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NOTA: La compra de este producto requiere que complete su proceso de compra dentro de 48 horas. Patient information: See related handout on lifestyle changes to manage type 2 diabetes, written by the authors of this article. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Assessment with oral glucose tolerance test and measurement of HbA1c levels is recommended at 1–4 months postpartum to stratify risk. Insulin resistance, decreased insulin secretion, and increased hepatic glucose output are the hallmarks of type 2 diabetes, and each class of medication targets one or more of these defects. The American Diabetes Association recommends an A1C goal of less than 7 percent.7 Glycemic control requires the patient to have cognitive, visual, and motor skills to monitor and manage blood glucose levels, and identifying and minimizing barriers for effective self-management is an important first step to setting individualized goals. Metformin, which decreases hepatic glucose output and sensitizes peripheral tissues to insulin, has been shown to decrease mortality rates in patients with type 2 diabetes and is considered a first-line agent. Other medications include sulfonylureas and nonsulfonylurea secretagogues, alpha glucosidase inhibitors, and thiazolidinediones. Gastrointestinal symptoms associated with its use can be minimized by beginning with a low dose and titrating slowly. They should participate in intensive lifestyle modification programmes47, 49 to reduce weight and they should have HbA1c levels checked every 3–6 months to assess their response to this approach.

Insulin can be used acutely in patients newly diagnosed with type 2 diabetes to normalize blood glucose, or it can be added to a regimen of oral medication to improve glycemic control. It is also critical to remember that the goal of treatment is not only to reduce A1C levels, but also to prevent premature mortality and morbidity. Additional agents include sulfonylureas, nonsulfonylurea secretagogues, thiazolidinediones, and alpha-glucosidase inhibitors.
Except in patients taking multiple insulin injections, home monitoring of blood glucose levels has questionable utility, especially in relatively well-controlled patients. Women whose initial postpartum result is normoglycaemia are still at an increased risk of T2DM. Once fasting blood glucose approaches near-normal levels, postprandial glucose is addressed by increasing the dose of the current medications or by adding additional agents. They should receive dietary and exercise advice to promote weight loss and be monitored at least annually by measurement of fasting plasma glucose and HbA1c levels. Sulfonylureas can cause weight gain; this effect is less common with nonsulfonylurea secretagogues.
The onset of hyperglycaemia, whether assessed by an oral glucose tolerance test or HbA1c level, is an indication of deterioration and a need for intensification of treatment.
However, progressive failure of the beta cells often occurs even with proper diet, exercise, and oral medications, so patients should be counseled that insulin is simply another management tool.

Although insulin is typically introduced when glucose control is no longer possible with oral agents, it can also be used when contraindications to oral medications exist. Prolonged hyperglycemia can cause glucose toxicity, a potentially reversible impairment in glucose-stimulated insulin secretion. This can be corrected with aggressive insulin therapy, then oral medications can be added as insulin is tapered or discontinued. Rapid-acting or premixed preparations can be added if fasting blood glucose levels are persistently high or if A1C has plateaued at about 7.5 percent, which indicates that postprandial glucose levels are high. Adding more basal insulin in this setting usually will not help patients reach their target levels.24 Sliding-scale doses can be set by counting carbohydrate grams or by a preset scale (Figure 2).
Metformin is approved for use in children 10 years and older and sustained-release preparations are approved for use in persons 17 years and older who cannot maintain glycemic control with diet and exercise.7,27The increased prevalence of comorbid conditions in older adults requires careful consideration of medications.
Serum creatinine levels are not always a reliable predictor of renal insufficiency in the elderly, so metformin should be used with caution. The high prevalence of heart failure in this population limits the use of thiazolidinediones.

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