Current guidelines recommend metformin for most patients when starting hypoglycemic agents.7 However additional patient factors determine which other agents are selected either at diagnosis or once HbA1c goals are no longer being achieved on monotherapy.
These recommendations are based on current evidence about medication efficacy in relation to clinical outcomes and not only HbA1c levels, as well as data on drug side effects. The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating physician based on the individual patient’s clinical condition.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Long-acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus. Appropriate use of insulin analogs in an increasingly complex type 2 diabetes mellitus (T2DM) landscape. Glycemic control and coronary heart disease risk in persons with and without diabetes: the atherosclerosis risk in communities study.
A one-year randomised, multicentre trial comparing insulin glargine with NPH insulin in combination with oral agents in patients with type 2 diabetes. A comparison of bedtime insulin glargine with bedtime insulin in patients with type 2 diabetes: subgroup analysis of patients taking once-daily insulin in a multi-center, randomized, parallel group study. Vegetables – Artichoke Asparagus Beets Carrots Cucumber Green Beans Leeks Mustard Greens Okra Olives Onion Parsnip Potato Squash Watercress Zucchini. It might sound crazy but having instant access to awesome PS3 quality games like Uncharted Need for Speed Most Diabetes Mellitus Treatment Algorithm 2014 Wanted Rayman MLB 12 and so many others has allowed me to still get in some gaming. Diabetes Melitus terjadi ketika kadar gula darah seseorang secara konsisten di atas normal. Pramlintide (brand name Symlin) is a synthetic form of the hormone amylin, which is produced along with insulin by the beta cells in the pancreas. We present the risks and benefits of the different treatment options and provide guidance on selecting the most appropriate agent for each patient. National diabetes statistics report: estimates of diabetes and its burden in the United States. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality and prediabetes prevalence.
The influence of age on the effects of lifestyle modification and metformin in prevention of diabetes.
Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial. The prevalence of these diseases in the Dominican Republic is high and the end stage complications common.
It is accompanied by an interpretation that will help clinicians put evidence into practice.
A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. There are many conditions in Western industrialised societies today that were unheard of or at least very rare just a century ago. Kandungan di dalam Noni Juice mengandung antioksidan yang dibutuhkan bagi penderita diabetes melitus untuk Diabetes Mellitus Treatment Algorithm 2014 mengurangi kemungkinan timbulnya komplikasi yang menjadi resiko setiap penderita diabetes melitus .. Happy new year everyone =] Insulin Therapy (Indian Pediatrics) by Padmesh Vadakepat 1985 views. However a tighter target, such as ?6.5%, may be appropriate for younger patients and newly diagnosed patients without existing cardiovascular disease. A treatment program utilizing modern protocols often thought too complex for the rural poor was initiated.
This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Diabetes Mellitus Treatment Algorithm 2014 i have a nice set of Creative brand speakers hooked up to my TV also. This is what most diabetics should aim for when diabetic weight loss workout eating their meals.
So in what way does too much Dopamine cause the neurons to malfunction and how does that affect the larger network of neurons?
For patients with multiple comorbidities, frail elderly, those at greatest risk of hypoglycemia or with a limited life expectancy, a less stringent HbA1c ?8% may be reasonable.
Methods: With local government permission, a pilot study utilized Dominican physicians and local healthcare advocates (cooperadores) to obtain medical histories and physical exams as well as to determine healthcare needs specifically for type 2 diabetes and hypertension. However, patients on insulin glargine and detemir reported fewer symptomatic and overall hypoglycemic episodes. Schooff and Gupta present a clinical scenario and question based on the Cochrane Abstract, followed by an evidence-based answer and a critique of the review. Although there is a primary narration voice the POV of the story shifts with each chapter as identified by the chapter title – it may be jarring for some but I found it made the pace of the book more brisk and enjoyable. And why does it seem to malfunction in a consistent way or at least consistent enough to put a name on it (schizophrenia psychosis)? Damn straight Chaps one day at work clearing some fallen trees off the trail system in my town I had a big kick back that I was unpreared for; hit my upper thigh. Blood pressure parameters per established standards were used to identify patients with hypertension.
Short-Term Intensive Insulin Therapy in Newly Diagnosed Type 2 Diabetes – Introduction.
As indicated, pharmacotherapy was initiated (see treatment protocols), multiple forms of education and awareness building utilized, and a protocoldriven follow-up program maintained under weekly review. The American Diabetes Association (ADA) and American Association of Clinical Endocrinologists affirm the importance of tight glycemic control.3 The United Kingdom Prospective Diabetes Study suggests that intensive therapy with A1C levels of less than 7 percent was associated with reduction in microvascular disease, but had no effect on macrovascular disease. Regular (Humulin R Novolin R) insulin has an onset of Insulin comes in three different forms-vials prefilled syringes and cartridges. The resulting stress from lack of sleep when the flashes occur all night long is a double whammy! The symptoms of Insulin Resistance vary greatly due to the overall health of the person the age as well as the person’s lifestyle and gender. I am a type 1 and i am on Novarapid Penfil (fasting acting insulin) three times aday, plus 2 x 500mg of Metformin twice daily and then Lantus last thing at night. Results: In fifteen months, 1405 patients were screened, 229 type 2 diabetes patients, 59 pre-diabetes patients, and 98 hypertension patients were identified and enrolled for education, treatment, and follow-up. However, there have been some emerging data suggesting a benefit of tight glycemic control in reducing the incidence of cardiovascular events.4Overall, the studies included in this Cochrane review showed no statistically significant differences in the A1C levels measured at the end of the studies in any treatment group. Gestational Diabetes: Nutrition and Questions General nutritional guidelines for the gestating diabetic, a sample diet plan, and other issues. Normalization of blood pressure in hypertensives at 6 month follow-up was 78% and reduction of A1c values to 1. Patients treated with insulin analogues had lower rates of symptomatic, nocturnal, and overt hypoglycemia, even though the frequency of hypoglycemic events in all of the studies was low overall for the treatment groups.1,5 This review found no evidence that the more expensive analogues are any better than the isophane insulin in terms of morbidity, mortality, or quality of life, but none of the studies were designed to specifically measure these patient-oriented outcomes.
According to the International Diabetes Federation 285 million people worldwide suffer from diabetes and 344 million have impaired glucose tolerance. By 2030 the number of people living with diabetes is projected to rise to 438 million and impaired glucose tolerance to 472 million. The World Health Organization  states that 80% of the world’s diabetes occurs in low to middle income countries. ILAC is a non-profit organization that provides education and health care for rural Dominicans. A pool of 160 cooperadores de salud (health promoters), who are elected by their respective villages, receive bi-annual educational updates and are supervised by two full time ILAC physicians. Two large studies, the United Kingdom Prospective Diabetes Study (UKPDS) and the University Group Diabetes Program (UGDP), did not find a reduction of cardiovascular end points through improvement of metabolic control. The cooperadores de salud provide education and assistance on basic health issues for their village members. In these trials, 1,715 patients were randomized to insulin glargine, and 578 patients to insulin detemir. A1c values, blood sugars, urine microalbumin, blood pressures, serum creatinines, eye and foot examinations were conducted on all patients. Metabolic control, measured A1C levels as a surrogate end point, and adverse effects did not differ in a clinically relevant way between treatment groups.
Although no statistically significant difference for severe hypoglycemia rates was shown in any of the trials, the rate of symptomatic, overall, and nocturnal hypoglycemia was statistically significantly lower in patients treated with insulin glargine or detemir.
There was an obvious need for improved care and because the ILAC catchment area has at least 150,000 citizens (54% rural), it was apparent there were many untreated diabetics. Until long-term effectiveness and safety data are available, a cautious approach to therapy with insulin glargine or detemir is suggested.These summaries have been derived from Cochrane reviews published in the Cochrane Database of Systematic Reviews in the Cochrane Library. The degree of social inequality present in the province of Sanchez Ramirez is one of the highest in the country, with 53.4% of the homes being considered poor. Fifteen percent of the population did not have any primary education at the time of the survey.2.
METHODSThe Institute of Latin American Concern (ILAC) board gave permission for the initiation of the Sanchez Ramirez program and funding was obtained from the Dominican Development Alliance, a division of USAID and Chicago Cubs Charities.
The primary goal of the Diabetes Hypertension program founders was to reduce the complications of these diseases in the long term. Initial outcome measure goals included reducing A1c levels to Permission to work in Sanchez Ramirez was obtained from the minister of health. A Dominican medical director, a physician living in Comedero, and a nurse living near Comedero were hired and 5 cooperadores de salud in the region agreed to assist with screening, education, and treatment. A protocol was written and treatment algorithms based on American Diabetes Association and American Heart Association standards were agreed upon (figures 2 and 3) and implemented.
A1c correction was defined as a level Screening was first performed by administering a questionnaire (n = 669) that determined risk factors and if at risk the patients then had a blood sugar and blood pressure assessment. Because both conditions were found to be prevalent, we changed screening to simply obtaining a blood sugar and a blood pressure. If either was elevated on two occasions they were enrolled in their respective program and if both parameters were elevated, the patient was treated for both conditions.
A history and physical examination was conducted by a program physician and initial blood work was drawn including an A1c, liver function tests, and a creatinine. Initial laboratory blood work performed locally was found unreliable and thereafter was performed in a certified laboratory in Santa Domingo. Algorithm for the evaluation and treatment of patients with type 2 Diabetes Mellitus.Figure 3. Algorithm for the evaluation and treatment of patients with hypertension.be controlled with oral anti-hyperglycemics were referred to an endocrinologists for insulin therapy (n = 5) and 3 patients with elevated serum creatinines were referred to a nephrologist. Hypertension was treated with titrated doses of Lisinopril and Hydrochlorathiazide was added when needed.
To provide a strong educational foundation for the cooperadores de salud and patients we utilized a CD series called Rosa’s Story. The story is not only appropriate for those with lower levels of education but is culturally sensitive.After patient diagnosis, cooperadores de salud then started the 5 session education series with newly identified pre-diabetic and diabetic patients. Small patient groups (8 - 12 people) were formed, and one or more of the patient’s family members attended the sessions. Compliance with enrollment goals and other logistic matters including medications, diabetic equipment and inventory were monitored by Dr. RESULTSAfter 15 months a total of 1,405 patients were screened and as a result 229 diabetic patients, 59 pre-diabetic patients and 98 hypertension patients had treatment initiated. A total of 21 patients have been lost to follow-up and 100 patients have returned for 9 month follow-up.Hypertension, pre-diabetes, and diabetes patients follow up visit frequency is shown in figures 4-6. Medication usage for the different diagnoses is shown in figures 7 and 8.Eighty-seven of 109 diabetic patients at the 6 month follow up had an A1c 4. DISCUSSIONTwo hundred and sixty two patients have been treated for the first time for diabetes and hypertension. Follow-up visits for diabetes patients.has ranged from 3 - 15 months and baseline and follow-up A1c and blood pressures were obtained. The initial results exceeded our expected outcomes and are attributed to physician algorithm compliance, patient medication adherence and less advanced disease. Medication adherence was due to the CD education group program “Rosas’ Story” , clinic visits, and frequent follow-up cooperadores de salud interactions with the patients.These results demonstrate the effects of implementing a standardized approach to type 2 diabetes and hypertension using algorithms based upon consensus guidelines.
As discussed above, this local experience is reflective of the challenges of diabetes and hypertension management worldwide.
Practitioners, policy makers, and patients alike will attest to the significant hurdles and ongoing difficulties in managing these chronic diseases. For populations in the developing world for whom morbidity and mortality are shifting from acute illnesses such as infections, to chronic illnesses, the need to find ways in which to facilitate such care is self-evident.
Not surprisingly, the underlying management guidelines are essentially unchanged from consensus statements around the globe.
The most notable points which are of particular relevance to this project include finding ways to bring the benefits of a consensus approach to patients in the Dominican Republic utilizing local resources including local providers. Overcoming the lack of availability of essential tests such as the A1c, liver, and kidney function tests was a barrier that needed to be resolved. The shortage of general practitioners to administer this care to the great number of potential patients is a challenge to be overcome in a way that is sustainable in the local context.Finding ways to screen potential patients for diabetes and hypertension that does not overwhelm the local provider and support services is essential.
Instead of using standard diagnostic testing as a first step, other groups have employed equation-based screening formulas supplemented after the first-pass with fasting blood sugar testing, blood pressure monitoring, and hemoglobin A1c testing of smaller subsets .
Whether our approach or a variation of the same as used in other projects is most appropriate depends in large part on the particulars of a given setting, the population being treated, local resources, as well as the availability of regional and national support.A cornerstone of our approach was education using a peer-to-peer model that we believe had significant impact upon our patients and their surrounding communities, offering the promise of lasting benefit via deeper understanding and community-level insight. This is not a new concept overall as education has certainly been part of the treatment strategy in Latin America  as well as globally. Nevertheless, in combination with the resources and algorithm-guided care described here, the outcome measures speak to the impact of our approach.The limitations in comparing the Dominican group of subjects to those in developed countries include that compliance in the latter relates to issues such as affordability of medications, availability of appropriate care providers, education and counseling to make patients aware of the benefits (short and long-term) of therapy, and what has been described as clinical inertia wherein proactive adjustment of therapy seems to lag behind what standard algorithms would predict . In the Dominican cohort, medications were provided free of charge to subjects, very engaged and readily available providers were incorporated into the program from the outset, an educational program utilizing multimedia and simultaneously peer-to-peer learning delineated risks and benefits of therapy versus the lack thereof, and finally, the treatment algorithm played a central role in medical - decision-making significantly diminishing clinical inertia.Placing this within the context of the developing world, a varied and inhomogeneous grouping, a striking case is made here by way of proof of principle that facilitation of appropriate and adequate care as outlined above and which has been shown to work in the developed world produces similar results. A robust educational program is shown to provide a foundation of understanding of the diseases being addressed as well as the short and long-term benefits of doing so. Defaulting to internationally agreed upon standards of care while allowing for individualization maintains the impetus to move treatment forward as indicated . Finally, overcoming the significant hurdle of medication availability and affordability makes this intervenetion possible.
The problem with blood test transportation has improved (lipid and liver function tests not withstanding) with the donation of a point of care A1c machine but the A1c cartridges still remain expensive at $6.50 per cartridge. In this model small groups (7 - 8) meet and a moderator (cooperadores de salud) facilitates the education session by reading questions and giving the group a chance to respond and discuss their answers.Sustainability of the program is essential. Good relationships with local health authorities and education on infrastructure development plus continued program outcome success are mandatory. Sustainable health care initiatives require accessibility, high quality care, disruptive technology (cell phones, internet access, A1c and other blood test point of care testing), sustainable growth and affordability . Essentials for another program include a well defined group of underserved patients, local political will, a native endocrinologist for consultation, a health provider network, local physician participation, medication and equipment donations, funding, and an organization able to provide support and coordination of services.
The ILAC center has the advantage of its own network of health care providers but this can be replicated elsewhere. The cooperadores de salud are an integral and trusted part of the patients’ communities—which is one of the main reasons for the program’s success to date.5.
CONCLUSIONThe application of a best practice approach, as has been shown to work in the developed world, has found traction in this poor rural setting in the Dominican Republic. More patient enrollment and a closer study of cooperadores de salud—patient interaction is planned as well as enhancements of the data infrastructure.
ACKNOWLEDGEMENTSMany people deserve thanks you for their participation and program dedication. These include the cooperadores de salud Isabel Evangelista, Silvia De Los Angeles, Maria Matias, Maribel Garcia and Bernardino Cruz, our program nurse Ana Mercedes Munoz, the Ricketts family and Chicago Cubs Charities, Dr.
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