RESUMEN
OBJECTIVE: To review the drug treatments and some of the popular, nontraditional remedies now available for type 2 diabetes mellitus, as well as selected investigational agents; to describe each medication's place in the overall approach to treatment. DATA SOURCES: English-language journals, abstracts, review articles, and newspaper accounts. DATA SYNTHESIS: In the past five years, there has been tremendous progress in the pharmacotherapy of diabetes, particularly type 2 diabetes. Several new agents have entered the clinical arena, and many more are in the late stages of investigation leading to approval. Sulfonylureas stimulate the production and release of insulin; these drugs must be used in patients with an intact pancreas. The meglitinides are nonsulfonylurea agents that are also insulin secretagogues. Unlike the sulfonylureas, repaglinide appears to require the presence of glucose to close the adenosine triphosphate-sensitive potassium channels and induce calcium influx. Metformin reduces hepatic glucose production in some patients and increases peripheral glucose utilization, but its use is hampered by a high percentage of adverse reactions. Disaccharidase inhibitors effectively compensate for the defective early-phase insulin release by slowing the production of sugars from carbohydrates. Thiazolidinediones appear to activate peroxisome proliferator-activated receptor gamma, which is involved in the metabolism of lipids. Short-acting insulin and the role of weight-loss agents are also discussed. CONCLUSIONS: The availability of new options for diabetes therapy provides a chance for successful therapy in a larger number of patients. However, it is important to consider how much true benefit these new forms of treatment will have on the diabetic community. The best choice for a patient remains controversial.
Asunto(s)
Biguanidas/uso terapéutico , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Compuestos de Sulfonilurea/uso terapéutico , Tiazolidinedionas , Fármacos Antiobesidad/uso terapéutico , Biguanidas/efectos adversos , Cromanos/uso terapéutico , Compuestos de Cromo/administración & dosificación , Compuestos de Cromo/uso terapéutico , Terapias Complementarias , Diabetes Mellitus Tipo 2/terapia , Dietoterapia , Disacaridasas/antagonistas & inhibidores , Humanos , Insulina/metabolismo , Insulina/uso terapéutico , Leptina/uso terapéutico , Tiazoles/uso terapéutico , Troglitazona , Reino Unido , Compuestos de Vanadio/efectos adversos , Compuestos de Vanadio/uso terapéuticoRESUMEN
OBJECTIVE: To determine the process for establishing community pharmacy-based anticoagulation education and monitoring programs using fingerstick capillary whole blood testing. DESIGN: Pilot community-based intervention study using convenience sample of patients. SETTING: Three community pharmacies with pre-established health education centers and laboratories certified for moderate complexity. PARTICIPANTS: 26 patients were referred to the clinics by 2 primary care physicians for each pharmacy, most with a diagnosis of atrial fibrillation. INTERVENTION: Patient assessment, including adherence to prescribed regimens; changes in medication use, including prescription and nonprescription medications, vitamins, health foods, and nutrition supplements; changes in diet and ethanol consumption; assessment of adverse experiences; and needed changes in warfarin dosage. MAIN OUTCOME MEASURES: Percentage of international normalized ratio (INR) values within therapeutic range, major bleeding events, and thrombotic events. RESULTS: A total of 21 patient charts were available for analysis. More than 80% of patients had INR values within their targeted range (+/- 0.2) 60% or more of the time, comparable with values reported for anticoagulation clinics. Of the 235 INR values obtained during the study, 75% were within the individualized targeted therapeutic range (e.g., 2 to 3 +/- 0.2). One patient experienced a major bleeding event related to an underlying cancer. None of the patients experienced a thrombotic event. CONCLUSION: Community pharmacies can effectively implement an anticoagulation education and monitoring program.
Asunto(s)
Anticoagulantes/uso terapéutico , Monitoreo Fisiológico , Educación del Paciente como Asunto , Farmacias/normas , Adulto , Anciano , Anticoagulantes/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Tiempo de Protrombina , Estados UnidosRESUMEN
Noninsulin-dependent diabetes mellitus has historically been treated with diet therapy alone or the addition of an oral hypoglycemic agent such as a sulfonylurea, or the two in combination with insulin. Although these medical interventions lower blood glucose concentrations, they may also potentiate hyperinsulinism through increased serum insulin concentrations. Insulin resistance and hyperinsulinism are associated with cardiovascular risk factors such as hypertriglyceridemia, decreased high-density lipoprotein cholesterol levels, hypertension, and hyperglycemia, among others. Therefore, a desirable therapeutic alternative would lower blood glucose, not result in hyperinsulinism, and have beneficial effects on lipid profiles. Metformin is a biguanide antihyperglycemic agent that provides these effects. When administered to carefully selected patients and monitored appropriately metformin may prove to be valuable in the treatment of diabetes mellitus and in altering its cardiovascular sequelae.
Asunto(s)
Diabetes Mellitus Tipo 2/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Metformina/uso terapéutico , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/fisiopatología , Humanos , Hipoglucemiantes/efectos adversos , Hipoglucemiantes/farmacocinética , Metformina/efectos adversos , Metformina/farmacocinéticaRESUMEN
There is considerable evidence that blood viscosity is greater than normal in diabetes, and decreased red blood cell deformability has been suggested as the cause. However, viscosity can be influenced by changes in the properties of blood proteins in addition to red cells. Direct interpretation of red cell filtrometry data in terms of deformability has been complicated by the interfering effect of white cells and platelets and clogging of micropores. We have thus used the cell transit time analyzer, a new filtrometric procedure that eliminates these complications and produces an individual red cell micropore transit time profile, to reassess diabetic red cell deformability. Samples from 26 patients with diabetes and an equal number of subjects without diabetes who served as controls were assayed by the cell transit time analyzer at 2 and at 4 cm hydrostatic pressure. Samples from patients with diabetes and controls were sex and age matched for daily runs. At 2 cm H2O, red blood cell transit time for the patients with diabetes was 2.73 +/- 0.05 milliseconds as compared with 2.67 +/- 0.05 milliseconds for controls (p not significant). The ratio of transit time for patients with diabetes to that of controls (Td/Tnd) was 1.03 +/- 0.01 (p less than 0.05, Wilcoxon) at 2 cm H2O and 1.02 +/- 0.01 (p not significant) at 4 cm H2O.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Glucemia/análisis , Diabetes Mellitus/sangre , Deformación Eritrocítica , Hemofiltración/instrumentación , Adulto , Diabetes Mellitus/terapia , Femenino , Humanos , Masculino , Valores de Referencia , Factores de TiempoRESUMEN
Continuous insulin infusions are a valuable way of managing highly selected patients, although patients and healthcare practitioners must be aware of the limits and the increased risks involved with this type of technology. Maximum benefit from the CSII technology is achieved when the patient is part of a complete healthcare team accessible on a daily basis to respond to the changing nature of the underlying diabetes. Intranasal and pulmonary delivery of insulin, in contrast, represent a minor technology that will potentially add convenience to some diabetic management plans and possibly provide a new treatment approach for noninsulin-dependent diabetic patients.
Asunto(s)
Diabetes Mellitus Tipo 1/tratamiento farmacológico , Bombas de Infusión/normas , Insulina/administración & dosificación , Diseño de Equipo , Estudios de Evaluación como Asunto , HumanosRESUMEN
It was hypothesized that subjects with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen via nasal cannulas have an impaired sense of smell and/or taste. To objectively evaluate the sense of smell and taste, this study used the University of Pennsylvania Identification Test (UPSIT), a 40-item "scratch-n-sniff" test and a 20-item taste test using the four basic taste sensations of sweet, salt, sour, and bitter. Twenty subjects (15 male, 5 female) with severe COPD receiving long-term oxygen therapy (group 1), and an equal number of age- and sex-matched subjects with COPD not receiving oxygen therapy (group 2), and a healthy control group (group 3) were studied. Twelve subjects (seven male, five female) from group 1 subsequently underwent transtracheal oxygen catheter installation. Mean +/- SD for the basic smell test was significantly greater in group 3 (35.35 +/- 3.58) as compared with group 1 (27.70 +/- 6.07) or group 2 (31.10 +/- 4.95) (p less than 0.005). The difference between group 1 and 2 was not significant (p = 0.066). However, when adjusted for pack years of smoking, there were no significant differences between the three groups. Mean +/- SD correct responses for the basic taste test were significantly greater in group 3 (15.75 +/- 1.81) as compared with group 2 (12.8 +/- 2.78) (p less than 0.005) and group 1 (14.00 +/- 2.33) (p less than 0.05). There was no significant difference between group 1 and 2. The corrected data for taste, adjusted for years since quitting smoking, did not alter the basic differences between the groups. Mean smell and taste test scores were essentially unchanged in 12 subjects after six months of transtracheal oxygen therapy. Long-term oxygen use via nasal cannulas in this group of subjects with COPD did not appear to impair their sense of smell and taste. Smoking had a significant but variable effect on the sense of smell and taste.
Asunto(s)
Enfermedades Pulmonares Obstructivas/fisiopatología , Terapia por Inhalación de Oxígeno , Olfato/fisiología , Gusto/fisiología , Femenino , Humanos , Intubación Intratraqueal/instrumentación , Enfermedades Pulmonares Obstructivas/terapia , Masculino , Persona de Mediana Edad , Terapia por Inhalación de Oxígeno/instrumentación , Distribución Aleatoria , Fumar/fisiopatología , Fumar/terapia , Umbral Gustativo/fisiología , Factores de TiempoRESUMEN
The present management of diabetes consists of attempting to control blood sugar tightly in the normal range and to treat individual complications such as neuropathy and retinopathy as they appear. Whereas these measures are perhaps effective in slowing the progress of diabetic complications, they do not cure the underlying process. The aldose reductase inhibitors have been investigated as possible remedies for various diabetic complications. Aldose reductase is an enzyme present in several human tissues that reduces glucose to sorbitol. In animal models there is evidence that the production of sorbitol is associated with the development of diabetic complications. Animal and human studies have tested the ability of aldose reductase inhibitors to halt or reverse diabetic complications. The weight of evidence leads to two conclusions: first, that aldose reductase inhibitors may bring significant relief to patients with certain diabetic complications; and second, that the current approach to proving clinical efficacy may not be adequate for these drugs.