting analogue glargine are further refinements of insulin therapy. Current treatment strategies for severe insulin deficiency are based on the need to provide 2 components of insulin replacement: basal and postprandial. ⋯ Experience and observations since 2001 indicate that insulin therapy should be introduced earlier in patients with type 2 diabetes to control blood glucose levels. More importantly, the greatest benefit of insulin glargine has been to change positively the way physicians and patients think about insulin therapy. Newer insulin analogues, improved devices for home glucose monitoring, and pulmonary inhaled insulin are other innovations that promise improvement of hemoglobin A(1c) levels.