Diabetes blood sugar level control questionnaire,type 2 diabetes diet to lose weight loss,m-87 microphone specification - PDF Books


All recommendations have been updated and reorganized to clarify management considerations for women with pregestational or gestational diabetes in the prepregnancy period, during pregnancy, and in the intrapartum and postpartum periods. 1.All women of reproductive age with type 1 or type 2 diabetes should receive advice on reliable birth control, the importance of glycemic control prior to pregnancy, the impact of BMI on pregnancy outcomes, the need for folic acid and the need to stop potentially embryopathic drugs prior to pregnancy [Grade D, Level 4 (1)].
4.Women with type 2 diabetes who are planning a pregnancy should switch from noninsulin antihyperglycemic agents to insulin for glycemic control [Grade D, Consensus]. 6.Women should be screened for chronic kidney disease prior to pregnancy (see Chronic Kidney Disease chapter, p.
9.Detemir [Grade C, Level 2 (24)] or glargine [Grade C, Level 3 (25)] may be used in women with pregestational diabetes as an alternative to NPH. 11.Women should receive adequate glucose during labour in order to meet their high-energy requirements [Grade D, Consensus]. 12.Women with pregestational diabetes should be carefully monitored postpartum as they have a high risk of hypoglycemia [Grade D, Consensus]. 15.All women should be encouraged to breastfeed since this may reduce offspring obesity, especially in the setting of maternal obesity [Grade C, Level 3 (28)]. 17.If there is a high risk of GDM based on multiple clinical factors, screening should be offered at any stage in the pregnancy [Grade D, Consensus]. 21.Receive nutrition counselling from a registered dietitian during pregnancy [Grade C, Level 3 (37)] and postpartum [Grade D, Consensus]. 22.If women with GDM do not achieve glycemic targets within 2 weeks from nutritional therapy alone, insulin therapy should be initiated [Grade D, Consensus]. 23.Insulin therapy in the form of multiple injections should be used [Grade A, Level 1 (20)].
24.Rapid-acting bolus analogue insulin may be used over regular insulin for postprandial glucose control, although perinatal outcomes are similar [Grade B, Level 2 (38,39)]. 27.Women should receive adequate glucose during labour in order to meet their high-energy requirements [Grade D, Consensus]. 29.Women should be screened with a 75 g OGTT between 6 weeks and 6 months postpartum to detect prediabetes and diabetes [Grade D, Consensus]. Depression following a recent acute myocardial infarction is very common and is an independent risk factor associated with increased cardiac mortality. In 1999, major depressive disorder (MDD) was the fifth leading cause of disability worldwide. Since the 1930s,4,5 clinicians have reported the association between a diagnosis of depression and higher risk for cardiac mortality. Four weeks after his discharge from the hospital, the patient started to report various physical symptoms. One day in May 2003, the patient tried the alprazolam that he filled in March and noticed mild improvement. Depression may directly predispose patients to cardiac events through biological mechanisms such as increased sympathetic activity, autonomic dysregulation, low heart-rate variability, and increased QT variability. Tricyclic antidepressants (TCAs) can cause increased heart rate and orthostatic hypotension. Selective serotonin reuptake inhibitors (SSRIs) are associated with fewer cardiovascular side effects, compared with other TCAs.29 The Sertraline Antidepressant Heart Attack Randomized Trial30 investigates the safety and efficacy of sertraline in patients with ischemic heart disease.
In a study of bupropion by Roose and colleagues,39 the cardiovascular effects of bupropion treatment were documented in 36 patients with depression and cardiovascular disease.
Choice of antidepressant, dosage, and course of treatment need to be individualized; for a first episode of MDD, patients require antidepressant treatment for a minimum of 6 months to prevent relapse, and lifelong antidepressant therapy may be necessary for patients with recurrent illness. Additionally, interpersonal or cognitive-behavioral therapy have demonstrated effectiveness as treatments for depression. Depression develops frequently after the onset of acute coronary event and a growing body of evidence suggests that it is an independent risk factor for cardiac mortality in patients with recent AMI. A drug-drug interaction (DDI) occurs when the presence of a coprescribed drug (the perpetrator) alters the nature, magnitude, or duration of the effect of a given dose of another drug (the victim). The goal of this guide is to provide a quick reference for prescribers about some of the major psychiatric DDIs. While the focus of this review is principally on neuropsychiatric medications, the authors will also address the effects of psychiatric on nonpsychiatric medications and vice versa where appropriate when covering DDIs. This guide will first review the scope of the problem, discuss strategies and approaches to avoiding untoward and unintended DDIs, and then present summary figures and tables highlighting major DDIs involving psychiatric medications. Over the last 15 years, prescribers of psychiatric medications have been blessed with an ever-expanding array of options to treat a wide variety of psychiatric maladies. While a blessing in many ways, this development poses serious challenges for practitioners trying to keep abreast of new developments.
For all of the above reasons, patients on psychiatric medications are at risk for DDIs and these DDIs are likely to involve more than just two drugs. To further put the numbers in perspective, consider that 10% of all Americans >18 years of age were taking five or more prescription drugs in the last week.
Given the above numbers, DDIs are, not surprisingly, a serious cause of concern for the US healthcare system.
An ignorance of important interactions threatens trust in physicians and other prescribers.
In the same way as it is important to develop some understanding of why fires occur and the characteristics of fatal airplane accidents, the importance to the public health of a mechanistic understanding of adverse drug events, and of a system to prevent them, cannot be understated.
The authors will attempt herein to describe the principal mechanisms by which important DDIs with neuropsychiatric drugs occur, and to list those that are most likely to occur and result in clinically significant changes in drug activity.
DDIs are of paramount importance to health professionals who practice in the pharmaceutical industry.
The value of a personal formulary in an era of polypharmacy and pervasive and potent marketing cannot be overemphasized. A personal formulary basically consists of a list of drugs that a particular physician is intimately familiar with.
At a minimum, a prescriber should be aware of the generic name of a medication on their personal formulary, without which it is impossible to search the medical literature on it or to recognize it on a board exam. Lastly, persistent confusion over the similarity of drug names, either written or spoken, accounts for approximately 25% of all reports to the US Pharmacopeia Medication Errors Reporting Program, and the case for the use of both a generic name and brand name in legible handwriting on prescriptions is strong. While a large number of possible adverse effects of any drug may be listed in the label that is available in the Physicians’ Desk Reference,34 relatively few matter to an individual patient. Prescribers should be aware of the routinely used doses and the serum half-life of the drugs they frequently use.
A therapeutic alliance is a group of people who communicate with each other about an individual patient’s therapeutic plan and medications.
A DDI occurs when the presence of a coprescribed drug (the perpetrator) alters the nature, magnitude, or duration of the effect of a given dose of another drug (the victim).
The focus of this guide, however, is to minimize the risk of an unintended and untoward DDI and therefore will not consider therapeutic DDIs.
Equation 1 presents the three variables that determine the effect a drug will produce in a patient. Equation 2 illustrates that a drug concentration is a function of the dosing rate the patient is taking relative to their ability to clear the drug.
The last variable in Equation 1 is the interindividual differences among patients, which can shift the dose response curve making patients either more or less sensitive to the effect of the drug. For polypharmacy to be rational, the prescriber in any area of medicine must be able to answer the following questions: (1) Why am I using more than one drug? The second reason listed in Table 9 is particularly relevant to psychiatry.3,36 Conditions such as bipolar and schizoaffective disorder have complex symptom clusters which wax and wane over the course of the illness.
The remaining reasons listed in Table 9 are all based on planned therapeutic DDIs, whether the prescriber thinks in these terms or not.3,36 When a second drug diminishes, amplifies, or speeds the onset of a first drug, that effect is by definition a DDI. The prescriber of psychiatric medications cannot simply focus on those medications but must examine all of the medications the patient is taking, including over-the-counter (OTC) medications, illicit substances, herbal products, and even dietary substances. All drugs, except anti-infectives, are given to change human physiology.44 Those changes can present in every way clinically imaginable.
Understanding and identifying DDIs with psychiatric medications is perhaps more challenging than in any other area of medicine. As psychiatric drugs are more rationally developed to affect only the brain, their adverse effects will not be on peripheral systems but on the brain.
Equation 1 illustrates that drug concentration determines what site(s) of action are engaged and to what degree, while Equation 2 illustrates that drug concentration is the dosing rate divided by the clearance.
If the prescriber is confident in the dosing rate (ie, noncompliance is not an issue), then measuring the drug concentration allows the prescriber to assess the patient’s clearance to determine whether it is usual or unusually fast or slow. This issue is of critical importance when understanding and avoiding untoward effects mediated by the co-prescription of a drug capable of either inducing or inhibiting the enzymes responsible for the clearance of the victim drug. The logic underlying pharmacokinetic interactions mediated by the induction or inhibition of CYP enzymes is outlined in Figure 3.3,32 This logic forms the basis for the section on CYP enzyme-mediated DDIs with psychiatric medications.
While the study that provided the results in Figure 4 was about the effect of fluoxetine on CYP 2D6,47 it graphically illustrates the point that the effect of a coprescribed perpetrator drug (eg, fluoxetine) on the response to the victim drug (eg, desipramine) can continue to increase for weeks after the perpetrator has been started and can persist for weeks after the perpetrator has been stopped. Drugs are approved and generally considered from the perspective of their therapeutic use; however, they interact on the basis of their pharmacodynamics and pharmacokinetics. Table 5 lists the neuropsychiatric medications to be covered in this guide by their principal mechanism of action.
A number of neuropsychiatric medications including tertiary amine tricyclic antidepressants and atypical antipsychotics affect more than one mechanism of action under clinically relevant dosing conditions. This guide restricted its discussion of pharmacokinetic DDIs to those mediated by CYP enzymes because of their clinical relevance. Appendix I lists Web sites that the reader can use to find additional information.2,3,60-64 Web sites have the advantage of being regularly updated so that the information will stay current even after this guide has been published. One major limitation is that there are no standard guidelines for producing such drug alert systems in terms of what constitutes sufficient evidence to list an interaction as possible.
Other systems may require that a formal study be conducted showing that the interaction occurs; they do not generalize the interaction to other drugs with the same mechanism.
Most drug alert systems only consider the effect of drug A on drug B, whereas many patients are on multiple drugs that may interact in complex ways.
We will be provided with an authorization token (please note: passwords are not shared with us) and will sync your accounts for you. Type 2 diabetes mellitus, a metabolic disorder, is spreading at epidemic proportions in Malaysia. Health locus of control describes a person’s characteristic attribution of health outcomes to internal or external causes. Past research focusing on individuals with a family history of type 2 diabetes has provided mixed results.
Sedentary lifestyle and poor diet are clearly key risk factors for type 2 diabetes (Moore et al., 2011).
Given the epidemic increase in rates of type 2 diabetes in Malaysia over recent decades, it is crucial to obtain a clearer portrait of exactly what is contributing to this rise, and to use this information to fashion more effective interventions. Do individuals with better knowledge of type 2 diabetes engage more in healthy lifestyle behaviors?
Are there any differences in terms of healthy lifestyle behaviors among people with and without family history of diabetes? Are there any ethnicity differences in terms of health knowledge and healthy lifestyle behaviors? Are there any relationships between perceived locus of control, health knowledge and healthy lifestyle behaviors? Prerequisites for participating in this study were being a resident of Malaysia, over 18 years of age, and having not been diagnosed with type 2 diabetes. In order to understand if family members of diabetics or members of different ethnosocial groups are more knowledgeable than others about diabetes mellitus, the DKT was used. The MHLC was used to assess locus of control, or perceived level of personal control, over health-related behavior. Participant’s gender, age, ethnicity, educational level, family medical history, and general health management method was gathered.
Individuals who were over 18, living in Malaysia, with no previous diagnosis of type 2 diabetes were recruited at markets and shopping areas frequented by a broad swath of the general population. Because data was collected from the same locations over a period of multiple days many participants returned with friends or relatives by as well. Pearson’s Correlation Coefficient was calculated for all relationships amongst the DKT, SLIQ subscales, MHLC subscales and education level (see Table 6). Women with pregestational diabetes who also have PCOS may continue metformin for ovulation induction [Grade D, Consensus]. S129) [Grade D, Level 4, for type 1 diabetes (17) ; Grade D, Consensus, for type 2 diabetes].
If the initial screening is performed before 24 weeks of gestation and is negative, rescreen between 24 and 28 weeks of gestation. Recommendations for weight gain during pregnancy should be based on pregravid BMI [Grade D, Consensus]. Use of oral agents in pregnancy is off-label and should be discussed with the patient [Grade D, Consensus]. Effectiveness of a regional prepregnancy care program in women with type 1 and type 2 diabetes: benefits beyond glycemic control. Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis. Preconception care and the risk of congenital anomalies in the offspring of women with diabetes mellitus: a meta-analysis. Poor glycated hemoglobin control and adverse pregnancy outcomes in type 1 and type 2 diabetes mellitus: systematic review of observational studies.
Glycemic control during early pregnancy and fetal malformations in women with type 1 diabetes mellitus. Use of maternal GHb concentration to estimate the risk of congenital anomalies in the offspring of women with pre-pregnancy diabetes.
Glycaemic control is associated with preeclampsia but not with pregnancy-induced hypertension in women with type 1 diabetes mellitus. Strategies for reducing the frequency of preeclampsia in pregnancies with insulin-dependent diabetes mellitus.
Effect of pregnancy on microvascular complications in the Diabetes Control and Complications Trial.
Maternal exposure to angiotensin converting enzyme inhibitors in the first trimester and risk of malformations in offspring: a retrospective cohort study.
Central nervous system and limb anomalies in case reports of first-trimester statin exposure. Microalbuminuria, preeclampsia, and preterm delivery in pregnancy women with type 1 diabetes: results from a nationwide Danish study. Improved pregnancy outcome in type 1 diabetic women with microalbuminuria or diabetic nephropathy: effect of intensified antihypertensive therapy? Twice daily versus four times daily insulin dose regimens for diabetes in pregnancy: randomised controlled trial.
Maternal glycemic control and hypoglycemia in type 1 diabetic pregnancy: a randomized trial of insulin aspart versus human insulin in 322 pregnant women. Glycemic control and perinatal outcomes of pregnancies complicated by type 1 diabetes: influence of continuous subcutaneous insulin and lispro insulin. A comparison of lispro and regular insulin for the management of type 1 and type 2 diabetes in pregnancy. Maternal efficacy and safety outcomes in a randomized, controlled trial comparing insulin detemir with NPH insulin in 310 pregnant women with type 1 diabetes.
Metformin therapy throughout pregnancy reduces the development of gestational diabetes in women with polycystic ovary syndrome. Breast-feeding and risk for childhood obesity: does maternal diabetes or obesity status matter? Fasting plasma glucose versus glucose challenge test: screening for gestational diabetes and cost effectiveness.
Impact of increasing carbohydrate intolerance on maternal-fetal outcomes in 3637 women without gestational diabetes. Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy.
Recommendations for nutrition best practice in the management of gestational diabetes mellitus. Maternal metabolic control and perinatal outcome in women with gestational diabetes treated with regular or lispro insulin: comparison with non-diabetic pregnant women.


Comparison of an insulin analog, insulin aspart, and regular human insulin with no insulin in gestational diabetes mellitus. Prospective observational study to establish predictors of glyburide success in women with gestational diabetes mellitus. Comparative placental transport of oral hypoglycemic agents in humans: a model of human placental drug transfer.
Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization.
Effects of early breastfeeding on neonatal glucose levels of term infants born to women with gestational diabetes. Association of breast-feeding and early childhood overweight in children from mothers with gestational diabetes mellitus.
Lactation intensity and postpartum maternal glucose tolerance and insulin resistance in women with recent GDM: the SWIFT cohort. The complex interplay of depression and cardiovascular disease following the onset of acute coronary event can often prevent patients from complying with treatment regimens and disease-modifying behaviors. The World Health Organization projects that by 2020, major causes of disability worldwide will be dominated by ischemic heart disease, motor vehicle collision, and MDD.1 Depression is most commonly reported and managed in primary care settings, but unfortunately still remains underdiagnosed and undertreated, even while effective treatments are available.
In recent medical literature, there is a growing body of evidence that suggests that depression may cause significant increase in the risk of cardiovascular complications. A, a 46-year-old man, was admitted to University Hospital in November of 2002 for acute ST segment elevation myocardial infarction (MI). A had previously been in good health, with no prior history of medical or psychiatric diagnosis. A visited University Health Center’s internal medicine clinic, complaining of difficulty sleeping.
Instead, the patient presented repeatedly with somatic symptoms, which camouflaged his condition and left depression unrecognized. TCAs also have significant antiarrhythmic activity because of an electrophysiologic profile similar to that of type 1A antiarrhythmic agents, such as quinidine and moricizine.
In this study, sertraline showed no significant effect on left ventricular function, as determined by multiple-gated acquisition scan, systolic or diastolic blood pressure, cardiac conduction intervals, including PR, QRS, QT, or ventricular premature complexes. SSRIs may reduce risk of cardiac mortality through attenuation of serotonin-mediated platelet activation and reduction of other depression-mediated mechanisms. There was no significant effect observed on heart rate, ejection fraction, or cardiac conduction. The response rate to antidepressant treatment appears to be similar to those reported in patients without comorbid illness. The Enhancing Recovery in Coronary Heart Disease study,40 a randomized trial of cognitive-behavioral therapy in patients with post-MI depression, has achieved significant improvement in depression and social support. Depression, which is extremely under-recognized and undertreated, can complicate treatment of coronary events, as it often prevents patients from complying with treatment regimens and health-promoting behaviors. The NIMH Depression Awareness, Recognition, and Treatment Program: structure, aims, and scientific basis.
Chin is resident in the Combined Internal Medicine and Psychiatry Program in the Departments of Internal Medicine and Psychiatry and Behavioral Neurosciences at Wayne State University School of Medicine in Detroit, Michigan. Balon is professor of psychiatry in the Department of Psychiatry and Behavioral Neurosciences at Wayne State University School of Medicine. These interactions can be therapeutic or adverse, planned or unintended, but are always determined by the pharmacodynamics and pharmacokinetics of the drugs involved rather than their therapeutic indication. DDIs have the potential for causing untoward outcomes, including morbidity and even mortality for the patient, liability for the prescriber, and increased costs for the healthcare system.
Furthermore, it presents general concepts which can aid prescribers in avoiding untoward DDIs when possible and quickly recognizing them when they occur. In fact, the authors will reclassify the drugs principally covered in this guide into other functional classes based on their pharmacodynamics and pharmacokinetics, such as CYP enzyme substrates, inducers, and inhibitors. These are most important for the prescriber who treats patients with conditions broadly defined as psychiatric illnesses.
The explosion in psychiatric medications began with the introduction of fluoxetine (Prozac) in 19886and is likely to continue and even accelerate in the future as a result of the human genome project and the characterization of novel therapeutic targets in the human brain.
The prescriber has more therapeutic options, each with different pharmacodynamics and pharmacokinetics, to understand and weigh. Thus, the problem may not just be the effect of drug A on drug B but this effect in the presence of drugs C and D as well. These numbers provide a frame of reference which explains why understanding and minimizing the risk of untoward and unintended DDIs is important and daunting.
As the number of prescribed medications has increased over the past 20 years, so have the number of possible interactions between therapies.These interactions have increased to the point where prescribers universally find it impossible to remember all conceivable interactions and are forced to rely on electronic media. Although all physicians are taught pharmacology in medical school, it is clear to anyone who has been out of medical school for >5 years that many, if not most, of the drugs that are commonly prescribed today were not available during their training. Diligent study of the drugs in question, careful evaluation of the literature pertaining to them, and ongoing checks of new developments should be a routine habit.
As medicine becomes more international and the world becomes smaller, the physician must be aware that medications have different brand names in different countries, and the brand name used in the US may not be the same as that used elsewhere (Table 4).32 The use of the generic name in prescriptions allows cheaper generic drugs to be used when they are available.
For example, confusion has been reported between the antidepressant nefazodone (Serzone) and the antipsychotic quetiapine (Seroquel), both of which are available as 100 mg and 200 mg tablets. The prescribing physician is in a unique position to assess which adverse effects are relevant to which patient through careful consideration of both the patient and the medication in question.
In the case of psychiatric drugs, they should also be aware of the mechanism of action, and of the potency of interaction with specific receptors (Tables 5–8). Even the highest quality of prescribing cannot possibly work well if patients are noncompliant, but patients often need help in maintaining adherence with what can be a demanding medication schedule.
It might be reducing a serum low-density lipoprotein or blood pressure or relieving depression, but regardless of the goal, a clear time expectation should be attached to it. Given this definition, DDIs can clearly be therapeutic or adverse, intended or unintended, but they are always determined by the pharmacodynamics and pharmacokinetics of the coprescribed drugs. First, the drug must work on a site of action (the first variable in Equation 1), which is capable of producing the effect observed. This equation explains why clearance is as important as dose in determining the nature, the magnitude, and the duration of a drug’s effect on the patient.
In this example, the prescriber is not planning a DDI, though one may occur because drugs interact on the basis of the mechanisms underlying their pharmacodynamics and pharmacokinetics, rather than on the basis of their therapeutic indication. Patients with these illnesses may need different medications for different phases of their illness. When using a drug for these purposes, the ideal situation would be one in which the pathophysiology of the illness and the effects of each drug on that pathophysiology are all clearly understood.
For example, ibuprofen, an OTC analgesic, can cause serious and even life-threatening elevations in lithium levels by affecting its rate of tubular reabsorption.41The duration of the effect of illicit substances can be prolonged by coprescribed drugs, which inhibit the enzymes responsible for clearing the illicit substance.
While such an event can occur and is obviously important to prevent, DDIs can present as virtually anything, including the worsening of the illness being treated or the emergence of a new illness. Thus, the result of psychiatric DDIs could present as changes in mentation, reality testing, emotional control, interpersonal relationships, and memory function. For example, if the clearance is faster than usual, then the dosing rate must be increased proportionately to reach the usual drug concentration achieved on the usually effective dose; in other words, the usual site(s) of action must be engaged to the usual degree associated with optimal response as determined by the registration trials that lead to the marketing of the drug.
Induction can increase the clearance of the victim drug such that its levels fall below what is usually therapeutic, resulting in either loss of efficacy or withdrawal symptoms.46 Inhibition can decrease the clearance of the victim drug such that its levels rise causing consequences, which may range from an increase in the frequency and severity of dose-dependent adverse effects, such as extrapyramidal side effects in the case of conventional antipsychotics to life-threatening toxicity in the case of tricyclic antidepressants. Thus, the potential for an interaction may persist for days to weeks and even months after one of the drugs has been discontinued.
Over the next 3 weeks, the desipramine levels fell as fluoxetine and norfluoxetine cleared from the body and CYP 2D6 inhibition in parallel was reversed, leading to an increase in desipramine clearance. Sometimes that is because the perpetrator has a long residual time in the body, as in the case of fluoxetine, and sometimes it is because the perpetrator’s effect persists long after it has been cleared. Next, the major tables for summarizing knowledge relevant to avoiding pharmacodynamic and pharmacokinetic DDIs are provided. Table 1451 enumerates the pharmacodynamically mediated DDIs that can occur for each mechanism of action listed in Table 5.
The reader can also use this information to determine whether he or she might wish to employ TDM to further establish the actual concentrations being achieved in their specific patient and relate that to both relative binding affinity for its multiple targets as well as relative to the concentration usually achieved on the dose being used. Parenthetically, CYP-mediated DDIs are the most common, clinically meaningful type of pharmacokinetic DDIs. This mechanism virtually never mediates a DDI of clinical significance, although it is well ensconced in the literature and the minds of physicians.
Thus, software packages can either be overly conservative and can list interactions based on theory rather than fact or based on a single case report of dubious validity.
This means that you will not need to remember your user name and password in the future and you will be able to login with the account you choose to sync, with the click of a button. This page doesn't support Internet Explorer 6, 7 and 8.Please upgrade your browser or activate Google Chrome Frame to improve your experience. This study is a preliminary investigation of possible factors contributing to this epidemic. Are people not aware of the factors that contribute to type 2 diabetes and other non-communicable diseases? Most current intervention programs are focused on education, which may be important: Geiss et al. Self-report questionnaires were used to investigate various sociocultural groups’ understanding of diabetes risk factors, their feelings of control over personal health outcomes, and how these factors predict lifestyle behaviors and preventive practices. 794 people completed the questionnaire, 24 of whom were later excluded for incomplete responses or having existing medical conditions.
There are five domains that are assessed which are diet, activity, stress, smoking and alcohol consumption.
Because these areas serve as social centers of the community in Malaysia, this was deemed to be a convenient way of accessing participants from many different social and economic backgrounds. Independent sample t-test comparing differences between those with and without family history of diabetes on diabetes knowledge, life style behaviors and stress. One-way multivariate analysis of variance of education level, diabetes knowledge, diet, activity level, alcohol consumption, and life stress by ethnicity.
Thus Malaysians with higher levels of education, tended toward greater diabetes knowledge, eating healthier and experiencing higher levels of stress. Thus, older Malaysians’ diabetes knowledge, internal locus of control, and powerful-others locus of control tend be higher.
This suggests that Malaysians with higher internal locus of control tend toward greater diabetes knowledge, healthier diets, and have higher stress level. Women with microalbuminuria or overt nephropathy are at increased risk for development of hypertension and preeclampsia [Grade A, Level 1 (17,18)] and should be followed closely for these conditions [Grade D, Consensus]. Furthermore, despite the availability of effective treatments, major depression remains underdiagnosed and undertreated. Approximately 50% of people with symptoms of depression do not seek treatment,2 and for those who do seek treatment, 50% are misdiagnosed and mismanaged.3 In the setting of medical illness, depression is often considered to be a common psychological reaction, a response to distress from physical illness, or a result of a decrease in activities of daily living due to medical illness.
During the hospitalization, the patient underwent primary percutaneous transluminal coronary angioplasty, due to left anterior descending occlusion; the patient was treated by stent placement. The patient was referred to a neurologist for back pain and headache, and a gastroenterologist for abdominal pain. During the visit, the patient was offered alprazolam and was recommended to see a psychiatrist for an evaluation.
During a follow-up visit, the cardiologist decided to start the patient on zolpidem for sleep disturbance and chose not to renew the alprazolam.
The physician thoroughly discussed with the patient and his wife the high incidence of post-MI depression and the potential severe consequences of it. In July, on patient request, he was referred to a psychologist for psychotherapy and sertraline was increased. Due to the fact that his mood symptoms were not appropriately addressed early in his treatment, the patient continued to seek medical subspecialists to deal with his overall distress. Many people in the general population look at mental illness as a reflection of weakness in character.
Insomnia is a very common presenting symptom among depressed patients immediately following AMI. There was no difference between sertraline compared with placebo on any cardiovascular parameter evaluated. Newer antidepressants, particularly venlafaxine and mirtazapine, have not been studied in the depressed patients with ischemic heart disease. In the treatment of depression, fluoxetine,29 sertraline,30 paroxetine,35 and bupropion39 appear to be reasonably safe in patients with cardiovascular disease. Thus, appropriate treatments should be built on a foundation of good therapeutic alliance between patient and clinician, so that a patient can be diagnosed correctly while also being heard and understood by his or her practitioner. Course of depression in patients with hypertension, myocardial infarction or insulin-dependent diabetes. Stigma as a barrier to recovery: perceived stigma and patient-related severity of illness as predictors of antidepressant drug adherence. Ventricular tachycardia and psychiatric depression in patients with coronary artery disease. Influence of serotonin-transporter–linked promoter region polymorphism on platelet activation in geriatric depression. The relationship of depression to cardiovascular disease: epidemiology, biology, and treatment. Potential vascular and bleeding complications of treatment with selective serotonin reuptake inhibitors. Elevated platelet factor 4 and b-thromboglobulin plasma levels in depressed patients with ischemic heart disease. Effect of selective serotonin reuptake inhibitors on platelets in patients with coronary artery disease. Platelet 5-hydroxytryptamine is decreased in a preliminary group of depressed patients receiving the 5-hydroxytryptamine re-uptake inhibiting drug fluoxetine. Platelet activation in depression and effects of sertraline treatment: an open-label study. Comparison of paroxetine and nortriptyline in depressed patients with ischemic heart disease. Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: population based case-control study.
Inhibition of serotonin reuptake by antidepressants and upper gastrointestinal bleeding in elderly patients: retrospective cohort study. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. The risk of unintended and untoward DDIs is increasing in concert with both the increasing number of pharmaceuticals available and the number of patients on multiple medications.
An example is serotonin syndrome, which consists of marked autonomic instability and can be fatal. Flockhart’s Web site2 summarizes data on cytochrome P450 (CYP) enzymes and the drugs they metabolize and outlines which drugs inhibit or induce CYP enzymes. The reason for taking this approach is that those are mechanisms relevant to clinically significant DDIs.
As illustrated by the answers to the questions above, this situation is in part due to the large number of new prescription drugs available to prescribers. For the drugs in their personal formulary, the physician should be familiar with generic and brand names, pharmacokinetics, pharmacodynamics, adverse effects, and potential DDIs. If nothing else, these criteria allow the prescriber a means of focusing his or her attention within the sea of the medical literature. Despite claims to the contrary, there are only a small number of examples where an approved generic is not an effective substitute for the brand name drug.
The antidepressant paroxetine (Paxil) has been confused with the antiplatelet agent clopidogrel (Plavix).
No one else is in this position and many patient surveys over the years clearly show that patients much prefer that their physician acquaint them with the benefits and side effects of drugs that the physician prescribes.35 That is not to say that pharmacists and nurses are not also important to the prescribing process, but instead that physicians have a central role in the prescribing process that they must recognize.
This basic information can guide prescribing in a number of valuable ways, particularly by making prescribers aware of the potential DDIs and consequences. To this end, a therapeutic alliance involving the patient and the people around them is nearly always valuable. For all drugs, except anti-infectives, the site of action is a human regulatory protein such as a receptor, an enzyme, or an uptake pump.


The environment variable refers to the internal environment of the body, which includes other drugs or dietary substances the patient may be taking. For this reason, the prescriber of psychiatric medications must be aware of and consider all of the medications the patient is taking. While mood stabilizers (eg, lithium) are usually the foundation for the treatment of a patient with bipolar disorder, at different phases of the illness the patient may need to have antidepressants, antipsychotics, or anxiolytics added and may even need treatment with more than one mood stabilizer. The prescriber of psychiatric medications must be a good behavioral pharmacologist as well as a good diagnostician, and must also keep in mind that changes in these outputs of the human brain may be because of the medications that the patient is receiving rather than in spite of them.
Thus, the goal of therapeutic drug monitoring (TDM) is not to simply know whether the concentration is therapeutic but to know whether the patient’s ability to clear the drug is usual or not.
Without changing the dose of desipramine, its levels increased >4-fold over the next 3 weeks as fluoxetine and its active metabolite, norfluoxetine, accumulated, resulting in the inhibition of CYP 2D6. Nevertheless, desipramine levels even 3 weeks after fluoxetine was discontinued were still double what they were before fluoxetine was added because norfluoxetine was still present in the body and still inhibiting CYP 2D6-mediated clearance. For example, most selective serotonin reuptake inhibitors were initially approved as antidepressants but several have subsequently gained approved labeling for the treatment of a variety of anxiety disorders.
The resulting ratio reflects the increase in concentration needed for the drug to affect its less potent target in relationship to its most potent target. The clinician could use TDM to determine whether his or her specific patient has unusually fast or slow clearance relative to the usual clearance found in the registration trials and whether the patient is developing concentrations comparable to or concentrations much higher or lower than those found in registration trials. Table 15 lists which CYP enzymes metabolize which drugs and which drugs inhibit or induce specific CYP enzymes. Knowledge of diabetes, health locus of control, diet and exercise habits, as well as family history, education level and other demographic factors to better understand the correlates of risky and healthy behaviors.
Identifying the roots of this disease’s rapid spread, thus, is a high priority from both public health and economic perspectives. For example, Fitzpatrick (2011) found that educational programs aimed at adolescents with high blood pressure could be successful at increasing health knowledge, self-efficacy, and readiness for change. Thus, data from a total of 770 participants from three different states; Penang, Selangor, and Terengganu, is included in these analyses. Participants will be given contact information for the researcher if they wish to be informed of the research results. The researchers situated themselves at tables in well trafficked areas throughout the day for several days and spoke to potential participants about the research. Prior to answering the questionnaire, all participants read a statement of purpose and provided their consent to participate. Thus, appropriate and acceptable treatments need to be built on a foundation of good therapeutic alliance with patients, so that they may feel heard and understood.
For this reason, patients’ comorbid depression is often deemed unsuitable for treatment. Approximately one in six patients with AMI has been identified as experiencing MDD,6,8,9 and the rate of MDD in patients with coronary heart disease is three times higher than in the general population.10 Although the biological mechanism for increased cardiac mortality is not yet clear, depression is clearly associated with poor compliance in risk-modifying behavior. For the past 15 years, he had been working in the automotive industry as a division director.
The patient described appropriate sleep hygiene, averaged less than a single cup of coffee in a 24-hour interval, denied reading or working in bed, and denied having a television in his bedroom.
Thereafter, the patient’s somatic symptoms showed gradual improvement and he was able to sleep a full 5 hours at night without disturbance. When the symptoms of depression remain untreated, patients overuse general medical services, have an higher risk of social and occupational impairment, and experience increased duration of symptoms.11 In a study by Koenig and colleagues,12 41 older inpatients with active MDD were matched with nondepressed controls from the same population.
Even when an individual is in dire need of treatment, the fear that others may be critical and rejecting remains powerful.
However, patients with heart disease are usually on multiple medications to improve mortality or enhance function.
This can only be accomplished if physicians are responsive and look closely for signs of depression in patients with recent MI. A recent survey found that 10% of all Americans >18 years of age were taking five or more prescription medications. The physician should truly be an expert on a small number of medications that he or she uses commonly.
Thus, physicians become real experts in the use of a small number of drugs important to their practice.
Patients expect physicians to educate them about their medications, and greatly appreciate when a physician takes time to explain the side effects of a medicine they have prescribed.
Family members should often be part of the therapeutic alliance, as well as the pharmacist, nurse practitioner, home health visitors, and friends (when appropriate). The same applies to the treatment of psychiatric disorders other than depressive disorders, as well as nonpsychiatric medical illness. By binding to its target(s), the drug is capable of altering the functional status of the target(s) and thus altering human physiology.
These four variables modify the first two variables and thus explain how the magnitude, duration, or even the nature of the effect of the drug in a specific patient may differ from the usual effect produced by a given dose of the drug.
That number may double in the next 10 years as a result of discoveries made possible by the human genome project.
This discussion further emphasizes the limitations of this guide and of all information systems in clinical psychopharmacology. If not, the results of TDM?can provide a rational basis for determining what sort of an adjustment in the dosing rate must be made to compensate for the patient’s unusual clearance. The inhibition of CYP 2D6 resulted in a reduction in the clearance of desipramine (Equation 2), hence an increase in desipramine levels without a change in dose. In a similar way, enzyme inducers have their induction effect immediately, though the time course for the maximum effect on increased clearance is not achieved until a new steady-state level of enzyme protein has been produced as a result of increased protein synthesis.
In a similar way, a number of atypical antipsychotics are seeking approval as mood stabilizers. For example, quetiapine binds most avidly to the a1 adrenergic receptor and binds almost as avidly to the H1 receptor, but requires a 23-fold increase in dose to bind to the dopamine D2 receptor (Table 6).
The Ministry of Health estimates that, in 2011 alone, Malaysia spent RM18,000,000,000 (about $5.4 billion USD) treating non-communicable diseases (of which diabetes is the most prevalent).
Are there certain resources or knowledge that various groups are lacking which would enable them to live healthier lifestyles? Recent research has also linked internal locus of control to healthy eating and exercise habits (Schurer et al., 2012) both of which are key components in the prevention of type 2 diabetes.
Janssen (2012) found the greatest risk factor for both men and women in Canada was physical inactivity.
Three questions ask about how often participants consume leafy green vegetables, fruits, and high fiber cereals or grains. To ensure that participants had not been previously diagnosed with type 2 diabetes, in addition to screening at the time of survey distribution an additional question was included in the demographics section asking if the participant had ever been diagnosed with a chronic disease – 11 participants were excluded from analysis because they answered yes to this question. In other words, more educated people engaged in less physical activity and drank alcohol somewhat less.
Physicians should be responsive and look for signs of depression in patients with recent myocardial infarction, as successful treatment of major depression can improve prognosis of cardiovascular disease and enhance the overall quality of life. Moreover, psychological barriers to treatment, such as stigma associated with mental illness and minimization of the need for care, may be important obstacles in the treatment of MDD. Consequently, depression is considered an independent risk factor for heart disease and is associated with increased mortality after AMI.7 The following case report and discussion will illustrate the complex interplay of depression and cardiovascular disease. He turned to acupuncture, herbal treatment, chiropractic and homeopathic medicine; he spent 8 weeks and thousands of dollars without clear benefit. During this visit, the patient appeared thin and slightly older than stated age, but groomed and hygienic. Survival and healthcare utilization were examined during a mean follow-up period of 5 months.
SSRIs, especially fluoxetine, paroxetine, and fluvoxamine, have significant cytochrome P450 isoenzyme inhibitions27; therefore, clinicians need to be familiar with the potential drug-drug interactions. Fortunately, successful treatment of MDD can improve prognosis of cardiovascular disease and enhance overall quality of life. Additional studies have found that patients on psychiatric medications, such as antidepressants, are on more medications than patients not on psychiatric medication. Given the speed with which new drugs are entering the market and new discoveries about the mechanisms underlying DDIs are being made, the authors recognize that this educational review, like all printed material on this topic, will quickly become dated.
A high level of knowledge about a few drugs insulates the physician against trivial advertising and protects one’s patients from prescribing errors. A system of prescribing, in which members of the therapeutic alliance are identified early in a patient’s therapeutic plan and then involved in the follow-up, is as important as the valuable practice of routine checks by telephone or e-mail within a few days after a drug is prescribed. Therapeutic goals should be clearly delineated in charts and communicated to patients and the care providers that are involved with each patient.
The ability of the drug to bind to the regulatory protein gives it its potential action (ie, its pharmacodynamics). Thus, DDIs occur when one drug (the perpetrator) changes the effect of a given dose of another drug (the victim) by either interacting with it pharmacodynamically or pharmacokinetically (ie, the first and second variables in Equation 1). For the same reason, the increased clearance persists for several weeks after the enzyme inducer has been stopped.50 These delayed onsets and offsets are not simply limited to pharmacokinetic interactions as witnessed by MAO inhibition (which is a pharmacodynamic interaction) but can be applied to all interactions in which the effect of the perpetrator persists for a sustained period after the perpetrator has been discontinued (eg, receptor supersensitivity or subsensitivity).
In recognition of these facts, the tables in this guide outlining DDIs will consider these drugs in terms of their pharmacodynamics and pharmacokinetics rather than in terms of their labeled therapeutic indication. That explains why low doses of quetiapine can be used for sedative effects but why higher doses are needed for antipsychotic efficacy. Questionnaires were completed by 770 individuals from three Malaysian states: Selangor, Penang, and Terengganu. Thus, diabetes is set to create a massive burden on public healthcare services if its spread is allowed to continue unchecked. Also, regardless of overweight or obesity status, higher intake of fried foods, snacks, and soft drinks, as well as sedentary lifestyle increased the risk of type 2 diabetes while consumption of fruit and vegetables was protective (Bauer et al., 2013).
Thus, this study looks at the degree to which Malaysians are aware of diabetes and its risk factors and to what degree this and other variables such as family history of diabetes relate to lower risk lifestyles. This scale also has good criterion validity, correlating with participants’ state of health. Three questions inquire about the frequency of various light, moderate, and vigorous physical activities.
People who were more knowledgeable about diabetes drank less alcohol, but appeared to have more life stress.
He used to be a long-time chain smoker but had decided to stop smoking in November 2002, soon after his MI.
The patient was placed on narcotic analgesics for pain, which resulted in only a minimal improvement. According to his wife, during this period the patient had mood instability, hostility, suspiciousness, and irritability.
In-hospital mortality was significantly higher among the depressed compared with nondepressed controls (6 versus 0 deaths, P=.03).
A, a middle-aged man in management position, any sign of weakness might jeopardize his achievements in the industry. In addition, medications interact not on the basis of their therapeutic use but on the basis of their pharmacodynamics and pharmacokinetics. The authors have addressed some of these limitations by providing the reader with a list of Web sites that are more comprehensive and continuously updated (Appendices I and II). Preskorn’s Web site3 provides content on topics relevant to the safe and effective use of psychiatric medications. The number of drugs in a personal formulary will vary, but it is generally reasonable for a practicing psychiatrist, family practitioner, or internist to have 10–15 such drugs as the core of his or her personal formulary. This foundation of knowledge can then serve as a basis for the evaluation of new drugs as they appear. For the drug to express its potential action, it must reach the target to a sufficient degree to engage it to a physiologically relevant extent. Thus, the human brain may contain thousands of receptors, which are the primary targets of drug action.
In the interim, the goal of this guide is to summarize what is known, to explain the limits of current knowledge, and to define good clinical practices as they relate to avoiding untoward DDIs. For the same reason, quetiapine can have the same pharmacodynamic DDIs as other potent histamine H1 receptor antagonists even though those other drugs might not have any efficacy as an antipsychotic medication. Findings showed that people with better health knowledge and those who have a family history of type 2 diabetes were more likely to have healthy diets. He drank small amounts alcohol on occasion (averaging four drinks per month) and denied any history of recreational drug use.
Furthermore, perceived social stigma associated with and individual views about mental illness play a significant role in adherence to treatment for depression. For these reasons, the prescriber of psychiatric medications must consider all of the medications the patient is taking. This general guide provides an introduction to the topic and serves as a gateway to ready sources of additional information via the Internet. The essential elements of knowledge that the physicians should know about each drug in their personal formulary is listed in Table 3. There are also different enzymes for the synthesis and degradation of these neurotransmitters, different uptake pumps, and storage mechanisms. If healthier lifestyles can be increased among the general population as well as among those with family histories of diabetes it will slow the spread of this preventable disease and greatly reduce its burden on society (NSPNCD, Omar, 2011). A had repeated arguments with his wife, was unable to tolerate his children, and progressed to self-isolation at home. Hence, medically ill patients with MDD consume more healthcare services and experience higher mortality during their initial hospitalization.
This educational review discusses major pharmacologic principles to guide the safe and effective use of multiple medications with a focus on neuropsychiatric medications. Preskorn presents and discusses real life case examples of how DDIs present clinically and the mechanisms responsible for the DDI.4 The authors will refer to these and other Web sites as a reference for the reader who wants a more extended discussion of a topic or for those who want to check for updates after this guide has been published.
Drug concentration in relation to the drug’s binding-affinity profile determines what site of action the drug will bind to and to what degree.
Research has shown that risk factors for type 2 diabetes vary in prevalence within Malaysia by geographic area (Nuur Amalina et al., 2012), and ethnicity. Thus, having a family history of diabetes in some cases relates to better health practices, possibly through increased knowledge.
It also presents tables outlining major pharmacodynamic and pharmacokinetic mechanisms mediating DDIs relevant to the patient on psychiatric medications.
Thus, current drugs may interact pharmacodynamically in ways that are neither understood nor predictable at the present time.3 Their detection is dependent on the careful assessment at the time of a medcheck by the prescriber as discussed in the next paragraph.
Counterintuitively, higher educational levels, higher internal locus of control, better health knowledge, as well as a family history of diabetes all correlated with lower levels of physical activity. Alcohol consumption is based on the total number of drinks consumed per week and the smoking score is based on whether the participant is a current, past, or non-smoker.
Even with all these symptoms, the patient continued his regular schedule at work and strived to maintain social functioning.
As the concentration increases, the drug will bind more substantially to that target until it is saturated. Thus, it is suggested that, while increasing health knowledge will be important in addressing the type 2 diabetes epidemic in Malaysia, especially in relation to diet, other cultural factors, specifically norms related to exercise and physical activity, also need to be addressed if the spread of type 2 diabetes is to be addressed over the long term. It is not known, however, why these differences exist; or, to what degree knowledge, attitudes, and behaviors vary from group to group.
Other factors, such as knowledge and feelings of control may be important mediators in this relationship. For the purpose of this study, raw scores from each of these categories were used for analysis.
There was a correlation coefficient of 0.77 between the scores of the participants and blinded raters.




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