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2008 Resource Guide. Diabetes Forecast. 61(1): RG1-RG60. January 2008.

This special section of Diabetes Forecast offers the annual guide to diabetes products and services. The guide lists items in seven categories: new diabetes products, type 2 oral medications, insulin, insulin delivery, blood glucose monitoring and data management systems, products for treating low blood glucose, and urine testing. Specific products include human and analog insulin, syringes, injection aids, insulin pens and pen needles, insulin pumps, aids for people who are visually and physically impaired, blood glucose meters, ways to pair the blood glucose meter with software, blood-sampling supplies, meter supplies, glycohemoglobin tests, microalbuminuria testing kits, and over-the-counter products for meal replacement. Each category includes a section of text, bringing readers up to date on the changes in that area, and charts summarizing the products available. The guide includes a list of manufacturers and distributors, arranged alphabetically. 10 figures. 20 tables.

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Appendix IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 103-123.

This appendix is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. This appendix offers a wealth of resource materials, including information about diabetes medications and insulin pumps, how to measure insulin, insulin storage guidelines, a recommended schedule of health care for adults, questions and information to prepare before going to see a health care provider, healthy snacks, restaurant favorites for people following a healthy diabetes diet, using the glycemic index, sample menus for weight loss, and a list of learning resources, including the website addresses of a number of organizations. Much of the information is provided in figures, lists, and charts for ease of access and understanding. 1 figure. 11 tables.

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Bariatric Surgery in Patients With Morbid Obesity And Type 2 Diabetes. Diabetes Care. 31(Suppl 2): S297-S302. February 2008.

This article brings readers up to date on current options of bariatric surgery in patients with morbid obesity and type 2 diabetes. The authors briefly review the various approaches to weight loss, including lifestyle intervention, diet therapy, behavior modification, exercise programs, and drug therapy, noting that these usually result in only modest and transient weight loss, particularly in patients with severe obesity. Recent studies show that surgical treatment was significantly more effective than nonsurgical therapy in reducing weight, resolving the metabolic syndrome, and improving quality of life during a 24-month treatment program. The authors summarize the different types of bariatric surgical procedures that can be used and report the results found with each type. They discuss the reversibility of type 2 diabetes after bariatric surgery, observing that euglycemic and normal insulin levels can occur within days after surgery, long before there is any significant weight loss. Other topics discussed include perioperative risk and care of bariatric surgery; and the complications, failures, and weight gain that can be seen as long-term results after bariatric surgery. The authors conclude that the only effective and enduring therapy for morbid obesity is weight-loss surgery. Certain risks exist for weight-loss surgery that can be reduced by surgical experience and patient selection, education, and lifelong surveillance. 65 references.

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Bariatric Surgery in Patients With Morbid Obesity And Type 2 Diabetes. Diabetes Care. 31(Suppl 2): S297-S302. February 2008.

This article brings readers up to date on current options of bariatric surgery in patients with morbid obesity and type 2 diabetes. The authors briefly review the various approaches to weight loss, including lifestyle intervention, diet therapy, behavior modification, exercise programs, and drug therapy, noting that these usually result in only modest and transient weight loss, particularly in patients with severe obesity. Recent studies show that surgical treatment was significantly more effective than nonsurgical therapy in reducing weight, resolving the metabolic syndrome, and improving quality of life during a 24-month treatment program. The authors summarize the different types of bariatric surgical procedures that can be used, and report the results found with each type. They discuss the reversibility of type 2 diabetes after bariatric surgery, observing that euglycemic and normal insulin levels can occur within days after surgery, long before there is any significant weight loss. Other topics discussed include perioperative risk and care of bariatric surgery and the complications, failures, and weight gain that can be seen as long-term results after bariatric surgery. The authors conclude that the only effective and enduring therapy for morbid obesity is weight loss surgery. Certain risks exist for weight loss surgery that can be reduced by surgical experience and patient selection, education, and lifelong surveillance. 65 references.

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Combined Therapy with Insulin Plus Oral Agents: Is There Any Advantage? An Argument in Favor. Diabetes Care. 31(Suppl 2): S125-S130. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the use of combined therapy with insulin plus oral agents for patients with type 2 diabetes. The authors describe an argument in favor of combined therapy in a recent debate examining the advantages and limitations of this approach. They describe the pharmacologic rationale for combining agents, present some new physiologic evidence for combining an oral agent with insulin, and offer a few examples of clinical studies showing advantages of combined therapy over insulin used alone. The authors conclude that, when oral therapy is continued during insulin therapy, enhancing either the availability or effectiveness of endogenous insulin, glycemic stability may improve and may lead to better overall glycemic control with similar hypoglycemic risk, or equal glycemic control with less hypoglycemia. In the case of metformin, combination with insulin limits the risk of weight gain. The authors call for additional, longer term medical outcome studies that compare insulin alone with insulin plus oral therapy. 5 figures. 28 references.

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Coming of Age for the Incretins. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press.2008. pp 269-290.

This chapter about the incretin hormones, glucose-dependent insulinotropic polypeptide (GIP), and glucagon-like peptide-1 (GLP-1), is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter consider the role of these incretin hormones in postprandial insulin secretion, which is insulin secretion that happens after a meal. They note that, in type 2 diabetes, the incretin effect is severely reduced. Substitution therapy with GLP-1 can result in glucose-induced insulin secretion, up-regulation of insulin and other beta-cell genes, stimulation of beta-cell proliferation, neogenesis and inhibition of beta-cell destruction, inhibition of glucagon secretion, inhibition of gastric emptying, and inhibition of appetite and food intake. However, GLP-1 is rapidly destroyed by an enzyme called dipeptidyl peptidase IV (DPP-IV), so any drug therapy that uses GLP-1 will require orally active DPP-IV inhibitors. The authors describe the animal studies and clinical trials that have focused on these incretins. One GLP-1 receptor activator (Byetta) and one of the DPP-IV inhibitors are already on the market and other compounds are in late phases of development or awaiting approval. 110 references.

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Insulin And Incretins. Clinical Diabetes. 26(1): 35-39. Winter 2008.

This article is part of a 12-part series for physicians in training that reviews the fundamentals of diabetes care; this article summarizes the use of insulin and Incretins. The author notes that insulin has been combined with additives and modified at the molecular level to changes its pharmacokinetic properties. Some insulin preparations accelerate insulin’s effects in the bloodstream, and others prolong the pharmacokinetic profile. The author describes specific drugs, including regular insulin, insulin analogs, inhaled insulin, protamine solutions, zinc solutions, and long-acting insulin analogs, including glargine and detemir. The article outlines standard insulin regimens, newer insulin regimens, the approach to initiating insulin therapy, and the use of incretins, such as exenatide, and the amylin analog, pramlintide. The author emphasizes that good understanding of the pharmacokinetics of insulin action and proper management on insulin regimens allow health care providers and patients to control blood glucose levels and safely avoid hypoglycemia and hyperglycemia. 32 references.

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Insulin as a First-Line Therapy in Type 2 Diabetes: Should the Use of Sulfonylureas be Halted?. Diabetes Care. 31(Suppl 2): S136-S139. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the use of insulin as a first-line therapy in patients with type 2 diabetes, supplanting the use of sulfonylurea compounds. The authors explore the advantages and drawbacks to each therapy, focusing on the evidence base, the limitations of present information, other treatment options, pathogenesis, and the impact of specific drug regimens on cardiovascular disease (CVD). The authors conclude that it is not easy to recommend a simple treatment regimen for patients with type 2 diabetes, and the complexities are not only based on whether or not insulin should be a first-line therapy. They stress that appropriate therapy of type 2 diabetes needs to be highly individualized, taking contraindications and potential downsides of treatment options into account and trying to define and target the leading pathogenetic defects behind the prevailing metabolic phenotype. Cost considerations must be figured into the decision. A patient care algorithm for the management of hyperglycemia in type 2 diabetes is presented. 1 figure. 23 references.

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Living With Diabetes IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 3-12.

This chapter about living with diabetes is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors define the different types of diabetes, including type 1, type 2, and gestational diabetes; describe the tests used to diagnose diabetes; explain the glycosylated hemoglobin (HbA1c) test and how it is used to monitor diabetes management; review common diabetes symptoms; explain the stepped progression of diabetes care; and address concerns that readers may have about taking insulin. Readers are reminded that needing to go on insulin does not mean that they have failed in their diabetes care, but merely that their body needs the additional treatment that insulin can provide. Much of the information throughout the chapter is provided in figures, lists, and charts for ease of access and understanding. 4 figures. 3 tables.

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Long-Acting Insulin Analogs Versus Insulin Pump Therapy for the Treatment of Type 1 And Type 2 Diabetes. Diabetes Care. 31(Suppl 2): S140-S145. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reports on the use of long-acting insulin analogs versus insulin pump therapy for the treatment of patients with either type 1 or type 2 diabetes. The authors consider whether multiple daily injection (MDI) regimens based on new long-acting insulin analogs such as glargine and detemir have now replaced the need for continuous subcutaneous insulin infusion (CSII). They discuss hypoglycemia, elevated glycosylated hemoglobin (A1C ) levels and glycemic variability, the dawn phenomenon, the problems of poor control in type 2 diabetes, and CSII as a management strategy in type 2 diabetes. They conclude that long-acting insulin analogs have not yet replaced the need for insulin pump therapy in type 1 diabetes, and CSII is the best current treatment option for some people with type 1 diabetes. In type 2 diabetes, CSII and MDI produce similar glycemic control, although there is little research on the use of MDI based on long-acting analogs compared with insulin pumps. 4 figures. 2 tables. 47 references.

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Nonalcoholic Fatty Liver Disease. IN: Hauser, S., ed. Mayo Clinic Gastroenterology and Hepatology Board Review. 3rd ed. New York, NY: Informa Healthcare USA. 2008. pp 407-418.

This chapter on nonalcoholic fatty liver disease (NAFLD) is from a comprehensive textbook that provides an in-depth examination of essential knowledge in gastroenterology, hepatology, and the related areas of pathology, endoscopy, nutrition, and radiology. The author defines NAFLD as the accumulation of fat, mainly triglycerides, in hepatocytes that results from insulin resistance. NAFLD includes a wide range of disease, from bland hepatic steatosis, which is generally benign, to nonalcoholic steatohepatitis (NASH), which may progress to cirrhosis and liver failure. The chapter covers clinical manifestations, imaging features, diagnosis, staging with liver biopsy, prognosis, drug therapy, treatment of associated conditions, and prevention strategies. The author cautions that weight gain and obesity resulting from an increased sedentary lifestyle and diets with a high content of fat and carbohydrates seem to be key factors in the development of insulin resistance and NAFLD. The chapter includes full-color and black-and-white illustrations. 4 figures. 4 tables. 20 references.

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Staying Healthy For a Lifetime. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 87-102.

This chapter about staying healthy with diabetes is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors emphasize that complications associated with diabetes are not inevitable but that readers must be aware of them and implement treatment plans when they do occur. Topics include balancing stress, how to manage diabetes and a busy lifestyle, the psychosocial impact of dealing with a chronic disease, the different types of diabetes complications, cardiovascular diseases and how to prevent them, high blood pressure or hypertension, cholesterol management strategies, smoking and diabetes, steps to good foot care, sensory nerves and blood circulation, planning for pregnancy, and other diabetes complications. Much of the information is provided in figures, lists, and charts for ease of access and understanding. 6 figures. 1 table.

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Taking Insulin. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 13-22.

This chapter about taking insulin is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors review the different types of insulin, outline the most common insulin plans used, explain how to measure insulin and inject it, discuss insulin storage, and help readers understand the emotions they might experience as they adjust to using insulin. Readers are referred to three resource organizations for help in locating a mental health care provider. Much of the information is provided in figures, lists, and charts for ease of access and understanding. 4 figures. 1 table.

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Targets for Intervention in Dyslipidemia in Diabetes. Diabetes Care. 31(Suppl 2): S241-S248. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reviews the targets used for intervention in dyslipidemia in people with diabetes. Topics include atherosclerosis and blood glucose control, atherosclerosis and diabetic dyslipidemia, diabetes and hypertriglyceridemia, low-density lipoprotein (LDL) in diabetes, high-density lipoprotein (HDL) activity, fatty acids and insulin secretion, the lipoprotein cascade, regulation of the chylomicron, and plant sterols and diabetes. The author notes that the abnormalities in fatty acid metabolism caused by diabetes result in an abnormal lipoprotein cascade from the large chylomicron particle to the small HDL particle. Thus, drugs that alter formation of the chylomicron particle might have a very important role in diabetic dyslipidemia. The author reviews some of the newer treatment options, including drug therapy and dietary recommendations, for patients with dyslipidemia and diabetes. 2 figures. 79 references.

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Treatment of Type 2 Diabetes with Combined Therapy: What Are the Pros and Cons?. Diabetes Care. 31(Suppl 2): S131-S135. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the advantages and limitations of the treatment of type 2 diabetes with combination therapy. The authors recommend a stepwise approach for the treatment of type 2 diabetes, tailored according to the natural course of the disease, including adding insulin when hypoglycemic oral agents fail. They stress that treatment with insulin alone should eventually be considered in a relevant number of cases. Insulin can result in protective effects on beta-cell survival and function, resulting in more stable metabolic control. In comparison, treatment with most insulin secretagogues has been associated with increased beta-cell apoptosis, reduced responsiveness to high glucose, and impairment of myocardial function during ischemic conditions. Insulin treatment, particularly with rapid-acting analogs, has been demonstrated to successfully control postprandial hyperglycemia. The authors voice a final concern about combination regimens in the evidence that polypharmacy can reduce patient compliance to the treatment regimen. 56 references.

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Understanding Insulin And Amylin. 3rd ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).

This DVD program reviews how insulin works in the body and how it can be used to help people with diabetes keep their blood glucose levels in a healthy range. The program introduces amylin, another pancreatic hormone, and explains how taking the drug pramlintide (Symlin) can help people who use insulin maintain greater control of their blood glucose levels. Other topics include insulin and amylin safety, storage, recordkeeping, hypoglycemia, and how to handle sick days. Viewers are reminded of the importance of a comprehensive self-management plan for keeping diabetes under control. The video depicts a variety of people who share their experiences with diabetes management, insulin use, and pramlintide use. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.

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What I Need to Know About Diabetes Medicines. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 16 p.

This booklet helps readers with diabetes understand how diabetes medicines help keep their blood glucose levels in healthy target ranges. Written in nontechnical language, the booklet describes how these medications work; recommended targets for blood glucose levels, including for before and after meals; how blood glucose levels are affected by the presence of diabetes; medicines that may be used for each of the types of diabetes, including type 1, type 2, and gestational diabetes; and the types of diabetes medications and their forms, including insulin injections and insulin pumps, the side effects of insulin, the different types of insulin, oral medications, and injections other than insulin. Inside the back cover of the booklet is a folder with numerous inserts that provide information about specific drugs. The first insert is a form on which readers and their health care providers can record the medications currently prescribed. A second insert offers a list of questions patients might want to ask about their diabetes medications, and a third insert summarizes the different types of insulin. The remaining inserts provide specific information about the following drugs: the alpha-glucosidase inhibitors Glyset (miglitol) and Precose (acarbose); the biguanides Glucophage (metformin), Glucophage XR (long-acting metformin), and Riomet (liquid metformin); Starlix (nateglinide); the DPP-4 inhibitor Januvia (sitagliptin); a meglitinide called Prandin (repaglinide); sulfonylurea compounds including Amaryl (glimepiride), DiaBeta (glyburide), Diabinese (chlorpropamide), Glucotrol (glipizide), Glucotrol XL (long-acting glipizide), Glynase (glyburide), Micronase (glyburide), and the generics tolazamide and tolbutamide; thiazolidinediones Actos (pioglitazone) and Avandia (rosiglitazone); the combination pill Actoplus Met (pioglitazone and metformin); and the amylin mimetic Symlin (pramlintide). Each drug insert explains what the drug is supposed to do, who should and should not take the drug, and possible side effects. A final insert discusses low blood glucose levels. Blank spaces in different sections of the booklet allow readers to note their own individual prescriptions. The booklet concludes with a list of resources from which readers can get more information and a brief description of the goals and activities of the National Diabetes Information Clearinghouse.

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Clinical Practice Recommendation 3: Diabetes and Chronic Kidney Disease in Special Populations [KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease]. American Journal of Kidney Diseases. 49 (2 Suppl 2): s120-s130. February 2007.

The increasing incidence of diabetes in children, young adults, the elderly, and members of disadvantaged and transitional populations is responsible for a concurrently increasing incidence of diabetic kidney disease (DKD) in these groups. In pregnant women, the presence of diabetes and chronic kidney disease (CKD) may adversely affect the health of both the mother and her baby. This article is from a special supplement to the American Journal of Kidney Diseases that presents the Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. This is the first set of guidelines that considers the unique aspects of the evaluation, diagnosis, and management of the complex patient with both diabetes mellitus and CKD. The guidelines emphasize these patients’ high risk of cardiovascular disease. This article presents and discusses the third clinical practice recommendation: management of diabetes and CKD in special populations. The article focuses on six clinical practice recommendations: screening and interventions for diabetes and CKD should focus on populations at greatest risk; treatment of children, adolescents, and older adults warrants special considerations; population-based interventions may be the most cost-effective means for addressing the burden of CKD in special populations; specialists in high-risk pregnancy and kidney disease should co-manage pregnancy in women with diabetes and CKD; treatment of DKD with RAS inhibitors before pregnancy may improve fetal and maternal outcomes, but these medicines should be discontinued during pregnancy; and insulin should be used to control hyperglycemia if drug therapy is necessary in pregnant women with diabetes and CKD. A final section discusses implementation issues. The article features tables that summarize the research studies used to establish the guidelines. 2 figures. 6 tables.

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Designing a Conventional Insulin Treatment Program. IN: Beaser, R.S., ed. Joslin’s Diabetes Deskbook: A Guide For Primary Care Providers. 2nd ed. Boston, MA: Joslin Diabetes Center. 2007. pp 281-324.

This chapter on conventional insulin treatment programs for diabetes is from a book that gives primary care providers a comprehensive overview of diabetes care. The author briefly describes some of the psychosocial perspectives on insulin, reminding physicians that their own attitudes can have an impact on their patient’s willingness to incorporate insulin into their treatment regimen. The chapter covers the indications for insulin therapy, for both type 1 and type 2 diabetes, and concerns about insulinopenia; the goals of insulin treatment; glucose monitoring programs for patients using insulin; the initiation of insulin therapy for type 1 diabetes, including choosing the appropriate insulin program and designing a specific insulin program; initiation of insulin therapy for type 2 diabetes; the implications of insulin quantity; specific insulin regimens; intensified conventional therapy; modifying the insulin treatment program; coping with rebound hyperglycemia; and adjustment guidelines, notably redesigning the insulin program. A lengthy table provides guidelines for insulin adjustment in response to specific problems that the patient is encountering. 10 figures. 3 tables.

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Diabetes and Incretin-Based Therapy. Chevy Chase, MD: Hormone Foundation. 2007. 1 p.

This brief fact sheet reviews the use of incretin-based therapy for treating diabetes, a disease characterized by blood glucose levels that are higher than normal. Diabetes occurs when the pancreas does not produce enough insulin or when the body becomes resistant to the effects of insulin. The fact sheet first outlines the three main types of diabetes: type 1, type 2, and gestational diabetes. The fact sheet then answers common questions about treatments for diabetes, a type of incretin called GLP-1, the effects of incretins on blood glucose levels, the details of incretin-based therapy, the use of incretin mimetics such as exenatide, the use of DPP-IV inhibitors, and indications for incretin-based therapy. The fact sheet notes that both exenatide and DPP-IV inhibitors are used primarily in people with poorly controlled diabetes, often in conjunction with other antidiabetic medications. The fact sheet concludes with a section of practical strategies for incorporating this information into one’s daily diabetes care. Readers are referred to the Hormone Foundation’s website at www.hormone.org and other resources for more information. The fact sheet is also available in Spanish. 4 references.

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Diabetes and New Insulins. Chevy Chase, MD: Hormone Foundation. 2007. 1 p.

This brief fact sheet reviews some of the new insulins that are available to help treat diabetes, a disease characterized by blood glucose levels that are higher than normal. Diabetes occurs when the pancreas does not produce enough insulin or when the body becomes resistant to the effects of insulin. The fact sheet first outlines the three main types of diabetes: type 1, type 2, and gestational diabetes. The fact sheet then answers common questions about how diabetes is treated, the different types of insulins, the differences between mealtime or bolus insulin and basal insulin, and the new insulin preparations, including insulin analogs and inhaled insulin. The fact sheet concludes with a section of practical strategies for incorporating this information into one’s daily diabetes care. Readers are referred to the Hormone Foundation’s website at www.hormone.org and other resources for more information. The fact sheet is also available in Spanish. 4 references.

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Diabetes and New Insulins. Chevy Chase, MD: Hormone Foundation. 2007. 1 p.

This brief fact sheet provides an overview of diabetes and new insulins. Insulin is a hormone that takes the glucose from the bloodstream and carries it inside the body’s cells, where it is used for energy. Diabetes occurs when the pancreas does not produce enough insulin or when the body becomes resistant to the effects of insulin. Written in nontechnical language, the fact sheet answers common questions about the three major types of diabetes, how diabetes is treated, the different types of insulin, and new insulin analogs, including glargine, detemir, lispro, aspart, glulisine, and inhaled insulin. Readers are referred to the Hormone Foundation (www.hormone.org or 1–800–HORMONE) for more information. The fact sheet is also available in Spanish. 1 figure.

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Diabetic Retinopathy and Diabetic Neuropathy. Diabetes Care. 30(3): 760-763. March 2007.

This is the sixth in a series of articles on presentations given at the American Diabetes Association’s 66th Scientific Sessions held in Washington, DC, in June 2006. In this entry, the author summarizes some of the presentations on diabetic retinopathy and neuropathy and lower extremity vascular disease. Topics include the use of insulin-like growth factor (IGF)-1 antagonists for treating diabetic retinopathy, octreotide, the relationship between dyslipidemia and diabetic retinopathy, the use of statins, the idea of the eye as a risk marker for cardiovascular disease (CVD), new therapies for diabetic retinopathy, drug therapy for patients with painful diabetic neuropathy, and the clinical syndrome and symptoms of diabetic neuropathy. The author includes results from the presentations and extensive references for readers wishing to obtain additional information. 45 references.

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Diagnosing and Managing the Metabolic Syndrome in Adults, Children, and Adolescents. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 43-87.

The term “metabolic syndrome” refers to a clustering of specific cardiovascular disease (CVD) risk factors whose underlying pathophysiology is believed to be related to insulin resistance. This chapter about diagnosing and managing metabolic syndrome in adults, children, and adolescents is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author briefly reviews the history of understanding metabolic syndrome, including its epidemiology, and then covers the risk factors; the role of obesity; treatments that focus on behavioral and lifestyle interventions; drug therapy, particularly for risk reduction intervention; the role of primary care physicians; and the importance of early recognition of symptoms and aggressive behavioral intervention. The author concludes by reiterating that health care providers should screen all at-risk children and adolescents for components of metabolic syndrome while promoting healthy lifestyle interventions with both the parents and the patient. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 6 figures. 16 tables. 118 references.

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Focal Fatty Liver: More Than Just a Radiographic Curiosity?. Gastroenterology and Hepatology. 3(3): 199-200. March 2007.

This article comments on an accompanying case report of a woman with multifocal nodular nonalcoholic steatohepatitis (NASH), in whom radiologic abnormalities dramatically resolved after she received the drug rosiglitazone. Nonalcoholic fatty liver disease (NAFLD) has been associated with insulin resistance, and insulin sensitizers have been previously shown to improve liver biochemistry and histology in NASH. This patient’s response to rosiglitazone included improvement in glycemic control, as well as improvement in insulin sensitivity in both the fasting and the fed states. In the commentary article, the authors review the different types of focal hepatic steatosis, note the lack of current understanding of focal fatty liver, briefly consider the natural history of focal hepatic steatosis, and discuss the physiology of vascular supply to the liver. The commentary concludes that the case report demonstrates an interesting variant of a very common cause of liver disease among both adults and children in the United States. The case also underscores the importance of liver imaging techniques in distinguishing focal hepatic steatosis from other mass lesions in the liver. 16 references.

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Guide to Insulin And Type 2 Diabetes. Alexandria, VA: American Diabetes Association. 2007. 234 p.

This handbook helps people with type 2 diabetes understand the role of insulin in a comprehensive program of care to manage their disease. The author first reminds readers that type 2 diabetes is a progressive disease, so even patients who are doing all the recommended strategies of diet, exercise, and medications may still find the need to incorporate insulin to maintain appropriate blood glucose levels. The book includes chapters that cover the basics of blood glucose physiology and the normal progression of type 2 diabetes, the psychological aspects of adding insulin into a care regimen, the myths surrounding insulin, the different types of insulin, the usual insulin regimen, using insulin to cover meals, carbohydrate counting, sliding scales and pattern management, preventing and treating hypoglycemia, sick-day guidelines, and special circumstances such as traveling, pregnancy, and religious fasting. A final section walks readers through the practical aspects of buying, storing, and injecting insulin. Throughout the book are lengthy quotes from people who have experienced the shift to insulin therapy and who share their thoughts and perspectives about the topics under consideration. The book concludes with a subject index, a description of some of the other titles available from the American Diabetes Association (ADA), and a summary of the activities and contact information for various components of the ADA.

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Insulin Analogs and Pregnancy. Diabetes Spectrum. 20(2): 94-101. Spring 2007.

Diabetes during pregnancy is a major risk factor for poor fetal, neonatal, and maternal outcomes; however, this risk can be greatly reduced by the early use of medical nutrition therapy (MNT) and insulin treatment. This article explores the use of insulin analogs and pregnancy, focusing on the newer, rapid-acting insulin analogs lispro and aspart. The author stresses that maintaining maternal glycemic as near to normal as possible reduces the risk of congenital anomalies, macrosomia, neonatal hypoglycemia, and large-for-gestational-age infants. Topics include pregestational diabetes; gestational diabetes mellitus (GDM); the use of NPH insulin during pregnancy; current categories for drug use in pregnancy; long-acting insulin analogs, such as glargine and detemir, problems with retinopathy and insulin analogs; concerns about congenital anomalies and insulin analogs; and macrosomia and insulin analogs. The author concludes that, when compared with human regular insulin, the rapid-acting insulin analogs are effective at reducing hyperglycemia during pregnancy, with a safety profile that resulted in a lower incidence of neonatal complications. The long-acting insulin analogs do not yet have sufficient safety evaluation in clinical studies to warrant their use during pregnancy. The article includes a patient treatment algorithm as a guideline for all insulin-requiring pregnant women with type 2 diabetes, GDM, or type 1 diabetes. 1 figure. 7 tables. 67 references.

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Insulin Delivery. Diabetes Forecast. 60(1 Suppl RG): RG20-RG35. January 2007.

This article, from the annual resource guide that is published as a supplement to Diabetes Forecast, brings readers up-to-date on the equipment and supplies that can help patients use insulin. The author notes that these devices carry insulin through the outermost layer of skin and into fatty tissue so it can be used by the body. The author describes syringes, pumps, jet injectors, pens, and infusers; a separate section considers injection aids. Much of the information is presented in a detailed chart that lists the product name, size, name of manufacturer, needle gauge, needle size, and packaging. Additional charts list insulin pens, pen needles, and other delivery systems; insulin pumps; aids for people who are visually or physically impaired; and jet injectors. 7 tables.

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Insulin Pump Therapy. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 265-320.

Insulin pump therapy allows patients to manage their diabetes intensively by using a method that is pharmacologically superior to multiple daily injections (MDI). This chapter about insulin pump therapy is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author discusses the evolution of modern insulin pump technology, patient selection for pump therapy, improved overall glycemic control and reduced glycemic variability in patients using insulin pumps, talking about pump therapy with prospective patients, initiating pump therapy in the primary care setting, fine-tuning pump therapy, long-term follow-up of insulin pump patients, exercising with an insulin pump, and the use of insulin pump therapy in patients with type 2 diabetes. The author concludes that, compared with MDIs, insulin pump therapy has better insulin pharmacokinetics, less variability in insulin absorption, and decreased risk of hypoglycemia. Patients using insulin pumps enjoy greater lifestyle flexibility and often become more proactive in their approach to diabetes self-management. Although more expensive than MDIs, pump therapy offers patients a much more physiologic approach to controlling their diabetes. Careful evaluation of pump candidates, ongoing patient education, and timely follow-up visits are vital to the success of pump therapy. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 3 appendices. 9 figures. 9 tables. 32 references.

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Management of Type 2 Diabetes in Youth: An Update. American Family Physician. 76(5): 658-664. September 1, 2007.

Type 2 diabetes is emerging as an important disease in children and adolescents, accounting for 8 to 45 percent of new childhood diabetes. This article provides an update from the National Diabetes Education Program (NDEP) on the management of type 2 diabetes in youth. High-risk youths older than 10 years would be those who have a body mass index (BMI) greater than the 85th percentile for age and sex plus two additional risk factors such as family history, high-risk ethnicity, acanthosis nigricans, polycystic ovary syndrome, hypertension, or dyslipidemia. The authors stress that reducing overweight and impaired glucose tolerance with increased physical activity and healthier eating habits may help prevent or delay the development of type 2 diabetes in high-risk youths. Although population-based screening of high-risk youths is not recommended, physicians are encouraged to closely monitor these patients because early diagnosis is beneficial. Young patients who are diagnosed with diabetes need to received self-management education, behavior interventions to promote healthy eating and physical activity, appropriate drug therapy for hyperglycemia––usually metformin and insulin––and treatment of any comorbidities. A final section briefly describes ongoing clinical studies of youths with diabetes. The article includes a side bar that summarizes the related key recommendations for practice. 6 tables. 25 references.

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Modifying Insulin Resistance to Prevent Stroke: The IRIS Trial. Practical Diabetology. 26(2): 19-23. June 2007.

Decades of epidemiologic studies have strongly suggested a major, and probably independent, role of insulin resistance in the genesis and progression of macrovascular diseases, including stroke. New drug agents that enhance insulin sensitivity present an opportunity to test the link between insulin resistance and macrovascular diseases. After an introductory section on the role of insulin resistance in stroke, this article describes the Insulin Resistance Intervention after Stroke (IRIS) Trial, undertaken to help resolve the controversy about insulin resistance and stroke. The IRIS trial will assess the effectiveness of pioglitazone in improving cardiovascular outcomes in insulin-resistant nondiabetic ischemic stroke survivors. The primary end points are recurrent stroke and myocardial infarction. The secondary end points include the individual components of the primary end point, acute coronary syndrome, development of overt type 2 diabetes mellitus, all-cause mortality, cognitive decline, and hospitalization for heart failure. Patients were still being recruited to the trial as of June 2007. 1 table.

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Multifocal Nodular Nonalcoholic Steatohepatitis: Resolution With Rosiglitazone. Gastroenterology and Hepatology. 3(3): 196-198. March 2007.

This article presents a case report of a woman with multifocal nodular nonalcoholic steatohepatitis (NASH), in whom radiologic abnormalities dramatically resolved after she received the drug rosiglitazone. Nonalcoholic fatty liver disease (NAFLD) has been associated with insulin resistance, and insulin sensitizers have been previously shown to improve liver biochemistry and histology in NASH. This patient’s response to rosiglitazone included improvement in glycemic control, as well as improvement in insulin sensitivity in both the fasting and the fed states. The authors report on the patient’s diagnosis, including concerns that a 10.5 centimeter mass found in the patient’s liver would be cancerous. The patient’s condition did not respond to diet, exercise, and vitamin E—the first therapy attempted—but improvement was marked after the addition of rosiglitazone to the regimen. The authors conclude that this case demonstrates the importance of insulin resistance in the development and treatment of NASH. 2 figures. 19 references.

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New Agents for the Treatment of Diabetes. Review of Endocrinology. 1(2): 42-46. June 2007.

This article reviews new delivery methods for insulin and new agents for the treatment of diabetes, notably those based on the incretin phenomenon. The authors describe inhaled human insulin; pramlintide, which is an injectable synthetic analog of amylin; the incretin effect, which explains up to 60 percent of the postprandial insulin secretion of the pancreas; GLP-1 agonists, including exenatide and liraglutide; DPP-4 inhibitors, notably sitagliptin and vildagliptin; and the benefits of using these newer drugs in combination with older antidiabetic agents, particularly in patients with type 2 diabetes. The authors conclude that the GLP-1 receptor agonists and DPP-4 enzyme inhibitors offer comparable HbA1c lowering with few side effects and may also lead to weight loss. 1 figure. 3 tables. 24 references.

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Physiologic Insulin Replacement Therapy. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 192-264.

This lengthy chapter about physiologic insulin replacement therapy is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author stresses that understanding the pharmacokinetics and glucodynamic profiles of different insulin preparations is necessary to direct patients toward the treatment protocols that will allow them to maintain a safe and practical level of hemoglobin A1C. Patients with type 2 diabetes may be able to attain their target goal of A1C using “treat-to-target” protocols that use either basal insulin or mixed insulin analog in addition to oral agents. Most patients with type 1 diabetes should optimize their management using basal-bolus insulin. The author covers the history of insulin, the pathogenesis of type 1 diabetes, determining appropriate glycemic targets, strategies to reduce the costs of managing diabetes, the psychological impact of introducing insulin therapy, hypoglycemia, reducing hyperglycemia, ways to optimize patient adherence and remove barriers to insulin therapy, and insulin analogue formulations. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 13 figures. 18 tables. 101 references.

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Physiologic Insulin Treatment Programs. IN: Beaser, R.S., ed. Joslin’s Diabetes Deskbook: A Guide For Primary Care Providers. 2nd ed. Boston, MA: Joslin Diabetes Center. 2007. pp 325-384.

This chapter on physiologic insulin treatment programs for diabetes is from a book that gives primary care providers a comprehensive overview of diabetes care. The authors define physiologic insulin therapy, formerly called intensive insulin therapy, as treatment using exogenous insulin in a manner that attempts to mimic normal endogenous insulin secretory patterns of basal and postprandial insulin secretion. They provide a rationale for using physiologic therapy and discuss patient selection; key considerations for replacement therapy; physiologic insulin dosing schedules, including estimating starting doses and descriptions of basal insulin patterns; preparing patients to start physiologic insulin; health care providers best suited to work with the patient using physiologic insulin therapy; treatment adjustments; adjusting for hyperglycemia, including fasting hyperglycemia; adjusting for hypoglycemia, including the use of a systematic approach to determine cause and determining which insulin to reduce; weight gain or weight loss on physiologic insulin; replacement therapies; insulin pump therapy, including the decision to use a pump, assessment of patient candidacy for pump therapy, initiation of pump treatment, pump insulin doses, potential problems, coping with sick days while using an insulin pump, exercise adjustments, and going off the pump; and the use of pramlintide. The authors conclude that the best approach for patients using physiologic insulin is a consultative relationship between the primary care provider and a specialty center, even though this best practice approach may encounter some barriers in real world situations.

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Pills for Type 2 Diabetes: A Guide for Adults. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ). 2007. 14 p.

This patient education guide provides information about the various drugs that may be used to treat type 2 diabetes. In type 2 diabetes, the body either does not make enough insulin or it does not use insulin as effectively as it should. The guide reviews the common kinds of diabetes medications, how they work in type 2 diabetes, their side effects, and costs. The authors remind readers that different kinds of diabetes pills work in different ways to control blood glucose levels, and sometimes combining two different kinds of diabetes pills can work better to lower blood glucose than a single medication can. Specific medications covered include biguanides, sulfonylureas, meglitinides, thiazolidinediones, and alpha-glucosidase inhibitors. The guide also describes self-monitoring of blood glucose (SMBG) tests, and readers are encouraged to perform an SMBG test and to have their glycosylated hemoglobin levels checked a few times a year. Some common side effects of diabetes medications include weight gain, stomach problems, swelling, effects on cholesterol levels, hypoglycemia, lactic acidosis, and congestive heart failure. The guide does not cover the other components of treating type 2 diabetes, including diet and exercise. Readers are encouraged to consult the Agency for Healthcare Research and Quality’s website at www.effectivehealthcare.ahrq.gov or the Medline Plus website at www.nlm.nih.gov/medlineplus/diabetes.html for more information.

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Probe to Bone: What Do the Data Tell Us?. Diabetes Care. 30(6): 1663-1669. June 2007.

This article is the second in a series of four articles about presentations at the World Congress on the insulin resistance syndrome (IRS), reviewing the relationship between insulin resistance and nonalcoholic fatty liver disease (NAFLD) and aspects of insulin resistance in children and adolescents. Topics include diagnostic approaches to NAFLD, the increases in hepatic free cholesterol and lipid peroxidation in NAFLD, the evaluation and management of NAFLD, tests used to diagnose and monitor liver function, management approaches, the avoidance of alcohol and drugs, correction of underlying risk factors, the problem of liver complications arising after bariatric surgery in obese patients, drug therapy for diabetes that may affect NAFLD, cardiovascular disease risk factors, diagnosing insulin resistance in childhood and adolescence, the incidence of metabolic syndrome, the impact of parents with insulin resistance on the incidence of metabolic syndrome in their children, the fetal origins of IRS, long-term complications of IRS, type 2 diabetes in youth, the spectrum of insulin resistance among obese children, nonalcoholic steatohepatitis (NASH) in children and adolescents, and insulin sensitivity changes during puberty. 53 references.

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Products, Innovative Delivery Systems for Type 2 Diabetes. Review of Endocrinology. 1(2): 56-58. June 2007.

This article reviews new products and innovative delivery systems for managing type 2 diabetes mellitus. The author stresses that alternative drug delivery systems are becoming an important trend in diabetes therapy. The article describes the h-Patch (Valeritas), which is a basal bolus insulin delivery system; the U-strip insulin patch (Encapsulation Systems), an ultrasonic drug delivery system; AIR inhaled insulin (Eli Lilly and Alkermes), which is in phase 3 clinical trials for both type 1 and type 2 diabetes patients; a digital insulin pen (Eli Lilly) that has a memory and delivers insulin lispro; the I-PORT injection port (Patton Medical Devices), a 3-day delivery device through which injected medications can be administered without the need to puncture the skin with each injection; and the Cleo 90 infusion set (Smiths Medical), a single-use disposable infusion set. The author explains how each of these products and devices might be used in everyday management of diabetes. Quotations from manufacturers, users of the devices, and physicians are included.

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Treatment With Insulin and Its Analogs in Pregnancies Complicated by Diabetes. Diabetes Care. 30(Suppl 2): S220-S224. July 2007.

This article presents a literature review about the safety and effectiveness of insulin analogs in pregnancy, with the goal of enabling clinicians to choose the optimal insulin treatment protocol to achieve and maintain normoglycemia throughout pregnancies complicated by diabetes. Topics include the rationale for the use of nonimmunogenic insulins during pregnancy, long-acting insulin analogs such as insulin glargine and insulin detemir, and the potential risks associated with insulin analogs. The authors note that, if postprandial glucose is the target of treatment, the rapid-acting insulin lispro and insulin aspart appear to be as safe and effective as regular human insulin in women with GDM and they achieve better postprandial glucose concentrations with less late prandial hypoglycemia. If the patient has elevated fasting and postprandial blood glucose levels and requires multiple daily injections to achieve good glycemic control, a basal-bolus regimen should be considered. 1 table. 44 references.

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Uncompromising Approach to Achieving Glycemic Goals. Diabetes Educator. 33(Supl 3): S52-S59. March-April 2007.

This section on achieving glycemic goals is from a special, supplement of the Diabetes Educator that presents a continuing education program on early intervention with insulin analogs, from the American Association of Diabetes Educators (AADE) 2006 Annual Meeting in Los Angeles. The author addresses concerns that, despite excellent treatment options, a large number of people with diabetes are not meeting treatment goals, putting them at high risk for diabetes-related morbidity and mortality, including vascular complications and early death. The author describes the use of new diabetes medications and management tools in a program of earlier, more aggressive, and more comprehensive diabetes treatment. For example, some patients may benefit from earlier use of insulin replacement in their treatment programs. Maximal use should be made of both lifestyle changes and drug therapy to achieve targeted goals. In general, treatment strategies for type 2 diabetes should emphasize lifetime control of risk factors with specific treatment targets. Targets should include goals for glycemia as well as blood lipids and blood pressure. 5 figures. 2 tables. 20 references.

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Using Insulin to Treat Diabetes - General Principles. IN: Beaser, R.S., ed. Joslin’s Diabetes Deskbook: A Guide For Primary Care Providers. 2nd ed. Boston, MA: Joslin Diabetes Center. 2007. pp 249-279.

This chapter on general principles of insulin therapy for diabetes is from a book that gives primary care providers a comprehensive overview of diabetes care. The author notes that the key to insulin treatment is to design treatments that replace insulin in a manner that resembles normal physiologic patterns. For those with type 1 diabetes, this means focusing on careful monitoring of glucose levels and adjusting doses accordingly, as well as accommodating variations in food consumption and activity. The chapter covers endogenous insulin, insulin for exogenous therapy, insulin antibodies, insulin allergy, insulin storage, insulin injection, syringe preparation techniques, injection techniques, common mixtures, insulin pens, automatic injection aids and jet injectors, injection aids for people with low vision, injection sites, syringe reuse, and disposal of syringes. The chapter reviews the different types, brands, and mode of delivery of insulins; the role of concentration and insulin purity; and biologic activity of insulin. Line drawings of recommended insulin injection techniques are provided. 3 figures. 2 tables.

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What's New in Diabetes Care?. Diabetes Wellness News. 13(4): 1-2. April 2007.

This article briefly summarizes some new medications, new ways to deliver insulin, and new ways to monitor blood glucose levels for people with diabetes. The author discusses inhaled insulin, Exubera; two new injectable medications: Byetta and Symlin, which have effects in addition to lowering blood glucose levels, notably in reducing hunger and helping patients to lose weight; a new class of oral medications, the DPP–4 inhibitors: Januvia and Galvus, which lower blood glucose levels but also help control blood glucose levels after meals when they tend to be highest; the use of the oral medication Avandia to prevent or delay type 2 diabetes; the use of continuous blood glucose monitoring; and work on islet transplants. 1 figure.

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Art and Science of Diabetes Self-Management Education: A Desk Reference for Healthcare Professionals. Chicago, IL: American Association of Diabetes Educators. 2006. 821 p.

This comprehensive text serves as a resource for all health professionals, community professionals, and individuals who provide education to individuals with diabetes. The book follows the American Association of Diabetes Educators (AADE) strategic mission and vision and is intended to enhance the contribution of skilled diabetes educators to the patient care team. The first section of six chapters on understanding the individual’s health behavior and choices presents background and theoretical foundations essential to providing effective self-management education. The second section includes 18 chapters discussing various aspects of the disease, therapies, and chronic complications. And the final section of 11 chapters focuses specifically on well-designed diabetes education. Specific topics covered include the emotional and psychological challenges of chronic illness, community and society support for diabetes self-management, the pathophysiology of the metabolic disorder, hyperglycemia, Type 1 diabetes, Type 2 diabetes, pregnancy with preexisting diabetes, gestational diabetes mellitus (GDM), medical nutrition therapy (MNT), physical activity, drug therapy for glucose management, patient empowerment, intensive insulin therapy, dyslipidemia and hypertension in people with diabetes, biological complementary therapies in diabetes, chronic complications, macrovascular disease in diabetes, diabetic eye disease, diabetic kidney disease, diabetic neuropathies, the implementation of diabetes education, and evaluating and documenting patient education outcomes. Each chapter includes a list of key points, a series of case studies, a summary of teaching strategies, suggested Internet resources, a glossary of key terms, and a lengthy list of references. The text concludes with a detailed subject index and a brief overview of the goals and activities of the AADE.

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Bariatric Surgery: A Promising Solution for Nonalcoholic Steatohepatitis in the Very Obese. Journal of Clinical Gastroenterology. 40(Suppl): S44-S50. March 2006.

This article reviews the use of bariatric surgery for management of nonalcoholic steatohepatitis (NASH) in obese patients. The author notes that the mainstays of treatment for NASH, diet and physical activity plus behavioral modifications, are not always successful, particularly in the very obese. Only limited evidence exists that liver enzymes improve with reduction in body weight. The drug therapy in current use has focused on treating insulin resistance and oxidative stress, but again with rather limited success. The author emphasizes that, in the severely obese, the best treatment option is bariatric surgery, which is safe and has been successful in producing a 61 percent weight loss overall. The result is improvement in diabetes mellitus, the metabolic syndrome, and presumably its sequelae. Early reports (and procedures) were attended with dramatic weight loss but markedly aggravated the inflammatory liver disease. In recent trials with more modest weight loss and less malnutrition, bariatric surgery reduced the fat, inflammation, and even the fibrosis in well-documented NASH. The laparoscopic adjustable banding procedure is deemed most suitable for this purpose. The author cautions that ongoing care will be necessary with a lifetime follow-up because of the metabolic and other complications from the weight loss. 4 figures. 59 references.

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Can Medication Help?. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 126-138.

This chapter on drug therapy is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author describes the use of medications to help lower the risk of developing diabetes. There are glucose-lowering medications for people with diabetes which can work by helping the pancreas release more insulin, making the cells more sensitive to insulin, reducing the amount of glucose made by the liver, blocking digestion of carbohydrates or fat, or substituting for human insulin to help the cells use glucose. The author also outlines non-diabetes medications that may be useful, including anti-hypertensive agents or cholesterol-lowering drugs. Vitamin, mineral, and herbal supplements may also be used; the author outlines some of the studies on these alternative therapies, commenting on benefits, efficacy, and side effects reported. Readers are encouraged to work closely in tandem with their health care providers and to become an active, educated member of their own health care team. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. 2 tables.

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Conclusion. IN: Sharing the Burden: The Role of Incretins in Glucose Control. Chicago, IL: American Association of Diabetes Educators. 2006. p. 15.

New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This concluding section is from a clinical monograph on the role of incretins in glucose control; the monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators' 2005 Annual Meeting. The authors briefly review the limitations of current treatments for type 2 diabetes mellitus and consider the role of glucagon in disease pathophysiology. The authors then summarize the role of incretins and incretin-based therapies in suppressing glucagon secretion, as well as their contributions to reducing the burden of glucose control. The incretin GLP-1 has been identified as a critical player in glucose homeostasis, and a number of antihyperglycemic therapies targeting this pathway are now under development or in use. GLP-1 is released in response to a meal and acts on pancreatic islets to increase insulin secretion and inhibit glucagon release. GLP-1 also exerts a number of effects beyond those on the islet cells, including improved gastric function and suppression of food intake. The authors conclude that knowledge of GLP-1 and its roles in glucose regulation provides new methods of controlling glucose concentration, as it helps address some of the pathologic aspects of type 2 diabetes that are not covered by present treatments.

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Conclusions. IN: Clinical Impact of Incretin-Based Therapies on Type 2 Diabetes Management. Littleton, CO: Medical Education Resources. p. 19.

New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This chapter is from a clinical monograph on the role of incretins in glucose control; the monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators’ 2005 Annual Meeting. In this conclusion, the authors briefly review the limitations of current treatments for type 2 diabetes mellitus and consider the role of glucagon in disease pathophysiology. The authors then summarize the role of incretins and incretin-based therapies in suppressing glucagon secretion, as well as their contributions to reducing the burden of glucose control. The incretin GLP-1 has been identified as a critical player in glucose homeostasis, and a number of antihyperglycemic therapies targeting this pathway are now under development or in use. GLP-1 is released in response to a meal and acts on pancreatic islets to increase insulin secretion and inhibit glucagon release. GLP-1 also exerts a number of effects beyond those on the islets, including improved gastric function and suppression of food intake. The authors conclude that knowledge of GLP-1 and its roles in glucose regulation provides new methods of controlling glucose concentration, as it helps address some of the pathologic aspects of type 2 diabetes that are not covered by present treatments.

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DPP-4 Inhibitors. IN: Clinical Impact of Incretin-Based Therapies on Type 2 Diabetes Management. Littleton, CO: Medical Education Resources. p. 13-15.

New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This chapter on the DPP-4 inhibitors is from a monograph on the clinical impact of incretin-based therapies on the management of people with type 2 diabetes. The monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators’ 2005 Annual Meeting. The authors describe DPP-4 inhibitors, which are used to prolong the effect of endogenous glucagon-like peptide (GLP-1); one of the DPP-4 inhibitors under study is called vildagliptin. These drugs inhibit DPP-4, so GLP-1 concentrations rise, resulting in benefits similar to a direct infusion of GLP-1. Vildagliptin decreases blood glucose levels, increases active GLP-1, decreases glucagon, and lowers glycosylated hemoglobin (A1C) with once-daily oral dosing. The chapter concludes with a discussion of sitagliptin, another DPP-4 inhibitor that was approved for treatment in type 2 diabetes mellitus in October 2006. One table summarizes the approval status, route and effective dose, and adverse effects of four incretin therapies: exenatide, liraglutide, vildagliptin, and sitagliptin. 3 figures.

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Exhuberance Over Exubera. Clinical Diabetes. 24(3): 110-114. Summer 2006.

This article reviews the history of the development of insulin used to treat diabetes, culminating in the newest entry in the insulin world, inhaled insulin (brand name Exubera). Exubera is recombinant-engineered human insulin that is delivered to the bloodstream via the lung's alveoli; approximately one-third of the administered dose is absorbed into the bloodstream. The onset of inhaled insulin acts as quickly as subcutaneously administered rapid-acting insulin and more quickly than subcutaneous regular insulin. The authors review the effectiveness of inhaled insulin, initiating inhaled insulin, tools for patients starting inhaled insulin, monitoring guidelines, and candidates for inhaled insulin use. The authors conclude that clinical data have shown increased patient acceptability with inhaled insulin compared to injectable insulin. More patients using insulin who need it results in better glycemic control, thereby reducing microvascular and macrovascular complications and leading to improved quality of life. Thus, although there are safety and cost considerations, inhaled insulin also offers potential adherence and satisfaction advantages. 4 tables. 22 references.

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Full Speed Ahead: Progressing Toward Better Diabetes Management. Today's Dietitian. 8(7): 26-30. July 2006.

This article brings dietitians and nutrition specialists up-to-date with advances in diabetes care. The author discusses the history of home blood glucose monitoring (SMBG) and insulin; the physiology and pharmacology of both old and new insulin analogues, including lispro, aspart, glulisine, detemir, and glargine insulins; exubera, the first inhaled insulin; and new therapies that mimic glucagon-like peptide (GLP-1) and amylin. The newer, rapid-acting insulin analogues (lispro, aspart, glusiline) have a structural difference that promotes rapid absorption. The longer-acting insulin analogues (detemir and glargine) are designed to produce a smooth, reliable basal insulin profile. Inhaled insulin (exubera) is a powdered form of insulin taken into the lungs via inhalers. Exubera has an onset of action similar to the rapid insulin analogues, with peak activity at 30 to 90 minutes after administration. Exenatide mimics the actions of native GLP-1 which controls blood glucose by stimulating insulin secretion, slowing gastric emptying, reducing glucagon release, and enhancing the sense of satiety. Pramlinitide is an amylin analogue that, when injected 15 minutes before a meal, slows gastric emptying, suppresses the release of glucagon, and improves satiety after a meal.

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GLP-1 Analogues. IN: Clinical Impact of Incretin-Based Therapies on Type 2 Diabetes Management. Littleton, CO: Medical Education Resources. pp. 11-13.

New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This chapter on the glucagon-like peptide (GLP-1) analogues is from a monograph on the clinical impact of incretin-based therapies on the management of people with type 2 diabetes. The monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators’ 2005 Annual Meeting. The authors describe the current research on exenatide, an incretin mimetic that has been shown to effectively lower blood glucose levels and improve glycosylated hemoglobin levels (a measure of blood glucose over time). Currently, exenatide is indicated for patients who are failing on metformin, sulfonylureas, or combination therapies. The chapter also mentions liraglutide, previously known as NN2211, which has a longer plasma half-life, enabling once-daily administration. The chapter includes a side bar summarizing the information that patients should know about exenatide injection. 2 figures. 1 table.

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Insulin Delivery. Diabetes Forecast. 59(1): RG23-RG39. January 2006.

Syringes, pumps, jet injectors, pens, and infusers are all ways to deliver insulin. These items carry insulin through the outermost layer of skin and into fatty tissue so it can be used by the body. This section on insulin delivery is from a special issue of Diabetes Forecast that offers the annual guide to diabetes products and services. The author discusses each type of insulin delivery method in turn, covering questions to ask one's doctor, purchasing guidelines, cost considerations, and patient selection. An additional section discusses injection aids and alternatives that can make giving injections easier, including those designed for people with visual impairment. The section concludes with lengthy, detailed charts that summarize the devices discussed. 7 tables.

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Insulin Detemir (Levemir) for Diabetes Mellitus. American Family Physician. 74(2): 323-324. July 15, 2006.

This article reviews insulin detemir (Levemir), a long-acting insulin analogue approved as basal therapy for the treatment of diabetes mellitus. Insulin detemir is indicated for use in adults and children in combination with short-acting insulin for type 1 diabetes and with oral agents or short-acting insulin for adults with type 2 diabetes. The article reviews the safety, tolerability, effectiveness, price, and simplicity of the drug. The author concludes that insulin detemir is suitable as basal insulin in a basal-bolus regimen. It has been shown to cause slightly fewer episodes of minor hypoglycemia and no weight gain in patients with type 1 and 2 diabetes, which is a benefit that must be balanced against its higher price. 1 table. 6 references.

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Insulin. Diabetes Forecast. 59(1): RG14-RG20. January 2006.

There are many different insulins available for different situations and lifestyles. This section on insulin is from a special issue of Diabetes Forecast that offers the annual guide to diabetes products and services. The author first reviews the three characteristics of insulin: onset, peak time, and duration. The author then summarizes these characteristics for each type of insulin: rapid-acting insulins, such as insulin lispro (Humalog) or insulin aspart (NovoLog), glulisine (Apidra); regular or short-acting insulin (human); intermediate-acting insulin, such as NPH and lente insulin; long-acting insulin, including ultralente, insulin glargine (Lantus), and insulin detemir (Levemir); and premixed insulins. The remainder of the article discusses sources of insulins, strengths used, mixing insulin, additives, consumer advice, and storage and safety considerations. The article includes tables that summarize the insulins currently available, covering the generic and brand names, form, manufacturer, duration, and physical appearance of each type. 3 tables.

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Intensifying Insulin Therapy: Multiple Daily Injections to Pump Therapy. IN: Mensing, C., ed. Art and Science of Diabetes Self-Management Education. Chicago, IL: American Association of Diabetes Educators. pp. 372-398.

Meticulous metabolic control minimizes the long-term complications of diabetes and improves the quality and length of life for individuals with the disease. To achieve this kind of glycemic control, insulin therapy often needs to be intensified. This can be undertaken either through multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII), also known as insulin pump therapy. This chapter on the use of intensive insulin therapy is from a comprehensive text that serves as a resource for all health professionals, community professionals, and individuals who provide education to individuals with diabetes. The authors stress that educators must understand the benefits, risks, and limitations of intensive therapy to counsel and assist patients who are using MDI or insulin pumps. Patients considered appropriate candidates for intensive insulin therapy include those who can reliably demonstrate and use safe, consistent self-care behaviors such as frequent blood glucose monitoring (SMBG), insulin injections, carbohydrate counting, and problem solving for high and low blood glucose and sick day management. Preparing the patient and support persons in problem-solving skills with intensive insulin therapy prior to pump therapy initiation is critical to using an insulin pump safely and effectively. Pump therapy is most commonly used by people with type 1 diabetes, but may also be of value for people with type 2 diabetes, older adults with profound insulin deficiency, and pregnant women with diabetes. The chapter includes a list of key points, a summary of teaching strategies, case studies, suggested Internet resources, a glossary of key terms, and a list of references. 5 tables. 87 references.

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Liver Disease in Patients with Diabetes Mellitus. Journal of Clinical Gastroenterology. 40(1): 68-76. January 2006.

In addition to the well-known cardiovascular, renal, and ophthalmologic complications of diabetes, liver-related complications occur commonly and are often underrecognized. This article reviews the relationship between diabetes mellitus and two common liver diseases: chronic hepatitis C and nonalcoholic fatty liver disease. The author also discusses the association of diabetes and cirrhosis, acute liver failure, hepatocellular carcinoma, and outcomes following orthotopic liver transplantation. The liver plays a significant role in energy homeostasis and glucose metabolism; insulin enhances glycogen synthesis within the liver and prevents glucose production. These normal physiologic processes become dysregulated with insulin resistance and type 2 diabetes mellitus. Insulin resistance may work synergistically with hepatitis C infection to make changes in the liver, in the form of steatosis, inflammation, and fibrosis development. Once this occurs, progression to diabetes may occur in patients with underlying genetic susceptibility. Current treatment for preventing liver complications is focused on therapies that improve underlying insulin resistance, including weight loss or drug therapy. 1 figure. 2 tables. 158 references.

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Liver Disease in Patients with Diabetes Mellitus. Journal of Clinical Gastroenterology. 40(1): 68-76. January 2006.

In addition to the well-known cardiovascular, renal, and ophthalmologic complications of diabetes, liver-related complications occur commonly and are often underrecognized. This article reviews the relationship between diabetes mellitus and two common liver diseases: chronic hepatitis C and nonalcoholic fatty liver disease. The author also discusses the association of diabetes and cirrhosis, acute liver failure, hepatocellular carcinoma, and outcomes following orthotopic liver transplantation. The liver plays a significant role in energy homeostasis and glucose metabolism; insulin enhances glycogen synthesis within the liver and prevents glucose production. These normal physiologic processes become dysregulated with insulin resistance and type 2 diabetes mellitus. Insulin resistance may work synergistically with hepatitis C infection to make changes in the liver, in the form of steatosis, inflammation, and fibrosis development. Once this occurs, progression to diabetes may occur in patients with underlying genetic susceptibility. Current treatment for preventing liver complications is focused on therapies that improve underlying insulin resistance, including weight loss or drug therapy. 1 figure. 2 tables. 158 references.

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Medical Treatment of the Obese Patient with Type 2 Diabetes. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 471-486.

This chapter, from a comprehensive textbook on diabetes and obesity, focuses on the medical treatment of type 2 diabetes, with a special emphasis on the approach to the obese patient with this disease. Topics include the pathophysiology and natural history of type 2 diabetes, the goals of therapy and monitoring in type 2 diabetes, medical nutrition therapy (MNT) and exercise, oral antihyperglycemic agents, available insulin formulations, the approach to insulin use in obese patients with type 2 diabetes, and future therapies. The authors conclude that the goal of treatment is to achieve and maintain near-normal glycemic control without increasing the risk of hypoglycemia. MNT and exercise form the cornerstone of a comprehensive management program, but the vast majority of patients require drug therapy to achieve and maintain optimal blood glucose levels. For the obese patient with diabetes, insulin sensitizers are effective medications, and combination therapy with insulin secretagogues and sensitizers should be considered in patients with suboptimal control. Insulin remains an important component of the treatment regimens for patients not achieving target blood glucose goals with oral agents. 1 figure. 4 tables. 110 references.

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Metformin: Now or Later?. Harvard Health Letter. 32(1): 4. November 2006.

This newsletter article considers the use of metformin (Glucophage) and when it should be started in people newly diagnosed with type 2 diabetes. Metformin lowers blood sugar levels by decreasing the liver’s production of sugar and by increasing the effectiveness of insulin, the hormone that escorts sugar into the cells where it can be used. Insulin resistance is one of the main features of type 2 diabetes. Metformin is a first-line medication for several reasons: It is effective, lowering blood sugar levels by about 20 percent; people do not tend to gain weight when they take it, in contrast to insulin and the sulfonylurea drugs; and it is relatively inexpensive. Proponents of this type of drug therapy say that these medications tame conditions that are too serious to allow to progress. Critics counter that not nearly enough has been invested in devising ways to make diet and exercise programs work; approaches that do not carry the side effects that medications cause. The author concludes that the most important thing for people with newly diagnosed type 2 diabetes is to get their blood glucose levels under control. If this can be achieved without the drug therapy, that is fine, but if metformin is required to reach appropriate glycosylated hemoglobin levels, patients should not hesitate to include the drug in their diabetes management plan.

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New Drug Therapies. IN: Sharing the Burden: The Role of Incretins in Glucose Control. Chicago, IL: American Association of Diabetes Educators. 2006. p. 11-14.

New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This section on new drug therapies is from a clinical monograph on the role of incretins in glucose control; the monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators' 2005 Annual Meeting. The authors describe the current research on exenatide, an incretin mimetic that has been shown to effectively lower blood glucose levels and improve glycosylated hemoglobin levels—a measure of blood glucose over time. Currently, exenatide is indicated for patients who are failing on metformin, sulfonylureas, or combination therapies. The chapter continues by describes DPP-4 inhibitors, used to prolong the effect of endogenous glucagon-like peptide (GLP-1); one of the DPP-4 inhibitors under study is called vildagliptin. These drugs inhibit DPP-4, so GLP-1 concentrations rise, resulting in benefits similar to a direct infusion of GLP-1. Vildagliptin decreases blood glucose levels, increases active GLP-1, decreases glucagon, and lowers glycosylated hemoglobin (A1C) with once-daily oral dosing. One sidebar explains the differences between incretins and pramlintide, a drug that is a synthetic analog of human amylin—a naturally occurring hormone that is made by the beta cells of the pancreas and is co-secreted with insulin. 6 figures.

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New Therapies in Diabetes. IN: Katsilambros, N., et al. Diabetes in Clinical Practice: Questions and Answers From Case Studies. . Somerset, NJ: John Wiley & Sons. 2006. pp 409-436.

This chapter on new therapies in diabetes is from a book that deals with various aspects of diabetes in clinical practice, presented in the form of questions concerning diabetes diagnosis, management, and therapy, all based on real-life case studies. Topics covered include the use of continuous subcutaneous insulin infusion pumps, the different types of insulin pumps available, the components of an insulin pump, how the basal rate is determined, how the boluses are determined, patient indications for the use of an insulin pump, the use of an insulin pump to help prevent hypoglycemia unawareness, complications associated with an insulin pump, patient care management and follow up for a patient using an insulin pump, the use of inhaled insulin, the metabolism of inhaled insulin, complications regarding the use of inhaled insulin, the use of inhaled insulin in patients who smoke, kidney and pancreas transplantation, transplantation of pancreatic islets, glucagon-like peptide (GLP-1) in patients with type 2 diabetes, amylin, pramlintide, and the artificial pancreas. The chapter presents one detailed case study, with relevant questions posed and answered. Readers are walked through the diagnostic and patient care management process for the case study presented. 1 figure. 28 references.

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Nonalcoholic Fatty Liver Disease: A Clinic Approach and Review. Canadian Journal of Gastroenterology. 20(5): 345-349. May 2006.

This article reviews advances in nonalcoholic fatty liver disease (NAFLD), the most common cause of incidental elevation of liver enzymes in North America and Europe. Risk factors for NAFLD include a body mass index of 25 or greater, central obesity, and diabetes mellitus. The spectrum of disease is wide, ranging from simple steatosis with benign prognosis to nonalcoholic steatohepatitis and cirrhosis, with associated increases in morbidity and mortality. Topics covered include epidemiology and risk factors, diagnosis, pathogenesis, and patient care management, notably drug therapy in NAFLD, bariatric surgery, and the role of liver biopsy. The first abnormality in NAFLD is insulin resistance leading to hepatic steatosis. The second problem involves multiple proinflammatory cytokines, resulting in nonalcoholic steatohepatitis. Treatment is aimed at aggressive risk factor control and weight loss. 1 figure. 3 tables. 38 references.

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Pathophysiology of the Metabolic Disorders. IN: Mensing, C., ed. Art and Science of Diabetes Self-Management Education. Chicago, IL: American Association of Diabetes Educators. pp. 144-161.

Diabetes is a disease characterized by abnormal metabolism of carbohydrates, proteins, and fats. This chapter on the pathophysiology of the metabolic disorder is from a comprehensive text that serves as a resource for all health professionals, community professionals, and individuals who provide education to individuals with diabetes. The authors note that newly discovered hormones and systems that regulate energy balance have increased understanding of normal physiology and the pathophysiology of diabetes. The chapter covers normal fuel metabolism, the role of hormones, the different types of diabetes, and the pathogenesis of type 1 diabetes and of type 2 diabetes. Type 1 diabetes results from autoimmune beta cell destruction, leading to absolute insulin deficiency. Type 2 diabetes is a multihormonal pathophysiology involving a progressive insulin secretory defect along with insulin resistance. This disease progresses from an early asymptomatic state with insulin resistance, to mild postprandial hyperglycemia, to clinical diabetes requiring drug therapy. Obesity, weight gain in adulthood, and physical inactivity are environmental factors affecting the progression at all points along the continuum. The chapter includes a list of key points, a summary of teaching strategies, suggested Internet resources, a glossary of key terms, and a list of references. 2 figures. 3 tables. 79 references.

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Switching from Insulin to Oral Sulfonylureas in Patients with Diabetes Due to Kir6.2 Mutations. New England Journal of Medicine. 355(5): 467-477. August 3, 2006.

In diabetes patients diagnosed at six months of age or younger, approximately 30 to 58 percent of cases are caused by heterozygous activating mutations in KCNJ11, encoding the Kir6.2 subunit of the ATP-sensitive potassium channel. These patients present with ketoacidosis or severe hyperglycemia and are treated with insulin. This article reports on a study of glycemic control in 49 patients with Kir6.2 mutations who received appropriate doses of sulfonylureas. The authors also investigated, in smaller subgroups, the insulin secretory responses to intravenous and oral glucose, a mixed meal, and glucagon. A total of 44 patients (90 percent) successfully discontinued insulin after receiving sulfonylureas. Glycated hemoglobin levels improved in all patients who switched to sulfonylurea therapy. Improved glycemic control was sustained at one year. Sulfonylurea treatment increased insulin secretion, which was more highly stimulated by oral glucose or a mixed meal than by intravenous glucose. The authors conclude that sulfonylurea therapy is safe in the short term for patient with diabetes caused by KCNJ11 mutations and is probably more effective than insulin therapy. This pharmacogenetic response to sulfonylureas may result from the closing of the mutant ATP-sensitive potassium channels, thereby increasing insulin secretion in response to incretins and glucose metabolism. 4 figures. 1 table. 30 references.

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Therapy of NAFLD: Insulin Sensitizing Agents. Journal of Clinical Gastroenterology. 40(Suppl 1): S61-S66. March 2006.

Insulin resistance is an integral part of the underlying pathophysiology in most patients with nonalcoholic fatty liver disease (NAFLD), a chronic liver disease that can lead to cirrhosis and liver cancer. This article reviews the current literature on the use of insulin-sensitizing agents in the treatment of patients with NAFLD, particularly in those patients with the more severe form known as nonalcoholic steatohepatitis (NASH). The authors review the use of two major insulin-sensitizing agents: the thiazolidinediones and metformin (the only available biguanide). Thiazolidinedione administration in human NAFLD has been shown to decrease hepatic fat by several different measures and to decrease evidence of cellular injury, but it has also been associated with increased peripheral fat and weight gain. In contrast, metformin has been shown to improve biochemical markers without weight gain, but with more variable improvement in histology. Neither agent has current FDA approval for use in NAFLD, but existing studies provide hope for the benefits of incorporating these medications into NAFLD management strategies in selected patients. In addition, most of the studies do not determine the relative contribution of lifestyle changes compared with drug therapy, which can confound the results. 4 figures. 1 table. 61 references.

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Treatment of Diabetes With Insulin. IN: Katsilambros, N., et al. Diabetes in Clinical Practice: Questions and Answers From Case Studies. Somerset, NJ: John Wiley & Sons. 2006. pp 371-408.

This chapter on treating diabetes with insulin is from a book that deals with various aspects of diabetes in clinical practice, presented in the form of questions concerning diabetes diagnosis, management, and therapy, all based on real-life case studies. Topics covered include how insulin is produced commercially, the different types of insulin preparations available, insulin analogues, the speed of insulin absorption, insulin bioavailability, insulin pens and their indications, the side effects of insulin treatment, the use of an intensified insulin regimen, basal-bolus insulin regimens, recommended basal insulins, prandial insulins, dosing and administration, the use of insulin in patients with type 2 diabetes, and the use of premixed insulin preparations. The chapter presents five detailed case studies, with relevant questions posed and answered. Readers are walked through the diagnostic and patient care management process for the case studies presented; insulin dosages are noted for each. 5 figures. 16 tables. 17 references.

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Care of Children and Adolescents With Type 1 Diabetes: A Statement of the American Diabetes Association. Diabetes Care. 28(1): 186-212. January 2005.

In caring for children with diabetes, professionals need to understand the importance of involving adults in the child's diabetes management. The education about how to care for a child or adolescent with diabetes must be provided to the entire family unit, emphasizing age and developmentally appropriate self-care and integrating same into the child's diabetes management. This American Diabetes Association Statement provides a single resource on current standards of care pertaining specifically to children and adolescents with type 1 diabetes. It is not meant to be an exhaustive compendium on all aspects of the management of pediatric diabetes. However, relevant references are provided and current works in progress are indicated as such. The information provided is based on evidence from published studies whenever possible and, when not, supported by expert opinion or consensus. The Statement discusses and provides recommendations in the areas of diagnosis, initial care, diabetes education, identification (medical tags), appropriate self-management by age, glycemic control, insulin management of diabetes, blood glucose monitoring, nutrition, medical nutrition therapy (MNT), exercise, assessment of child and family risk factors at diagnosis, psychosocial issues, acute complications, immunization, chronic complications, associated autoimmune conditions, adjustment and psychiatric disorders, adolescence, adherence to self-management, and special situations, including sick day management, and diabetes care at school and day care. A final section considers risk behaviors, including use of tobacco and recreational drugs and unprotected sexual intercourse. 4 tables. 237 references.

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Elevated Liver Function Tests in Type 2 Diabetes. Clinical Diabetes. 23(3): 115-119. Summer 2005.

Individuals with type 2 diabetes have a higher incidence of liver function test (LFT) abnormalities than individuals who do not have diabetes. This article reviews the pathology, incidence, causes, and drug therapy related to type 2 diabetes and elevated LFTs. Mild chronic elevations of transaminases often reflect underlying insulin resistance. Elevation of transaminases within three times the upper limits of normal is not a contraindication for starting oral antidiabetic or lipid-modifying therapy. In contrast, antidiabetic agents have generally been shown to decrease alanine aminotransferase levels as tighter blood glucose levels are achieved. The most common cause of elevated LFTs in type 2 diabetes patients in non-alcoholic fatty liver disease (NAFLD). Hepatitis C virus (HCV), the leading cause of liver disease in the United States, is a known independent predictor of type 2 diabetes. The author notes that, for diabetes patients over the age of 40 years, and certainly in the setting of multiple cardiovascular risk factors or know cardiovascular disease, the potential risk of statin therapy (hepatotoxicity) is far outweighed by the proven benefit from CVD risk reduction. The author concludes by reviewing relevant research studies on the use of oral antidiabetes agents in type 2 diabetes patients with elevated transaminases.

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Exenatide Versus Insulin Glargine in Patients with Suboptimally Controlled Type 2 Diabetes. A Randomized Trial. Annals of Internal Medicine. 143(8): 559-569. October 2005.

This article reports on a study that compared the effects of exenatide and insulin glargine (both injectable drugs) on blood glucose control in patients with type 2 diabetes mellitus that is suboptimally controlled with metformin and a sulfonylurea (oral hypoglycemic agents). The 26-week multicenter, open-label, randomized, controlled trial utilized 82 outpatient study centers in 13 countries and included 551 patients with type 2 diabetes and inadequate glycemic control. Inadequate glycemic control is defined as hemoglobin A1c (HbA1c, a measure of blood glucose over time) level ranging from 7.0 percent to 10.0 percent, despite combination metformin and sulfonylurea therapy. Baseline mean HbA1c level was 8.2 percent for patients receiving exenatide and 8.3 percent for those receiving insulin glargine. At week 26, both exenatide and insulin glargine reduced hemoglobin A1c levels by 1.11 percent. Exenatide reduced postprandial glucose excursions (changes in blood glucose levels after a meal) more than insulin glargine, while insulin glargine reduced fasting glucose concentrations more than exenatide. Body weight decreased 2.3 kilograms with exenatide and increased 1.8 kilograms with insulin glargine. Rates of symptomatic hypoglycemia were similar, but nocturnal hypoglycemia occurred less frequently with exenatide. Gastrointestinal symptoms were more common in the exenatide group than in the insulin glargine group, including nausea (57.1 percent versus 8.6 percent), vomiting (17.4 percent versus 3.7 percent) and diarrhea (8.5 percent versus 3.0 percent). The authors conclude that exenatide and insulin glargine achieved similar improvements in overall glycemic control in this patient population. Exenatide was associated with weight reduction and had a higher incidence of gastrointestinal adverse effects than insulin glargine. 3 figures. 3 tables. 34 references.

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Inhaled Insulin Improves Glycemic Control When Substituted for or Added to Oral Combination Therapy in Type 2 Diabetes: A Randomized, Controlled Trial. Annals of Internal Medicine. 143(8): 549-558. October 2005.

Patients with type 2 diabetes who do not achieve glycemic control with oral drug therapy eventually require insulin. This article reports on a study undertaken to determine the effect on glycemic control of inhaled insulin alone or added to dual oral therapy (insulin secretagogue and sensitizer) after failure of dual oral therapy. The open-label, randomized, controlled trial set in 48 outpatient centers in the United States and Canada included 309 patients with type 2 diabetes, no clinically significant respiratory disease, and HbA1c (glycosylated hemoglobin, a measure of blood glucose over time) level of 8 percent to 11 percent who were receiving dual oral therapy. The patients were given inhaled insulin (Exubera), titrated to blood glucose, administered alone (n = 104) or added to dual oral agents (n = 103) versus oral therapy alone (n = 99). Results showed that reductions in HbA1c level were greater with inhaled insulin. HbA1c level less than 7 percent was achieved by 32 percent of the patients using inhaled insulin plus oral agents and by 1 percent of patients on oral agent therapy. Hypoglycemia, mild weight gain, mild cough, and insulin antibodies were more frequent with inhaled insulin than with oral agent therapy alone. Pulmonary function was similar in all groups. The authors conclude that inhaled insulin improved overall glycemic control and HbA1c level when added to or substituted for dual oral agent therapy with an insulin secretagogue and sensitizer. Similar to other insulin therapies, hypoglycemia and mild weight gain occurred. 4 figures. 3 tables. 42 references.

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Insulin and Type 2 Diabetes Management. Today's Dietitian. 7(9): 19-20. September 2005.

This article reviews the use of insulin in the management of type 2 diabetes. Recent research has established the importance of intensive blood glucose control in reducing diabetes-related morbidity and mortality. The author notes that aggressive treatment with oral medications and the early introduction of insulin therapy may improve metabolic outcomes and reduce hyperglycemia-associated morbidity in people with type 2 diabetes. The author explains the pathophysiology of type 2 diabetes and the indications for drug therapy, primarily when medical nutrition therapy (MNT) and physical activity fail to maintain blood glucose levels within healthy guidelines. When multiple oral agents fail to achieve metabolic control, insulin is added to the treatment regimen. The author reviews some of the studies that indicate the benefits of early intervention with insulin. A final section discusses the resistance to initiating insulin therapy that is often encountered in patients with type 2 diabetes.

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Medications and Supplements. IN: Thomas, A.M.; Gutierrez, Y.M., eds. American Dietetic Association Guide to Gestational Diabetes Mellitus. Chicago, IL: American Dietetic Association. 2005. pp. 65-80.

This chapter on medications and supplements in gestational diabetes mellitus (GDM) is from a Guide that serves as a resource for health professionals involved in the care of women who develop diabetes during their pregnancy. The Guide helps readers to promote sound nutrition principles in GDM, to achieve optimal outcomes for the woman and her infant. The author of this chapter begins by summarizing the types, action, peak times, and duration of insulin used in pregnancy. Other topics covered include the treatment modalities used for hypoglycemia, the use of oral agents used to treat diabetes in pregnancy, the use of multivitamin-mineral supplements in pregnancy, and the benefits and adverse effects of herbal and botanical supplements on pregnancy outcome. The author concludes that the goal in the management of GDM is normoglycemia. The first course of treatment is medical nutrition therapy (MNT); if blood glucose levels cannot be maintained by MNT, insulin must be initiated. The author emphasizes that nutrition assessment and counseling are recommended for all pregnant women. 6 figures. 4 tables. 64 references.

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Neonatal Diabetes Mellitus: From Understudy to Center Stage. Current Opinion in Pediatrics. 17(4): 512-518. August 2005.

Neonatal diabetes mellitus (NDM) is defined as persistent hyperglycemia occurring in the first months of life, lasting more than 2 weeks, and requiring insulin for management. NDM is currently the focus of research for the insights it provides into the genes regulating pancreatic islet formation, differentiation, and function, including the regulation of insulin secretion. This review article highlights recent discoveries concerning the genetic and molecular basis of the spectrum of disorders constituting neonatal diabetes mellitus. Recent reports, primarily in 2005, have identified activating mutations in the ATP-sensitive potassium channel that prevent its closure and hence insulin secretion as the major cause of permanent NDM. The authors report on a transgenic mouse model being used to study transient NDM. The authors conclude that these studies are exciting milestones on the way to understanding and treating the more common forms of type 1 and type 2 diabetes mellitus in children and adolescents. 1 figure. 2 tables. 65 references.

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Rapid-Acting Insulin: Timing It Just Right. Diabetes Self-Management. 22(1): 20-26. January-February 2005.

This article describes rapid-acting insulin and gives information to help readers use this type of insulin more effectively. In most cases, rapid-acting insulin (insulin lispro, brand name Humalog) is absorbed quickly and begins lowering blood glucose quickly. The author begins by describing the different ways that insulin may be used to help people with diabetes match the way that insulin is normally secreted by people without diabetes. The author then discusses the three phases of insulin action: onset, when the insulin starts to lower blood glucose; peak, when insulin has its greatest effect on blood glucose; and duration, how long the insulin continues to have some blood-glucose-lowering effect. In addition to understanding this action curve of the insulin, patients must learn how the food they choose affects blood glucose levels, so appropriate insulin can be used. The article includes a section of practical tips for special situations: high blood glucose before a meal, low blood glucose before a meal, low glycemic index foods, uncertain carbohydrate intake, large meals, drawn-out meals, and snacks. A final section addresses the importance of good recordkeeping, both for food intake and insulin use, to help fine-tune blood glucose control. One sidebar lists resources for readers wishing to learn more about insulin. 1 figure. 5 references.

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Type 2 Diabetes in Children and Adolescents: Risk Factors, Diagnosis, and Treatment. Clinical Diabetes. 23(4): 181-185. Fall 2005.

Due to the current epidemic of obesity among children and adolescents, physicians can logically expect to encounter increasing numbers of young patients presenting initially with signs and symptoms associated with uncontrolled hyperglycemia (high blood glucose) and relatively advanced cases of diabetes. This article reviews the risk factors, diagnosis, and treatment of type 2 diabetes in children and adolescents. The authors use the case of a young adolescent (a 13-year-old Hispanic girl) with multiple risk factors for type 2 diabetes. The authors first discuss the role of family history and genetics, insulin resistance, criteria for diagnosis of diabetes, and classification of diabetes. One section covers some of the issues to consider when initiating a therapeutic regimen for this patient population, including illness severity and stage, anticipated adherence, developmental stage, and family socioeconomic status and level of support. Lifestyle changes that involve the entire family, including detailed attention to diet and exercise, constitute the foundation of an effective treatment plan. The authors also discuss drug therapy, including the use of insulin. Health care providers are encouraged to match a younger patient's level of commitment with an appropriately designed therapy, considering any possibilities to increase the likelihood of adherence and compliance to therapy. 2 figures. 27 references.

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Effect of Oestrogen Plus Progestin on the Incidence of Diabetes in Postmenopausal Women: Results from the Women's Health Initiative Hormone Trial. Diabetologia. 47(7): 1175- 1187. July 2004.

This article reports on a randomized, double-blind trial that compared the effect of daily 0.625 milligrams of conjugated equine estrogen plus 2.5 milligram of medroxyprogesterone actate (progestin) with that of a placebo during 5.6 years of follow up in 15,641 postmenopausal women enrolled in the Women's Health Initiative Hormone Trial. The women were aged 50 to 79 and all had an intact uterus. Diabetes incidence was determined by self-report of treatment with insulin or oral hypoglycemic medications. The results showed a cumulative incidence of treated diabetes of 3.5 percent in the hormone therapy group and 4.2 percent in the placebo group. There was little change in the hazard ratio after adjustment for changes in body mass index (BMI) and waist circumference. During the first year of follow up, changes in fasting glucose and insulin indicated a significant fall in insulin resistance in actively treated women compared to the control subjects. The authors conclude that combined estrogen and progestin therapy reduces the incidence of diabetes, possibly mediated by a decrease in insulin resistance unrelated to body size. 2 figures. 5 tables. 61 references.

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Impact of a Decade of Changing Treatment on Rates of Severe Hypoglycemia in a Population-Based Cohort of Children with Type 1 Diabetes. Diabetes Care. 27(10): 2293-2298. October 2004.

This article reports on a study undertaken to determine the impact of changes to treatment on the incidence of severe hypoglycemia (low blood glucose) and its risk factors in a large population-based cohort of children with Type 1 diabetes (n = 1,335, mean age at entry was 9.5 years). The mean follow-up period was 4.7 years (plus or minus 3.1 years), yielding 6,928 patient-years of data. Patients were reviewed every 3 months for a period between 1992 and 2002; prospected assessment of severe hypoglycemia (an event leading to loss of consciousness or seizure) and associated clinical factors and outcomes was made. A total of 944 severe events were recorded. The incidence of severe hypoglycemia increased significantly by 29 percent per year for the first 5 years but appeared to plateau over the last 5 years. The overall average HbA1c (glycosylated hemoglobin, a measure of blood glucose over time) significantly decreased (by 0.2 percent per year) over the entire follow-up period. An increased risk of severe hypoglycemia was associated with lower HbA1c, younger age, higher insulin dose, male sex, and lower parental socioeconomic status. Of insulin therapies, only pump treatment was associated with reduced rates of severe hypoglycemia. The authors conclude that severe hypoglycemia remains a major problem for children and adolescents with Type 1 diabetes. 2 figures. 3 tables. 25 references.

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Insulin Glulisine Provides Improved Glycemic Control in Patients With Type 2 Diabetes. Diabetes Care. 27(10): 2363-2368. October 2004.

Insulin glulisine is a new analog of human insulin designed for use as a rapid-acting insulin. This article reports on a study that compared the safety and effectiveness of glulisine with regular human insulin (RHI) in combination with NPH insulin. The authors studied 876 relatively well-controlled patients with type 2 diabetes (mean HbA1c levels 7.55 percent). Patients were treated with glulisine and NPH (n = 435) or RHI and NPH (n = 441) for up to 26 weeks in this randomized, multicenter, open label, parallel group study. Subjects continued to use the same dose of prestudy regimens of oral antidiabetes agents, unless hypoglycemia necessitated a dose change. Results showed a slightly greater reduction from baseline to end point HbA1c in the glulisine group versus RHI. Also at end point, lower postbreakfast and postdinner blood glucose levels were noted. Symptomatic hypoglycemia and weight gain were comparable between the two treatment groups. The authors conclude that twice-daily glulisine associated with NPH can provide small improvements in glycemic control compared with RHI in patients with type 2 diabetes who are already relatively well controlled on insulin alone or insulin plus oral antidiabetes drugs. 2 figures. 1 table. 14 references.

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Insulin Therapy. In: Harmel, A.P. and Mathur, R. Davidson's Diabetes Mellitus: Diagnosis and Treatment. 5th ed. Orlando, FL: W.B. Saunders Company. 2004. p. 109-145.

More types of insulin are becoming available, ranging from the traditional insulins to insulin analogues. This diversity of choice, in terms of onset and duration of action, allows use of exogenous insulin to mimic normal physiology more closely, thereby allowing for improvements in glycemic control with less hypoglycemia. This chapter on insulin therapy is from a textbook that provides readers with current information on the diagnosis and treatment of patients with diabetes, including the latest advances, medications, and research studies. The beginning of the chapter focuses on choosing the concentrations and types of insulin to use. Other characteristics of insulin preparations, such as species source and purity, are discussed later in conjunction with a description of the immunologic responses to insulin therapy. Other topics covered include insulin allergy, insulin resistance, and insulin-induced lipoatrophy. One section also considers initiation of insulin therapy in hospitalized patients. The chapter includes illustrative case reports. 10 figures. 11 tables. 109 references.

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Quick Guide to Medications. Chicago, IL: American Association of Diabetes Educators. 2004. 19 p.

Approximately 90 percent of people with diabetes require oral glucose-lowering medications, insulin injections, or both, to reach blood glucose goals. This lengthy brochure is designed to provide in quick reference format an overview of the oral medications used to manage diabetes mellitus. In addition to oral medications and insulin, the drug therapies for a person with diabetes often include other medications to treat the associated conditions or complications of diabetes. The drugs are considered in separate categories: oral glucose-lowering agents, insulins available in the United States, major classes of agents used to treat high blood pressure, and lipid-lowering therapies. Other charts cover a comparison of human insulins and analogs, guidelines for mixing insulin or prefilling syringes, the use of glucagons injection for severe hypoglycemia, drug-food interactions of diabetes medications, adverse effects of drugs on body systems, drug-disease and drug-drug interactions, and drug therapies for the treatment of dyslipidemia in people with diabetes. The brochure emphasizes that health care professionals must be knowledgeable of the total range of therapies that are available for comprehensive diabetes care, not just the therapies that are used for glycemic control. 2 figures. 6 tables. 1 reference.

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Working Together to Manage Diabetes: Diabetes Medications Supplement. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2004. 10 p.

This booklet consists primarily of charts listing diabetes medications (oral agents used to treat type 2 diabetes), information about different types of insulin, storage guidelines for different types of insulin, measures to control glycemia, medications used to treat high blood cholesterol, and medications to lower high blood pressure. The chart for diabetes medications has eight sections: the name of the agent, the class it belongs in, its primary action, typical dosage, side effects, precautions, critical tests (tests used to monitor any drug side effects), and comments. The chart for medications used to lower hypertension has seven sections: the category of drug, brand names in that category, corresponding generic names, the manufacturer, minimum daily dose, maximum daily dose, and special considerations. There is very little text in the booklet, just a final note that offers three websites for readers seeking additional information about high blood pressure. 7 tables.

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