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  • image Diabetes mellitus (DM) is a group of metabolic disorders of fat, carbohydrate, and protein metabolism that results from defects in insulin secretion, insulin action (sensitivity), or both.
  • image The incidence of type 2 DM is increasing. This has been attributed in part to a Western-style diet, increasing obesity, sedentary lifestyle, and an increasing minority population.
  • image The two major classifications of DM are type 1 (insulin deficient) and type 2 (combined insulin resistance and relative deficiency in insulin secretion). They differ in clinical presentation, onset, etiology, and progression of disease. Both are associated with microvascular and macrovascular disease complications.
  • image Diagnosis of diabetes is made by four criteria: fasting plasma glucose ≥126 mg/dL (≥7 mmol/L), a 2-hour value from a 75-g oral glucose tolerance test ≥200 mg/dL (≥11.1 mmol/L), a casual plasma glucose level of ≥200 mg/dL (≥11.1 mmol/L) with symptoms of diabetes, or a hemoglobin A1c [HbA1c] ≥6.5% (≥0.065; ≥48 mmol/mol Hb). The diagnosis should be confirmed by repeat testing if obvious hyperglycemia is not present.
  • image Goals of therapy in DM are directed toward attaining normoglycemia (or appropriate glycemic control based on the patient’s comorbidities), reducing the onset and progression of retinopathy, nephropathy, and neuropathy complications, intensive therapy for associated cardiovascular risk factors, and improving quality and quantity of life.
  • imageMetformin should be included in the therapy for all type 2 DM patients, if tolerated and not contraindicated, as it is the only oral antihyperglycemic medication proven to reduce the risk of total mortality, according to the United Kingdom Prospective Diabetes Study (UKPDS).
  • image Intensive glycemic control is paramount for reduction of microvascular complications (neuropathy, retinopathy, and nephropathy) as evidenced by the Diabetes Control and Complications Trial (DCCT) in type 1 DM and the UKPDS in type 2 DM. The UKPDS also reported that control of hypertension in patients with diabetes will not only reduce the risk of retinopathy and nephropathy but also reduce cardiovascular risk.
  • image Short-term (3 to 5 years), intensive glycemic control does not lower the risk of macrovascular events as reported by the Action in Diabetes and Vascular Disease, Action to Control Cardiovascular Risk in Diabetes, and Veterans Administration Diabetes Trial trials. Microvascular event reduction may be sustained, and macrovascular events reduced by improved early glycemic control, as evidenced by the UKPDS and DCCT follow-up studies. Significant reductions in macrovascular risk may take 15 to 20 years. This sustained reduction in microvascular risk and new reduction in macrovascular risk has been coined metabolic memory.
  • image Knowledge of the patient’s quantitative and qualitative meal patterns, activity levels, pharmacokinetics of insulin preparations, and pharmacology of oral and injected antihyperglycemic agents is essential to individualize the treatment plan and optimize blood glucose control while minimizing risks for hypoglycemia and other adverse effects of pharmacologic therapies.
  • image Type 1 DM treatment necessitates insulin therapy. Currently, the basal–bolus insulin therapy or pump therapy in motivated individuals often leads to successful glycemic outcomes. Basal–bolus therapy includes a basal insulin for fasting and postabsorptive control, and rapid-acting bolus insulin for mealtime coverage. Addition of ...

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