Treatment of lipid disorders in diabetes mellitus

Effects of insulin, glimepiride and combination therapy of insulin and metformin on blood sugar and lipid profile of NIDDM patients

In the present study the efficacies of therapy with insulin, sulphonylurea or insulin + metformin on NIDDM patients are compared. One group which was on a definite dose of insulin therapy, but with uncontrolled diabetes was treated by doubling the insulin dose, a second group whose diabetes was not controlled by glibenclamide was switched over to another sulphonylurea viz; glimepiride and a third group whose diabetes was not controlled by insulin therapy was switched over to a combination therapy with insulin +metformin. After recording their initial blood parameters all the groups were treated as above for 3 months, and the parameters were again determined. The fasting blood sugar and serum lipids of the first group were controlled significantly, but the values were far above normal range. However HDL Cholesterol and atherogenic index were near normal range. In glimepiride treated group, none of the parameters showed any amelioration. In the combined therapy group, control of blood sugar and atherogenic index was more or less the same as for group 1, but hyperlipidemia remained slightly above that of the same. From the findings we can infer that in long term diabetes treatment higher doses of insulin and combined therapy with insulin and metformin may be more beneficial than with low doses of insulin or sulfonyl urea alone.

Oral antidiabetic drug use in the elderly

Non-insulin-dependent diabetes mellitus (NIDDM) is a metabolic disease that is common in the elderly, and is characterised by insulin insufficiency and resistance. Measures such as bodyweight reduction and exercise improve the metabolic defects, but pharmacological therapy is the most frequently used and successful therapy. The sulphonylureas stimulate insulin secretion. Metformin and troglitazone increase glucose disposal and decrease hepatic glucose output without causing hypoglycaemia. Acarbose is a dietary aid that spreads the dietary carbohydrate challenge to endogenous insulin over time. These pharmacological agents, either alone or in combination, should improve blood glucose regulation in patients with NIDDM.

Impact of cardiovascular disease on health care utilization in a defined diabetic population

We studied the impact on annual medical care utilization and costs in 1988 of cardiovascular disease (CVD) in a population-based sample of 435 diabetic (DM) and 435 matched non-DM members of a Health Maintenance Organization. 58% of DM had at least one diagnosed CVD, compared to 26% of non-DM. 22.7% of outpatient visits, 38.7% of hospital days, and 30% of pharmacy expenditures by those with DM were primarily attributable to CVD. Up to 27% of all CABG recipients in the population had diabetes. In total, CVD directly accounted for at least 24% of total medical care costs among DM, compared to 12% of costs for non-DM. The HMO spent 4.5 times per person more on CVD care in DM than in non-DM members. Treatment with insulin was associated with increased peripheral vascular disease. After adjusting for age, CVD was more prevalent and generated longer hospital stays in DMs with nephropathy. The etiologic association between CVD and DM is well documented but CVD's clinical and economic importance in DM seems underappreciated.

Serum lipoproteins in African Americans and whites with non-insulin-dependent diabetes in the US population

BACKGROUND

Despite the significant role that dyslipidemia is believed to play in the development of cardiovascular disease in diabetes, most studies examining diabetic dyslipidemia in the United States have not been population based, and very little data are available for African Americans with diabetes. We used data from a national survey to compare the effect of diabetes on lipid concentrations in African-American and white men and women. In addition, we examined other factors related to lipid concentrations and controlled for these factors in our analyses.

METHODS AND RESULTS

The Second National Health and Nutrition Examination Survey included a representative sample of 4177 African Americans and whites in the US civilian noninstitutionalized population 20 to 74 years old. These persons were classified as having non-insulin-dependent diabetes mellitus (NIDDM) (n = 720) or as being nondiabetic (n = 3457) based on an oral glucose tolerance test and a medical history of diabetes. Subjects were given an interview and physical examination that included measurement of serum lipoproteins, body mass index, body fat distribution, dietary fat intake, alcohol consumption, frequency of smoking, and use of medications. By univariate analysis, a worse profile of mean cholesterol, triglycerides, and high-density lipoprotein cholesterol levels was generally apparent in NIDDM than in nondiabetic subjects, regardless of race or sex; a similar pattern was found for the prevalence of abnormal concentrations of these lipids. Lipid profiles appeared to be worse in whites with NIDDM than in African Americans. For mean total and low-density lipoprotein cholesterol, concentrations tended to be worse in women with NIDDM than in men. When other factors significantly affecting lipid levels were adjusted by multivariate analysis, we found that in all race/sex groups, total cholesterol was higher in NIDDM than in nondiabetic subjects but differences were not significant (P = 54), triglyceride concentrations were significantly higher in NIDDM subjects (P < .0001), and high-density lipoprotein cholesterol concentrations were lower in NIDDM subjects (P = .003). An interaction of diabetes with race was found for low-density lipoprotein cholesterol (P = .0001), where concentrations were substantially lower in NIDDM than in nondiabetic subjects among African Americans (P < .01) but slightly higher in NIDDM subjects among whites (P = .33). For other lipids, no differential effect of NIDDM was found by race or sex.

CONCLUSIONS

In African-American and white men and women in the United States, NIDDM is associated with a pattern of dyslipidemia that may potentiate the atherosclerotic process. Diabetic treatment should include aggressive treatment of dyslipidemia to reduce this increased risk.

Nicotinic acid for the treatment of hyperlipoproteinemia

Nicotinic acid is a water-soluble B-complex vitamin that has been shown, in high doses, to lower total plasma cholesterol (C), LDL-C, and VLDL-triglycerides (Tg), while raising HDL-C in patients with type II, III, IV, and V hyperlipoproteinemia. Its exact mechanism of action is not known, but it appears to lower the production of VLDL in the liver while activating lipoprotein lipase. The drug may also influence the metabolism of HDL-C. The drug is a second or third choice for isolated hypercholesterolemia because of a high incidence of side effects. However, it has a therapeutic advantage as a monotherapy when reduction of both LDL-C and triglycerides are needed in patients with severe combined hyperlipidemia. The drug can be used in combination with other cholesterol-lowering agents to maximize lipid-lowering activity. Nicotinic acid has been associated with a reduced risk of cardiovascular morbidity in clinical trials.