Miscellaneous

Most patients with both Type 1 and Type 2 succumb to either the macrovascular or microvascular complications — especially ischaemic heart disease and diabetic nephropathy, respectively. Indeed diabetes is the major indication for dialysis and transplantation. As discussed in other chapters, the treatment of hypertension and hyperlipidaemia is particularly important in patients with diabetes. Patients with diabetic nephropathy should receive either an ACE inhibitor or angiotensin receptor

• Diabetes me Hi tus is important in global terms because of its chronicity.and high incidence and frequency of major complications. It Is of two kinds:Type I (previously, insulin dependent diabetes mellitus) and Type 2 (previously, non-insulin dependent diabetes).

• Type I diabetes is commoner among young, thin patients with diabetes. Insulin may also be required when glycaemic control is not achieved by oral drugs inType 2 pateints,

• Insulin is given s.c to stable patients, usually as a biphasic mixture of soluble, short-acting human insulin, and a longer-acting suspension of insulin with protamine or line.

• In the treatment of diabetic ketoacidosis, in the perioperative patient, and at other times of changing insulin requirement, insulin is best given by i.v. infusion of the soluble form,

• Diet plays a major role in the treatment ofType 1 diabetes with obesity.

• There is now a clear difference in the choice of firstline drug, if a drug is required, inType 2 diabetes. A sulphonylurea is used for the nonobese.and metformin (a biguanide) for the obese.

• Aggressive treatment ofType I, and probably Type 2. successfully reduces microvascular complications. Close attention to associated risk factors, especially hyperlipidaemia and hypertension.is important in reducing risk of macrovascular disease.

antagonist, with the evidence for the latter being particularly strong that they are superior to other antihypertensive agents in reducing progression to renal failure.12 Addition of an ACE inhibitor to other drugs may also improve overall outcome in patients with diabetes.13 Most impressively, the Heart Protection Study showed that addition of simvastatin 40 mg daily to the treatment of 4000 patients with diabetes reduced all cardiovascular complications by 30%14 (see p. 486).

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