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The elderly patient with type II diabetes should be treated in much the same fashion as a younger person with the same disease, although emphasis needs to be placed on minimizing side effects, drug interactions, and hypoglycemia. Chlorpropamide should not be used in these patients, unless there is no other choice. The remaining agents--tolbutamide, acetohexamide, tolazamide, glyburide, and glipizide--should be started at low doses and gradually increased until optimal diabetic control is reached. The initial treatment goal is a FPG level of less than 180 mg/dl and a final goal is a 1- to 2-hour PPG concentration between 140 and 180 mg/dl. The glycosylated hemoglobin value should be no greater than 1.5% above the upper limit of normal, and should be lower, if possible. It must be kept in mind, however, that the closer diabetic patients are to achieving euglycemia, the more likely is hypoglycemia. Treatment goals therefore may have to be relaxed in someone at increased risk of hypoglycemia (e.g., patients with irregular eating habits or renal insufficiency) or when hypoglycemia may pose a greater hazard (e.g., patients with coronary artery or cerebral vascular disease). Patients on sulfonylurea agents should have blood glucose values measured once a month and glycosylated hemoglobin levels determined once every 3 months to alert the clinician to the possible need to adjust therapy. In this way, potential hypoglycemia can be avoided if blood glucose levels are drifting too low and chronic hyperglycemia can be identified and treated within a short period of time. When a patient's status changes--e.g., he is placed on new medication, becomes depressed and anorexic, or develops another medical problem--care must be taken to re-evaluate his diabetes management. Drugs such as sulfonamide antibiotics can potentiate the action of the sulfonylureas and cause hypoglycemia, renal insufficiency may necessitate changing the type of sulfonylurea agent or decreasing the dose, and malnutrition may obviate any need for therapy with an oral hypoglycemic agent. If these guidelines are kept in mind, the older diabetic patient can be managed on a sulfonylurea agent in conjunction with the appropriate diet. Should these measures prove to be ineffective, then insulin therapy should be instituted. Controlling chronic hyperglycemia will help improve the quality of life for patients with diabetes and decrease the probability of developing some of the devastating complications associated with this disease.
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PMID:Use of sulfonylurea agents in older diabetic patients. 222 54

To examine the effects of intensive patient and/or physician diabetes education on patient health outcomes, a controlled trial was conducted in which internal medicine residents and their 532 diabetic patients were randomly assigned to: routine care; patient education; physician education; or both patient and physician education. Patient outcome data were analyzed either by analysis of covariance on post intervention values (2-hour post-prandial plasma glucose [PPG]; body weight [BW]; blood pressure [BP]; or analysis of variance conducted on change values (fasting plasma glucose [FPG] and glycosylated hemoglobin [A1Hgb]). After patient education, significant improvements were observed in FPG, A1Hgb, BW, and systolic and diastolic BP. Physician education resulted in significant decreases in FPG, A1Hgb and BW. The combination of patient plus physician education resulted in the greatest improvements in patients' health outcomes including FPG, A1Hgb, PPG, BW and diastolic BP. Adjusted systolic BPs were not significantly different in the two groups. While these physiologic improvements were statistically and probably clinically significant, hyperglycemia and obesity still persisted. Thus, achieving optimal patient outcomes for a chronic disease like diabetes mellitus may require a greater or more effective use of resources than currently estimated.
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PMID:DIABEDS: a randomized trial of the effects of physician and/or patient education on diabetes patient outcomes. 354 57

Studies on the reliability of the HbA1 assay in mass surveys for diabetes mellitus were carried out with special reference to the preservation and transportation of blood samples. It is essential to confirm that the preservation and transportation of samples have no effect on values for HbA1, since most of the mass surveys are carried out as field works. In our experience the levels of HbA1 remained unchanged for one week, both in samples kept at 4 degrees C, and in frozen samples kept at -40 degrees C or -80 degrees C and transported on solid CO2. The levels of HbA1 in the samples transported from Manila to Wakayama by the above-mentioned methods did not differ from those obtained in corresponding fresh samples. There was a good correlation between levels of HbA1 and levels of plasma glucose obtained 1 or 2 hr after breakfast (PPG). It was concluded that the use of both criteria (HbA1 of more than 8.00% and PPG of more than 120 mg/100 ml) in the diagnosis of diabetes mellitus is more reliable than use of either one alone.
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PMID:Reliability of HbA1 assay in the mass survey for diabetes mellitus, with special reference to the preservation and transportation of blood samples. 668 May 50

Amaurosis fugax has frequently been related to carotid artery disease. In order to determine the relationship between amaurosis fugax and significant carotid artery stenosis, we prospectively studied 81 consecutive patients presenting to an ophthalmologist with this symptom. Neurologic and vascular evaluation with PPG and Duplex-scan were performed. A stenosis of greater than 70% was regarded as significant. DSA was performed in patients with significant stenosis (55 of 81). The presence of risk factors such as hypertension, diabetes, coronary artery disease, tobacco and hyperlipidemia was considered. Mean age was 64.96 years. There was a high prevalence of hypertension, smoking and previous CVA/TIAs. Patients with significant carotid stenosis were endarterectomized. Carotid atheromata plaques were classified in three groups: hemorrhagic plaque (5), dystrophic calcification (8) and ulcerated plaque (42). There was a high correlation (0.87) between ulcerated plaque and amaurosis fugax. We conclude that amaurosis fugax is an important symptom to allocate patients with high risk of carotid disease, specially carotid stenosis complicated with ulcerated plaque. Carotid duplex scan must be done if this symptom is present.
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PMID:Amaurosis fugax as a symptom of carotid artery stenosis. Its relationship with ulcerated plaque. 812 72

Combination of insulin and metformin has been shown to improve glycaemic control in clinical trials, particularly in obese patients with diabetes type 2. Insulin therapy can improve function of pancreatic beta cells and periphery insulin activity in target cells in order to enhance glycaemic homeostasis (1, 2, 3). In our study we included obese patients with diabetes type 2 in the early stage of the disease. The study is partially retrospective and partially prospective. The study encompassed 40 patients split in two groups. The first group of 20 patients received insulin therapy combined with metformin, while the patients of the second group were treated with oral antidiabetic drugs, sulfonylureas and metformin. Three months later, the group treated with insulin and metformin showed improvement in the monitored parameters, namely significant reduction in HbA1c (p = 0.003), MFBG (p = 0.0009), PPG (p = 0.028). Insulin therapy administered together with metformin, in obese patients with diabetes type 2, in the early stage of the disease, resulted in well regulated fasting blood glycaemia, as well as post challenge glycaemia and HbA1c.
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PMID:The effects of combined insulin and metformin therapy in obese patients with diabetes mellitus type 2 in the early stage of the disease. 1687 15

To determine the relationships between HbA1c, characteristics of hyperglycemia and glycemic variability in well-controlled type 2 diabetes (HbA1c<7.0%), we studied 63 primary-care patients (36 men and 27 women), aged 34-75 years, with type 2 diabetes for 2-32 years using a continuous glucose monitoring system (CGMS) and standardized meal test (MMT). Duration of hyperglycemia (>8.0 mmol/l), standard deviation score (S.D.-score) and mean amplitude of glycemic excursions (MAGE) were analyzed from CGMS data and postprandial glucose during MMT (PPG(MMT)). Patients were hyperglycemic for 5.7h/day (median), experienced 4.1 hyperglycemic episodes/day, and 78% exceeded PPG levels of 8.0 mmol/l. HbA1c, though associated with the extent of hyperglycemia (r=0.40, p<0.001), failed to correlate with S.D.-score and MAGE. Multiple regression analysis demonstrated that HbA1c was predicted only by fasting glucose (R(2)=0.24, p<0.001) but neither by PPG(MMT), duration of hyperglycemia, S.D.-score nor MAGE. CGMS and meal test provide the tools for complete characterization of glycemia in type 2 diabetes. In well-controlled type 2 diabetes, HbA1c correlates with chronic hyperglycemia but not with glucose variability. Our data suggest that chronic sustained hyperglycemia and glucose fluctuations are two independent components of dysglycemia in diabetes.
Diabetes Res Clin Pract 2007 Sep
PMID:Chronic hyperglycemia but not glucose variability determines HbA1c levels in well-controlled patients with type 2 diabetes. 1733 14

Diabetes mellitus is a major risk factor for cardiovascular disease and mortality. Diabetic patients have a two- to fourfold increased risk of developing cardiovascular disease. There is convincing evidence that tight glycemic control aimed at lowering HbA(1c) reduces cardiovascular risk. However, even well-controlled diabetic patients remain at increased risk. The reason is that, although antihyperglycemic agents have been available for many years, we have been unable to mimic physiological insulin secretion. Type 2 diabetic patients typically lose the first phase of insulin secretion very early in the course of their disease, resulting in increased postprandial glucose excursions (PPGEs). This has, until recently, been largely neglected. This review will discuss the physiological control of postprandial glucose, as well as the causes of increased PPGEs and of other features of postprandial dysregulation seen in subjects with abnormal glucose tolerance. It will also discuss the effects of increased PPGE on the endothelium and review the epidemiological data linking postprandial hyperglycemia to cardiovascular disease. Finally, the effectiveness of a number of therapeutic options in lowering postprandial glucose and their effect on the endothelium and outcome will be reviewed. However, the possible role of PPG in cancer risk and in cognitive function is beyond the scope of this review and will not be discussed.
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PMID:Role of postprandial hyperglycemia in cardiovascular disease. 1857 Jun 23

To examine the serum 1,5-anhydroglucitol (AG) levels as a surrogate measure of postprandial hyperglycemia (PPH) and insulin secretion in a wide range of hyperglycemia, we compared the relationship between the glycemic index during a 75g oral glucose tolerance test (OGTT) and the insulinogenic index and 1,5-AG according the overall glycemic state. Fasting serum 1,5-AG levels were lower in the type 2 diabetic group (18.0+/-7.0microg/mL) than in the normal glucose tolerance (NGT, 25.4+/-4.0microg/mL), impaired fasting glucose (IFG, 24.6+/-6.2microg/mL), and impaired glucose tolerance (IGT, 22.1+/-6.2microg/mL) groups and were clearly correlated with glycemic values from the OGTT. 120-min post-challenge plasma glucose (PPG(120)) emerged as an independent predictor for 1,5-AG levels after multiple linear regression analysis (beta=-0.554, P<0.001). Additionally, 1,5-AG levels were significantly correlated with PPG(120) in each quartile of A1C, and the coefficients increased with higher A1C quartiles. Subjects with low 1,5-AG levels had both increased insulin resistance and decreased insulin secretion. Decreased 1,5-AG levels are closely correlated with PPH and decreased insulin secretion capacity across a wide range of glycemia, even in relatively well-controlled diabetes.
Diabetes Res Clin Pract 2009 Apr
PMID:1,5-Anhydroglucitol reflects postprandial hyperglycemia and a decreased insulinogenic index, even in subjects with prediabetes and well-controlled type 2 diabetes. 1918 97

OBJECTIVE This study tested a model hypothesizing that treatment affects objective clinical outcomes, which in turn affect perceived consequences, which in turn affect satisfaction and preference judgments. RESEARCH DESIGN AND METHODS The model was tested in a double-blind, randomized clinical trial in which 266 patients with type 1 diabetes added active or placebo pramlintide to their insulin regimens. Objective clinical outcomes included changes in glucose and weight control, insulin requirements, incidence of hypoglycemia, and study drug tolerance. At the end of the trial, patients completed the validated PRAM-TSQ questionnaire measuring treatment satisfaction and preference and perceived medication benefits and side effects. RESULTS Statistical modeling demonstrated that active pramlintide was significantly associated with greater treatment satisfaction, preference, and perceived benefits (all except hypoglycemia prevention), as well as objective clinical outcomes (weight loss, lower postprandial glucose [PPG], lower medication tolerance, more hypoglycemia). Perceptions of treatment consequences were sensitive and specific to their cognate objective clinical outcomes (no halo effects). Clinical outcomes (especially PPG) accounted for almost half of the effect of the study medication on treatment satisfaction and preference. Treatment satisfaction and preference were strongly related to the perceived benefits/side effects of the study medication, and these perceptions (especially glucose control) mediated most of the association of clinical outcomes with satisfaction and preference. CONCLUSIONS This model received substantial empirical support. Improvements in objective clinical outcomes accounted for a large part of the association of pramlintide treatment with higher treatment satisfaction and preference. Perceived treatment consequences mediated the effect of objective clinical benefits on satisfaction with and preference for the study medication.
Diabetes Care 2009 Aug
PMID:How does treatment satisfaction work?: Modeling determinants of treatment satisfaction and preference. 1947 Aug 37

PPG is an important target to address in the overall management of T2DM. Lifestyle interventions play an important role in PPG control, as well as global diabetes management goals. Oral antihyperglycemic agents lower PPG to varying degrees. Our most powerful treatment option to address PPG is prandial insulin. Collaboration between patient, primary care clinician, diabetes educator, and dietitian is critical to successful initiation of insulin therapy.
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PMID:The importance and treatment of postprandial hyperglycemia. 2054 57


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