The tricyclic antidepressants are established treatments for peripheral diabetic neuropathy. The selective serotonin reuptake inhibitors present important benefits and risks in the treatment of comorbid depression and diabetes.
With regard to body weight, a meta-analysis shows fluoxetine can achieve moderate but statistically significant weight loss in adults with type 2 DM (Norris et al., 2004). The serotonin-norepinephrine reuptake inhibitors (SNRIs) venlafaxine (Effexor) and duloxetine (Cymbalta) present potential advantages in the treatment of comorbid diabetes and depression. To our knowledge, there are no studies of mirtazapine (Remeron) for depression with comorbid diabetes or for diabetic neuropathy. There are also no studies of bupropion (Wellbutrin) specifically for the treatment of depression comorbid with diabetes. Diabetes educator Elaine Blackwood urges parents and caregivers to be on alert because children and adults can be prone to the spikes and crashes of diabetes. Once your blood glucose rises, eat a small snack if your next planned meal is more than half an hour away. Diabetes Management & Supplies offers insulin pump training and accredited diabetes education services. At Diabetes Management & Supplies, we value the part we play on your treatment plan team and realize that winning is promoting good health. Estimates show that about 30% of diabetes cases in the United States are undiagnosed (CDC, 2003). Reports link MAOIs with sudden hypoglycemia requiring emergency intervention (Goodnick, 1997). Tricyclic antidepressants increase weight, although specific agents differ substantially in amount of weight gain (Zimmermann et al., 2003).

Neither drug has been specifically studied for treatment of depression and comorbid diabetes. A placebo-controlled trial of bupropion in men with diabetes and erectile dysfunction who weren't depressed showed no worsening of sexual function and no change in measures of diabetic control during treatment (Rowland et al., 1997). Lowering blood sugar levels is a common goal for children and adults with diabetes, but extreme lows can bring dangerous complications. Call your healthcare provider if it doesn’t go down after two checks, or if symptoms get worse. This could be three to four glucose tablets or ? cup (4 oz) of fruit juice or regular soda (not diet). Given that psychiatrists are often the main physician contact for patients with severe mental illness, they play a vital role in recognizing the signs and symptoms of new-onset diabetes as well as the potentially life-threatening symptoms of hyper- and hypoglycemia (Table 1). This effect could be particularly troubling with concomitant use of diabetes medications such as insulin and the sulfonylureas that can cause hypoglycemia. They may indirectly improve diabetes by improving depression but also have a direct hyperglycemic effect. A randomized, placebo-controlled study demonstrated fluoxetine effectively reduced depressive symptoms in an eight-week trial, with a trend toward improved glycemic control in patients with diabetes (both types 1 and 2) and MDD (Lustman et al., 2000b).
Despite evidence for improved depression, improved glycemic control and weight loss with SSRIs, one area in which they lack effectiveness is neuropathy. A single case report described new-onset type 2 DM in conjunction with mirtazapine-induced weight gain (Fisfalen and Hsiung, 2003).
Bupropion appears to be at least weight-neutral, if not weight-decreasing (Appolinario et al., 2004).
Each extreme carries symptoms that people with diabetes and family members should learn and be able to recognize as they develop.

Carefully following any medication orders and instructions is vital to your plan's success. Further evidence for potential benefits in glycemic control came from a study by Ghaeli et al.
Although extensively studied, SSRIs are not appropriate monotherapy for diabetic neuropathy (Duby et al., 2004). In terms of weight, phenelzine (Nardil) appears to induce weight gain, although reports on other MAOIs are mixed (Zimmermann et al., 2003). The same study found significantly increased fasting blood glucose in patients without diabetes treated with the TCA imipramine (Tofranil). This is important, given the association of these medications with the new onset of type 2 DM. However, path analysis showed the direct effect of nortriptyline was to worsen glycemic control (independent of weight gain), whereas depression improvement had an independent beneficial effect on glycosylated hemoglobin. Prudent patient care may dictate extending this surveillance to patients treated for depression. An open-label, 52-week trial of duloxetine for MDD showed a mean weight gain of approximately 5 lb (Raskin et al., 2003). Inhibiting the 2C9 isoenzyme will increase sulfonylurea levels, potentially leading to dangerous hypoglycemia (Cozza et al., 2003).

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