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Biomedical subjects

I B Hirsch

Publications and source records attributed to I B Hirsch.

At least 19 recordsLinked to original sources
PubMed2001

Hyperglycemic crises in diabetes mellitus type 2.

Hyperglycemic crises in type 2 diabetes are not rare and are becoming increasingly recognized as part of the spectrum of the presentation of previously undiagnosed diabetes mellitus and the decompensation of established diabetes mellitus. Contributing factors and associations are being elucidated but remain far from clear, particularly in DKA states. Medications commonly used in the treatment of many comorbid illnesses in patients with diabetes can themselves predispose to HHS. Endocrinopathies can contribute to insulin resistance and directly increase the glycemic load, leading to hyperglycemia. Medications such as the protease inhibitors may in the future lead to a better understanding of the pathophysiology of the metabolic derangements seen in the development of type 2 diabetes mellitus.

Diabetes Mellitus, Type 2↗
PubMed2001

Islet cell antibodies and glutamic acid decarboxylase antibodies, but not the clinical phenotype, help to identify type 1(1/2) diabetes in patients presenting with type 2 diabetes.

This study was undertaken to determine which type 1 diabetes-associated autoantibodies and what clinical characteristics are most useful to identify patients with type 1(1/2) diabetes. We studied 125 patients, recently diagnosed clinically with type 2 diabetes for the presence of islet cell antibodies (ICA), insulin autoantibodies (IAA), antibodies to glutamic acid decarboxylase(GADAb), and IA-2a (IA-2Ab). Patients with a diagnosis of type 2 diabetes who met all of the following criteria at diagnosis were studied: age > or = 30 years, no history of ketonuria or ketoacidosis, and not requiring insulin treatment. Thirty-six patients (29%) were positive for at least 1 antibody. Thirty-two (26%) were ICA positive and 20 (16%) GADAb positive. Insulin autoantibodies and IA-2Ab occurred less frequently in 2 (1.6%) and 8 (6.4%) patients, respectively. There was no significant difference in the ages at diagnosis between the Ab(+) and Ab(-) patients, age in years (range) 47.2 (32 to 64) versus 51.2 (31 to 77), respectively, P =.06. Body mass index (BMI) was different in the 2 groups, with Ab(+) patients being less obese, BMI (range) 28.3 kg/m(2) (17.6 to 54.9) versus 32.0 kg/m(2) (19.2 to 68.8), respectively, P =.01. Clinical presentation of diabetes was more commonly symptomatic with polyuria and polydipsia in Ab(+) patients, while in Ab(-) patients, diagnosis was more often incidental, P =.002. However, more than 95% of patients overlapped in both age and BMI irrespective of antibody status. Similarly, 42% of Ab(+) patients had their diabetes diagnosed incidentally, while 29% of Ab(-) patients presented with polyuria and polydipsia. We therefore conclude that screening with antibodies, mainly ICA and GAD, but not age, BMI, or clinical presentation should be used to identify type 1(1/2) diabetes.

Adult↗
PubMed2001

Improving the quality of outpatient care for older patients with diabetes: lessons from a comparison of rural and urban communities.

OBJECTIVE: Our goal was to compare the quality of diabetic care received by patients in rural and urban communities. STUDY DESIGN: We performed a retrospective analysis of claims data captured by the Medicare program. POPULATION: We included all fee-for-service Medicare patients 65 years and older living in the state of Washington who had 2 or more physician encounters for diabetes care during 1994. OUTCOME MEASURES: The outcomes were the extent to which patients received 3 specific recommended services: glycated hemoglobin determination, cholesterol measurement, and eye examination. RESULTS: A total of 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Generalists provided most diabetic care in all locations. Patients living in small rural towns received almost half their outpatient care in larger communities. Patients living in large rural towns remote from metropolitan areas were more likely to have received the recommended tests than patients in all other groups. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests. CONCLUSIONS: Large rural towns may provide the best conditions for high-quality care: They are vibrant, rapidly growing communities that serve as regional referral centers and have an adequate-but not excessive-supply of both generalist and specialist physicians. Generalists provide most diabetic care in all settings, and consultation with an endocrinologist may improve adherence to guidelines.

Aged↗
PubMed2000

Nonhypoglycemic drug reactions of agents used to treat diabetes.

The different classes of agents now available for the treatment of diabetes, each with its own unique mechanism of action, present the clinician with numerous choices to achieve glycemic control. Therapy can be tailored for each patient. If the primary problem is insulin resistance, a thiazolidinedione can be used. The clinician should remember the potential adverse reactions of the drugs and their potential interaction with other conditions a patient may have. After this careful consideration, the optimal therapeutic regimen for a patient can be developed.

Benzamides↗
PubMed2000

Less hypoglycemia with insulin glargine in intensive insulin therapy for type 1 diabetes. U.S. Study Group of Insulin Glargine in Type 1 Diabetes.

OBJECTIVE: Insulin glargine (21A-Gly-30Ba-L-Arg-30Bb-L-Arg-human insulin) is a biosynthetic insulin analog with a prolonged duration of action compared with NPH human insulin. This study compared insulin glargine with NPH human insulin in subjects with type 1 diabetes who had been previously treated with multiple daily injections of NPH insulin and regular insulin. RESEARCH DESIGN AND METHODS: This study was a multicenter randomized parallel-group study in which subjects were randomized to receive premeal regular insulin and either insulin glargine (at bedtime) or NPH insulin (at bedtime for patients on once-daily therapy and at bedtime and in the morning for patients on twice-daily therapy) for up to 28 weeks. Dose titration of both basal insulins was based on capillary fasting whole blood glucose (FBG) levels; the goal was a premeal blood glucose concentration of 4.4-6.7 mmol/l. RESULTS: A total of 534 well-controlled type 1 diabetic subjects (mean GHb 7.7%, mean fasting plasma glucose [FPG] 11.8 mmo/l) were treated. A small decrease in GHb levels was noted with both insulin glargine (-0.16%) and NPH insulin (-0.21%; P > 0.05). Significant reductions in median FPG levels from baseline (-1.67 vs. -0.33 mmol/l with NPH insulin, P = 0.0145) and a trend for a reduction in capillary FBG levels were achieved with insulin glargine. After the 1-month titration phase, significantly fewer subjects receiving insulin glargine experienced symptomatic hypoglycemia (39.9 vs. 49.2%, P = 0.0219) or nocturnal hypoglycemia (18.2 vs. 27.1%, P = 0.0116) with a blood glucose level <2.0 mmol/l compared with subjects receiving NPH insulin. CONCLUSIONS: Lower FPG levels with fewer episodes of hypoglycemia were achieved with insulin glargine compared with once- or twice-daily NPH insulin as part of a basal-bolus regimen in patients with type 1 diabetes.

Adult↗
PubMed1999

Type 1 diabetes mellitus and the use of flexible insulin regimens.

The management of type 1 diabetes mellitus (formerly known as insulin-dependent diabetes) has changed dramatically over the past 30 years. In particular, new insulin strategies have improved the ability to maintain near-normal glycemia. Factors such as onset, peak and duration of action can influence the ability of a particular insulin regimen to help control glucose levels. Patient factors, including individual variations in insulin absorption, levels of exercise and types of meals consumed, also influence the effectiveness of an insulin regimen. Rapid-acting insulin lispro is an ideal mealtime insulin. The premeal dose of insulin lispro can be adjusted based on the content of the meal and the patient's blood glucose level. Intermediate-acting and long-acting insulins should not be given to account for the content of a specific meal. Long-acting insulin can be administered once daily at bedtime or, ideally, twice daily in addition to another type of insulin. Patients with type 1 diabetes typically require an insulin dosage of 0.5 to 1.0 unit per kg per day. Newly diagnosed patients may have lower initial requirements because of continued endogenous insulin production. Flexible insulin regimens are based on predetermined actions in response to self-monitoring of blood glucose levels and carbohydrate intake.

Diabetes Mellitus, Type 1↗
PubMed1998

Cushing syndrome due to surreptitious glucocorticoid administration.

We report a case of subtle Cushing syndrome in a Pakistani man who self-treated his asthma with a potent long-acting oral glucocorticoid (betamethasone disodium phosphate [Bentelan]) for more than 30 years. He presented with cushingoid features, insulin resistance, and refractory hypertension. Laboratory evaluation revealed undetectable cortisol levels and suppression of the hypothalamic-pituitary-adrenal axis. The patient obtained the drug from his country of origin, with no understanding of the potential adverse effects imposed by long-term use of steroids. He is now being slowly weaned off the drug. The apparent widespread availability, access, and abuse of such potent steroids are a cause of concern in developing countries. We suggest that physicians in the United States be aware of the potential abuse of such potent drugs in all populations, including immigrants.

Asthma↗
PubMed1998

The effects of improved glycemic control on complications in type 2 diabetes.

Type 2 diabetes is 8 to 10 times more common than type 1 diabetes, but no single large trial has established that improved glycemic control can prevent complications in type 2 diabetes. We have reviewed the results of the existing epidemiologic and clinical trial studies and have arrived at the following conclusions: (1) Strong evidence exists that improved glycemic control is effective at lessening the risks of retinopathy, neuropathy, and nephropathy in type 2 diabetes. (2) The evidence about the effect on coronary heart disease is limited and equivocal. (3) The hypoglycemic risk from improved glycemic control is significantly less in type 2 diabetes than in type 1, and weight gain seems to be modest. In conclusion, although glycemic goals should be individualized based on several clinical factors, most patients with type 2 diabetes would probably benefit from glucose lowering to a hemoglobin A1c level between 7% and 8%.

Blood Glucose↗
PubMed1998

Intensive treatment of type 1 diabetes.

There have been amazing advances for the treatment of type 1 diabetes. As clinicians proceed into the twenty-first century, it is appropriate to reflect both about accomplishments and about the prospects of improved therapeutic options. Regarding the former, perhaps no advance can be compared to the discovery of insulin. Since then, the improvements in therapy have appeared to be too slow for physicians, patients, and their families. In actuality, over the past 20 years, the pace for the development of new tools for the treatment of this once fatal disease has been remarkable. The treatment of type 1 diabetes has evolved with advances in the treatment of microvascular, neuropathic, and macrovascular complications. The future is even more promising, with the possibility of even preventing the disease before the development of hyperglycemia. The challenge for the present is teaching all individuals involved with the management of patients with type 1 diabetes to manage the condition as effectively as possible.

Blood Glucose Self-Monitoring↗
PubMed1998

Severe insulin resistance in a patient with type 1 diabetes and stiff-man syndrome treated with insulin lispro.

We describe a patient with type 1 diabetes with recurrent diabetic ketoacidosis and severe insulin resistance. Extensive evaluation of the etiology of the insulin resistance did not reveal an etiology, and well over 1000 U of daily insulin did not prevent the ketoacidosis. Her blood glucose and insulin requirements were improved with glucocorticoids and octreotide, but the effects of both of these agents were short-lived. She was given a trial of insulin lispro with immediate and dramatic effects, lowering her HbA1c from 14.6 to 5.1% in 7 months with a decrease in insulin requirements of 1600-100 U per day. Besides her diabetes, she had a history of pain and stiffness affecting numerous muscle groups, and hospitalization was required for pain control. The diagnosis of stiff-man syndrome (SMS) was confirmed with high titers of glutamic acid decarboxylase 65 antibodies in both serum and cerebral spinal fluid. In summary, we describe the first patient with type 1 diabetes, SMS, and severe insulin resistance. Although the etiology of the insulin resistance is unknown, due to the efficacious response to insulin lispro, hydrocortisone, and perhaps octreotide, we propose an immune-mediated etiology. Although rare, this syndrome needs to be considered as an etiology of insulin resistance.

Adult↗
PubMed1998

Role of orlistat in the treatment of obese patients with type 2 diabetes. A 1-year randomized double-blind study.

OBJECTIVE: Obesity is an important risk factor for type 2 diabetes. Weight loss in patients with type 2 diabetes is associated with improved glycemic control and reduced cardiovascular disease risk factors, but weight loss is notably difficult to achieve and sustain with caloric restriction and exercise. The purpose of this study was to assess the impact of treatment with orlistat, a pancreatic lipase inhibitor, on weight loss, glycemic control, and serum lipid levels in obese patients with type 2 diabetes on sulfonylurea medications. RESEARCH DESIGN AND METHODS: In a multicenter 57-week randomized double-blind placebo-controlled study, 120 mg orlistat or placebo was administered orally three times a day with a mildly hypocaloric diet to 391 obese men and women with type 2 diabetes who were aged > 18 years, had a BMI of 28-40 kg/m2, and were clinically stable on oral sulfonylureas. Changes in body weight, glycemic control, lipid levels, and drug tolerability were measured. RESULTS: After 1 year of treatment, the orlistat group lost 6.2 +/- 0.45% (mean +/- SEM) of initial body weight vs. 4.3 +/- 0.49% in the placebo group (P < 0.001). Twice as many patients receiving orlistat (49 vs. 23%) lost > or = 5% of initial body weight (P < 0.001). Orlistat treatment plus diet compared with placebo plus diet was associated with significant improvement in glycemic control, as reflected in decreases in HbA1c (P < 0.001) and fasting plasma glucose (P < 0.001) and in dosage reductions of oral sulfonylurea medication (P < 0.01). Orlistat therapy also resulted in significantly greater improvements than placebo in several lipid parameters, namely, greater reductions in total cholesterol, (P < 0.001), LDL cholesterol (P < 0.001), triglycerides (P < 0.05), apolipoprotein B (P < 0.001), and the LDL-to-HDL cholesterol ratio (P < 0.001). Mild to moderate and transient gastrointestinal events were reported with orlistat therapy, although their association with study withdrawal was low. Fat-soluble vitamin levels generally remained within the reference range, and vitamin supplementation was required in only a few patients. CONCLUSIONS: Orlistat is an effective treatment modality in obese patients with type 2 diabetes with respect to clinically meaningful weight loss and maintenance of weight loss, improved glycemic control, and improved lipid profile.

Adult↗
PubMed1997

New oral therapies for type 2 diabetes.

Over the past few years, several oral agents for the treatment of type 2 diabetes have become available in the United States. Metformin, a biguanide that has been used for decades in other countries throughout the world, improves glycemic control without exacerbating hyperinsulinemia or promoting weight gain. This agent has recently been reintroduced in the United States. Acarbose is an alpha-glucosidase inhibitor that improves glycemic control by decreasing the intestinal absorption of glucose, thereby decreasing postprandial glucose elevations. The use of metformin and acarbose may be limited by their side effects and potential risks, especially the risk of lactic acidosis with metformin. The third newly available agent, troglitazone, has been shown to improve insulin sensitivity. Combinations of metformin, acarbose and troglitazone may facilitate improved glycemic control without the use of insulin, or they may allow sulfonylurea or insulin dosages to be reduced, in this way minimizing the adverse effects of hyperinsulinemia. Unfortunately, current oral therapies do not prevent the inevitable decline in glycemic control that occurs during the natural history of type 2 diabetes.

Acarbose↗