Pharmacologic Treatment of Diabetes



Patients with diabetes mellitus have a higher risk for cardiovascular heart disease (CHD) than does the general population, and once they develop CHD, mortality is higher. Good glycemic control will reduce CHD only modestly in patients with diabetes. Therefore, reduction in all cardiovascular risks such as dyslipidemia, hypertension, and smoking is warranted. The focus of this article is on therapy for dyslipidemia in patients with type 2 diabetes. Patients with the metabolic syndrome (insulin resistance) share similarities with patients with type 2 diabetes and may have a comparable cardiovascular risk profile. Diabetic patients tend to have higher triglyceride, lower high-density lipoprotein cholesterol (HDL), and similar low-density lipoprotein cholesterol (LDL) levels compared with those levels in nondiabetic patients. However, diabetic patients tend to have a higher concentration of small dense LDL particles, which are associated with higher CHD risk. Current recommendations are for an LDL goal of less than 100 mg/dl (an option of < 70 mg/dl in very high-risk patients), an HDL goal greater than 40 mg/dl for men and greater than 50 mg/dl for women, and a triglyceride goal less than 150 mg/dl. Nonpharmacologic interventions (diet and exercise) are first-line therapies and are used with pharmacologic therapy when necessary. Lowering LDL levels is the first priority in treating diabetic dyslipidemia. Statins are the first drug choice, followed by resins or ezetimibe, then fenofibrate or niacin. If a single agent is inadequate to achieve lipid goals, combinations of the preceding drugs may be used. For elevated triglyceride levels, hyperglycemia must be controlled first. If triglyceride or HDL levels remain uncontrolled, pharmacologic agents should be considered. Fibrates are slightly more effective than niacin in lowering triglyceride levels, but niacin increases HDL levels appreciably more than do fibrates. Unlike gemfibrozil, niacin selectively increases subfraction Lp A-I, a cardioprotective HDL. Niacin is distinct in that it has a broad spectrum of beneficial effects on lipids and atherogenic lipoprotein subfraction levels. Niacin produces additive results when used in combination therapy. Recent data suggest that lower dosages and newer formulations of niacin can be used safely in diabetic patients with good glycemic control. Current evidence and guidelines mandate that diabetic dyslipidemia be treated aggressively, and lipid goals can be achieved in most patients with diabetes when all available products are considered and, if necessary, used in combination.

Patients with diabetes mellitus have 2-4 times the risk for coronary heart disease (CHD) compared with patients without diabetes. In fact, the risk of developing myocardial infarction in a patient with diabetes who has not had a previous myocardial infarction is the same as that for patients without diabetes who have had a myocardial infarction. Approximately 75% of deaths in patients with diabetes are caused by cardiovascular disease. Mortality rates from coronary artery disease are at least 3 times higher in patients with diabetes than in the general population. In one study, the authors estimated that after a first myocardial infarction, about 40% of patients with diabetes are expected to die within 1 year.

Results from large trials conducted by the Diabetes Control and Complications Trial research group and the United Kingdom Prospective Diabetes Study group indicate that although intensive glucose control reduces microvascular complications, there is little effect on macrovascular disease. A strong relationship does not exist between the duration of diabetes or severity of hyperglycemia to CHD or atherosclerosis. Since glycemic control seems to have only a modest effect on reducing CHD, the emphasis should be placed on aggressive treatment of cardiovascular risk factors such as smoking, hypertension, and dyslipidemia. We focus on the treatment of one major CHD risk factor, dyslipidemia among patients with non-insulin-dependent (type 2) diabetes.

Comments

Post a Comment

Popular posts from this blog

Antimycobacterial Agents

Image
Historically, mycobacterial infections have been associated with signifi cant morbidity and mortality worldwide. In particular, Mycobacterium tuberculosis is a highly successful human pathogen, infecting one-third of the world’s population and leading to approximately 3 million deaths worldwide annually (1). The organism is unique in its ability to establish persistent infection, requiring prolonged treatment with antimicrobials in order to achieve clinical cure. In general, the goals of antituberculosis therapy include rapid reduction of the massive numbers of actively multiplying bacilli in the diseased host, prevention of acquired drug resistance, and sterilization of infected host tissues to prevent clinical relapse. In order to achieve these goals, currently accepted guidelines recommend administration of multiple active drugs for a minimum duration of 6 months (2). In areas where drug resistance is prevalent and resources permit, M. tuberculosis clinical isolates should be
Read more

Antibacterials

Image
Antibacterial: Anything that destroys bacteria or suppresses their growth or their ability to reproduce. Heat, chemicals such as chlorine, and antibiotic drugs all have antibacterial properties. Many antibacterial products for cleaning and handwashing are sold today. Such products do not reduce the risk for symptoms of viral infectious diseases in otherwise healthy persons. This does not preclude the potential contribution of antibacterial products to reducing symptoms of bacterial diseases in the home. Cultures and antibiotic sensitivity testing are essential for selecting a drug for serious infections. However, treatment must often begin before culture results are available, necessitating selection according to the most likely pathogens (empiric antibiotic selection). Whether chosen according to culture results or not, drugs with the narrowest spectrum of activity that can control the infection should be used. For empiric treatment of serious infections that may involve any on
Read more

Pharmacologic Treatment of Dyslipidemia

Image
Dyslipidemias are disorders of lipoprotein metabolism, including lipoprotein overproduction or deficiency. These disorders may be manifested by elevation of the serum total cholesterol, low-density lipoprotein (LDL) cholesterol and triglyceride concentrations, and a decrease in the high-density lipoprotein (HDL) cholesterol concentration. Epidemiologic, angiographic and postmortem studies have documented a causal relationship between elevated serum cholesterol levels and the genesis of coronary heart disease. Angiographic studies show that aggressive cholesterol reduction by a variety of methods, as opposed to dietary modifications alone, results in increased rates of plaque regression and stabilization. Treatment with cholesterol-lowering drugs appears to be accompanied by a reduction in the lipid content of atherosclerotic plaques, thereby making them more stable and less prone to rupture. The Scandinavian Simvastatin Survival Study demonstrated a 30 percent reduction in t
Read more