Diabetes

Apidra (insulin glulisine injection)from Aventis is approved by the FDAfor use in adult patients with type 1 ortype 2 diabetes mellitus for the controlof hyperglycemia. Compared withhuman insulin, Apidra has a morerapid onset and a shorter duration ofaction. The drug is designed to managemealtime spikes in glucose levelsby administration through subcutaneousinjection or continuous subcutaneouspump infusion either 15 minutesbefore or 20 minutes after startinga meal.

During an annual eye examination, a 65-year-old womanwith a 5-year history of type 2 insulin-dependent diabetescomplained that her vision had slightly worsened in botheyes. Her best corrected visual acuity was 20/30 in botheyes.

Your patient with type 2 diabetes wants to take a step exercise class. What recommendations will you offer? Another patient has diabetic retinopathy; which exercises are safest for her?

Foot ulcers develop in about 15% of patients who have diabetes mellitus.1 A major cause of morbidity and mortality, foot ulcers and resultant amputations impose a heavy emotional and physical burden on patients.

Persons with severe mental illnesses (SMI), such as schizophrenia, are at increased risk for comorbid conditions- including type 2 diabetes-independent of therapy. SMI sufferers especially at risk for type 2 diabetes are women, African Americans, and persons older than 45 years. Among the possible causes of increased susceptibility to type 2 diabetes are such schizophrenia-associated conditions as impaired glucose tolerance, overweight, obesity, inadequate nutrition, lack of exercise, and inadequate self-care. Other obstacles to good health care among patients with schizophrenia include impaired communication ability, denial of illness, social withdrawal, and undertreatment because of comorbid conditions. Different antipsychotic medications may also contribute to preexisting insulin resistance or glucose intolerance. Clinicians can optimize care by understanding the most significant barriers for each patient and incorporating this knowledge into an active treatment plan.

A 44-year-old man with type 2 diabetes was recently hospitalized for an acuteexacerbation of pancreatitis. This was his seventh admission for the conditionwithin the past several years. Although imaging studies revealed no calcifications,the hospitalist suspected that acute relapsing pancreatitis was evolvinginto chronic pancreatitis.

During a routine office visit, a 64-year-old woman who has had type 2 diabetesfor more than 10 years complains of increased pedal edema. The edema is minimalon awakening and worsens throughout the day.

How does amyloid in the pancreatic islets contribute tothe development and progression of type 2 diabetes?

Dr Gregory Rutecki's interactive teaching case, “A Middle-Aged Man WithPolyuria: The Initial Visit” (CONSULTANT, March 2001, page 357), provided awelcome opportunity for me to review the care I provide to my patients with type 2diabetes, who comprise a very large percentage of my practice.

Cutaneous manifestations develop inapproximately 30% of persons withdiabetes. Premature atherosclerosisis a common complication of thedisease and can cause peripheral infarction,ulceration, and necrosis.

Diabetic retinopathy is the most common cause of legal blindness in personsbetween the ages of 20 and 65 years. In this 56-year-old man with a 20-yearhistory of type 2 diabetes, multiple, scattered intraretinal (dot-blot) hemorrhagesand superficial nerve fiber layer (splinter) hemorrhages can be seen.An occasional Roth spot-an intraretinal hemorrhage with a white center thatrepresents a fibrin thrombus which occludes a ruptured blood vessel-is alsoevident. Numerous yellow, waxy, hard exudates are seen between the innerplexiform and inner nuclear layers of the retina. Cotton-wool spots are alsopresent, although no neovascularization is present.