Atypical Diabetes Mellitus Associated with Bone Marrow Transplantation

ObjectiveTo describe 3 cases of atypical diabetes mellitus following bone marrow transplantation.MethodsWe describe the clinical presentation and relevant laboratory findings of 3 patients who presented with new-onset diabetes mellitus after bone marrow transplantation and discuss the possible mechanisms.ResultsA 52-year-old white man with chronic myelogenous leukemia, a 51-year-old white woman with acute myelogenous leukemia, and a 38-year-old Hispanic woman with acute myelogenous leukemia presented with acute onset of diabetes mellitus after bone marrow transplantation. Although blood glucose levels were initially very high, the patients required only small insulin dosages for glycemic control. Both the acute onset and requirement of relatively small insulin dosages were characteristic of type 1 diabetes mellitus. Onset of diabetes appeared to be unrelated to immunosuppressive drug therapy because it happened several months after starting these drugs. C-peptide was detectable, and glutamic acid decarboxylase antibodies were absent. Diabetes mellitus remitted spontaneously after a few months while the immunosuppressive drugs were continued.ConclusionAlthough the underlying mechanisms are unknown, cytokine changes after bone marrow transplantation may have led to temporary b-cell dysfunction in these patients. (Endocr Pract. 2010;16:93-96)     

Diabetes Mellitus after Hematopoietic Stem Cell Transplantation

ObjectiveTo review the current literature on posttransplant diabetes mellitus after hematopoietic stem cell transplantation, including its epidemiologic features, transplant-related risk factors, and treatment.MethodsA literature search was conducted in PubMed for articles on diabetes mellitus after hematopoietic stem cell transplantation and effects of immunosuppressants on glucose metabolism.ResultsWithin 2 years after hematopoietic stem cell transplantation, up to 30% of patients may have diabetes. Although some of these cases resolve, the rates of diabetes and metabolic syndrome remain elevated in comparison with those in the nontransplant patient population during long-term follow-up. Traditional risk factors for diabetes as well as features related to the transplantation process, including immunosuppressive medications, are associated with posttransplant diabetes. Cardiovascular risk also appears to be increased in this population. Limited data are available on hypoglycemic agents for posttransplant diabetes; thus, treatment decisions must be based on safety, efficacy, and tolerability, with consideration of each patient’s transplant-related medications and comorbidities.ConclusionTreatment of diabetes mellitus in patients who have undergone hematopoietic stem cell transplantation necessitates attention to the posttransplant medication regimen and clinical course. Although no guidelines specific to treatment of posttransplant diabetes in this patient population currently exist, treatment to goals similar to those for nontransplant patients with diabetes should be considered in an attempt to help reduce long-term morbidity and mortality. (Endocr Pract. 2010;16:699-706)     

Development of Type 2 Diabetes Mellitus in the Obese Adolescent:A Growing Challenge

ObjectiveTo describe the metabolic phenotype of type 2 diabetes mellitus in youth and possible metabolic defects leading to its development with particular emphasis on fatty liver.MethodsWe present data gathered from studies performed in obese adolescents across the spectrum of glucose tolerance to assess both alterations in insulin sensitivity and secretion. Discussion regarding treatment options is presented using the data from the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study.ResultsAs the number of children with obesity continues to grow, the health implications of the condition are becoming increasingly evident. An unprecedented phenomenon rarely seen before has emerged: type 2 diabetes mellitus. At the time of diabetes diagnosis, cardiovascular disease may already be present, even in young adults. The progression from normal glucose tolerance to type 2 diabetes in adults occurs through an intermediate phase of altered glucose metabolism known as impaired glucose tolerance or prediabetes. Previous studies from our group and others reported a high prevalence of impaired glucose tolerance among children and adolescents with marked obesity. Cross-sectional studies demonstrate that impaired glucose tolerance in obese youth is associated with severe insulin resistance, β-cell dysfunction, and altered abdominal and muscle fat partitioning. We end briefly by discussing the current data available on treatment of this condition from the TODAY study, the largest clinical trial ever performed in youth with type 2 diabetes.ConclusionThe observed rapid progression of the glucose homeostasis alterations in adolescents underlines the importance of focusing attention on the earliest stages of the disease before the onset of any alterations in glucose tolerance. (Endocr Pract. 2012;18:791-795)     

Prevention of Type 1A Diabetes Mellitus

ObjectiveTo review prediction of type 1 diabetes mellitus in light of current trials for prevention and novel preclinical therapies.MethodsThe stages in the development of type 1A diabetes are reviewed and strategies for prevention are discussed.ResultsFrom islet autoantibody testing of random cadaveric donors, it is apparent that approximately one-half million persons in the United States express multiple islet autoantibodies and are in the process of developing type 1A (immune-mediated) diabetes. It is now possible to predict not only risk for type 1A diabetes but also the approximate age of diabetes onset in children followed up from birth. In animal models, diabetes can be prevented. Some of the immunologic therapies effective in animal models are able to delay loss of insulin secretion in humans.ConclusionsNone of the therapies studied to date in humans can completely arrest progressive loss of insulin secretion resulting from destruction of islet b cells. Nevertheless, current knowledge of pathogenesis (targeting trimolecular recognition complex: major histocompatibility complex, peptide, T-cell receptor) and natural history combined with newer diagnostic methods allows accurate diagnosis and has stimulated the search for novel safe and effective preventive therapies. (Endocr Pract. 2012;18:745-749)     

The Dawn Phenomenon Revisited: Implications for Diabetes Therapy

ObjectiveTo summarize current data on the magnitude, prevalence, variability, pathogenesis, and management of the dawn phenomenon in patients with diabetes mellitus.MethodsOn the basis of the pertinent available literature and clinical experience, we propose a quantitative definition of the dawn phenomenon, discuss potential pathogenic mechanisms, and suggest management options.ResultsThe “dawn phenomenon” is a term used to describe hyperglycemia or an increase in the amount of insulin needed to maintain normoglycemia, occurring in the absence of antecedent hypoglycemia or waning insulin levels, during the early morning hours. To be clinically relevant, the magnitude of the dawn increase in blood glucose level should be more than 10 mg/dL or the increase in insulin requirement should be at least 20% from the overnight nadir. Controversy exists regarding the frequency, reproducibility, and pathogenesis of the dawn phenomenon. Approximately 54% of patients with type 1 diabetes and 55% of patients with type 2 diabetes experience the dawn phenomenon when the foregoing quantitative definition is used. The most likely pathogenic mechanism underlying the dawn phenomenon is growth hormone-mediated impairment of insulin sensitivity at the liver and muscles. The exact biochemical pathways involved are unknown. Therapeutic decisions aimed at correcting fasting hyperglycemia should take into account the variability and magnitude of the dawn phenomenon within individual patients. Successful insulinization appears to minimize the effects of the dawn phenomenon. Currently, no subcutaneous depot preparation of insulin exists that is capable of mimicking the basal insulinsecretion of the healthy pancreas.ConclusionIncreases in the bedtime doses of hypoglycemic agents with nighttime peaks in action may correct early morning hyperglycemia but be associated with undesirable nocturnal hypoglycemia. Targeted continuous subcutaneous insulin infusion programming can facilitate the prevention of early morning hyperglycemia in selected patients. (Endocr Pract. 2005;11:55-64)     

Insulin Glargine or Neutral Protamine Hagedorn in Patients with Severe Insulin Resistance: is There A Benefit?

ObjectiveTo determine the benefit of neutral protamine Hagedorn (NPH) insulin compared with insulin glargine in a patient with type 2 diabetes mellitus and severe insulin resistance.MethodsWe describe the patient’s clinical findings and treatment course.ResultsA 52-year-old man with a 3-year history of type 2 diabetes mellitus did not achieve adequate glucose control despite escalation of his treatment regimen to insulin glargine, 80 units twice daily; insulin lispro, 60 units before each meal; and metformin. Dietary and lifestyle changes were emphasized and implemented while medication adherence with appropriate insulin technique was reviewed at each visit. Insulin glargine was replaced with the same dosage of NPH insulin. After 3 months, a significant drop in hemoglobin A_1c was noted, from 9.5% to 6.1%, consistent with the improved capillary glucose measurements. The effect was maintained over the following year, without any major hypoglycemic events.ConclusionNPH insulin might be superior to the long-acting analogue insulin glargine in cases of severe insulin resistance, but randomized studies are needed to confirm our finding and clarify the involved mechanisms. (Endocr Pract. 2012;18:e49-e51)     

Diabetes: A Cardiac Condition Manifesting as Hyperglycemia

ObjectiveTo investigate the reasons for the increased risk of cardiovascular events and mortality in individuals with type 2 diabetes mellitus.MethodsFrom January 1990 to March 2008, literature relevant to low-density lipoprotein (LDL) and highdensity lipoprotein (HDL) cholesterol, hemoglobin A1c, acute hyperglycemia, postprandial hyperglycemia, systolic blood pressure, insulin resistance, endothelial dysfunction, microalbuminuria, diabetic cardiomyopathy, left ventricular hypertrophy, function inhibitors of the renin-angiotensin system and sympathetic nervous system, statins, and antiplatelet therapy as related to cardiac events and mortality in type 2 diabetic patients was reviewed.ResultsIncreased numbers of cardiac events and mortality in type 2 diabetes are associated with low HDL and high LDL cholesterol, high hemoglobin A1c, and high systolic blood pressure. Acute hyperglycemia, postprandial hyperglycemia, and possibly use of traditional sulfonylureas also increase incidence of cardiac events and mortality. The presence of microalbuminuria signifies endothelial dysfunction and an increased risk of cardiac events. Hypertension should be treated to goals that are lower in the diabetic patient with multiple therapies, which include suppressors of the renin-angiotensin and sympathetic nervous systems. Decreased improvement in outcomes for the diabetic patient with cardiovascular disease may be accounted for by the failure to treat insulin resistance and ventricular dysfunction. The high incidence of heart failure in the diabetic patient is due to the toxic triad of diabetic cardiomyopathy, left ventricular hypertrophy, and extensive coronary artery disease.ConclusionHigh risk of cardiovascular events, heart failure, and mortality in type 2 diabetes can be lowered with risk factor reduction and therapies that prevent or improve ventricular function. (Endocr Pract. 2008;14:924-932)     

Cystic Fibrosis-Related Diabetes Mellitus: Etiology,Evaluation, and Management

ObjectiveTo review the pathophysiology, diagnosis, and management of cystic fibrosis-related diabetes mellitus (CFRD).MethodsWe performed a MEDLINE search of the literature, using the search terms “cystic fibrosis-related diabetes, “CFRD,” and “cystic fibrosis and diabetes,” to identify pertinent articles available in English.ResultsIn patients with cystic fibrosis (CF), CFRD is a major cause for an accelerated decline in health. It is the result of multiple pathophysiologic mechanisms, including destruction of pancreatic islet cells, impaired hepatic response to the antigluconeogenic effects of insulin, and impaired insulin sensitivity. Nutritional management and adequate caloric intake are paramount to successful management of CF. Although insulin remains the standard of care for treating CFRD in conjunction with fasting hyperglycemia, a small but growing body of literature supports the use of oral therapies. In this article, we discuss the benefits of and possible adverse reactions to the various classes of oral and injectable agents used in the treatment of diabetes mellitus, with special attention to the population of patients with CF.ConclusionOrally administered agents can have a role in the treatment of CFRD. Further study is needed to determine the optimal combination of therapeutic modalities for CFRD. (Endocr Pract. 2008;14:1169-1179)     

Outcomes Associated With Insulin Therapy Disruption After Hospital Discharge Among Patients with Type 2 Diabetes Mellitus who Had Used Insulin Before and During Hospitalization

ObjectiveTo evaluate outcomes associated with insulin therapy disruption after hospital discharge in patients with type 2 diabetes mellitus who had used insulin before and during hospitalization.MethodsIn this observational, retrospective analysis of medical records obtained from a coordinated health system in the United States, patients with type 2 diabetes mellitus who had used insulin 30 days before and during hospitalization were included. Clinical and cost outcomes were compared between patients who continued insulin therapy and those who had disrupted insulin therapy after hospital discharge.ResultsIn total, 2160 records were analyzed (851 patients with continued insulin therapy and 1309 patients with disrupted insulin therapy). Mean baseline glycated hemoglobin A_1c levels were 8.56% and 7.73% in patients who continued insulin therapy and patients who disrupted insulin therapy, respectively (P <.001), suggesting that patients who discontinued insulin therapy had better glycemic control at baseline. Continued insulin therapy was associated with an expected greater reduction in glycated hemoglobin A_1c (P <.001); similar hypoglycemia rates; lower risks of all-cause hospital readmission, diabetesrelated readmission, and all-cause emergency department visits; and improved survival. Continued insulin therapy was associated with $3432 lower total medical service costs than disrupted therapy over the 6-month postdischarge period.ConclusionEnsuring adherence to insulin therapy in patients who require insulin therapy after hospitalization should be a priority for postdischarge patient care programs. However, the clinical implications of this study are limited by the fact that it could not be determined whether all patients required insulin therapy after hospital discharge. (Endocr Pract. 2012;18:651-659)     

Hypoglycemia: Still The Limiting Factor in the Glycemic Management of Diabetes

ObjectiveTo review the prevalence of, risk factors for, and prevention of hypoglycemia from the perspective of the pathophysiologic aspects of glucose counterregulation in diabetes.MethodsThis review is based on personal experience and research and the relevant literature.ResultsAlthough it can result from insulin excess alone, iatrogenic hypoglycemia is generally the result of the interplay of therapeutic insulin excess and compromised defenses against declining plasma glucose concentrations. Failure of β-cells of the pancreas—early in patients with type 1 diabetes mellitus but later in those with type 2 diabetes mellitus (T2DM)—causes loss of the first 2 physiologic defenses: a decrease in insulin and an increase in glucagon. Such patients are critically dependent on epinephrine, the third physiologic defense, and neurogenic symptoms that prompt the behavioral defense (carbohydrate ingestion). An attenuated sympathoadrenal response to declining glucose levels—caused by recent antecedent hypoglycemia, prior exercise, or sleep—causes hypoglycemia-associated autonomic failure (HAAF) and thus a vicious cycle of recurrent hypoglycemia. Accordingly, hypoglycemia is infrequent early in T2DM but becomes increasingly more frequent in advanced (absolutely endogenous insulin-deficient) T2DM, and risk factors for HAAF include absolute endogenous insulin deficiency; a history of severe hypoglycemia, hypoglycemia unawareness, or both; and aggressive glycemic therapy per se.ConclusionBy practicing hypoglycemia risk reduction— addressing the issue, applying the principles of aggressive glycemic therapy, and considering both the conventional risk factors and those indicative of HAAF— it is possible both to improve glycemic control and to minimize the risk of hypoglycemia in many patients. (Endocr Pract. 2008;14:750-756)     

Failure of Multiple Therapies in the Treatment of a Type 1 Diabetic Patient with Insulin Allergy: A Case Report

ObjectiveTo describe the clinical manifestations of insulin allergy and explain a systematic management approach.MethodsWe present the clinical, laboratory, and pathologic findings of a type 1 diabetic patient with allergy to subcutaneous insulin and briefly review the related literature.ResultsAn 18-year old woman with type 1 diabetes mellitus had an insulin allergy and developed subcutaneous nodules after insulin administration. Human and analogue insulins were used, but painful nodule formation persisted. Treatment with antihistamines, steroids, and omalizumab and insulin desensitization were ineffective. The patient required pancreatic transplant because glycemic control could not be achieved due to the insulin allergy.ConclusionsInsulin allergy is not a common condition and can be challenging in patients with type 1 diabetes. Therefore, identifying patients with true insulin allergy and applying a stepwise approach to their treatment is important. (Endocr Pract. 2011;17:91-94)     

Resolution Of Diabetes After Initiation Of Antiretroviral Therapy In Two Human Immunodeficiency Virus-Infected Patients

ObjectiveTo describe two cases of human immunodeficiency virus (HlV)-infected patients who had diabetes mellitus, which resolved after initiation of antiretroviral therapy.MethodsWe present the clinical and laboratory findings and describe the clinical course of these two patients.ResultsA 48-year-old HIV-infected black woman presented with multiple infections and hyperglycemia. After her acute infections were treated and she was feeling well, she continued to have diabetes that necessitated insulin therapy. Administration of a protease inhibitor-based antiretroviral regimen resolved her diabetes and eliminated the need for insulin or oral therapy. Our second patient, a 37-year-old HIV-infected black man, presented with polyuria and polydipsia and a hemoglobin A1c value of 11%. He received antiretroviral therapy, and his diabetes resolved after a period of 2½ months.ConclusionProtease inhibitor-based antiretroviral therapy is associated with diabetes mellitus in up to 6% of HIV-infected patients. Although most HIV-infected patients in whom diabetes develops have this disorder after initiation of protease inhibitor therapy, the current two cases illustrate patients in whom diabetes resolved after use of antiretroviral therapy. This finding supports the presence of other mechanisms that affect glucose metabolism in patients infected with HIV and suggests that control of HIV infection may have a role in controlling diabetes. (Endocr Pract. 2004;10:199-202)     

An individual approach to feline diabetes care: a case report and literature review

Background

Achieving insulin independence is emerging as a realistic therapeutic goal in the management of feline diabetes mellitus.

Case presentation

The management of an 11-year-old spayed female Burmese cat presenting with diabetes mellitus after corticosteroid administration is described. Remission was achieved after the frequency of insulin administration was increased to four times a day, and supported by intensive home blood glucose monitoring and a high protein, low carbohydrate diet.

Conclusion

Owners are important collaborators in feline diabetes care and, with intensive home monitoring, more frequent insulin treatment may lead to remission without hypoglycemia. More frequent insulin injections than recommended in the literature may be necessary to achieve glycemic control and used as an alternative to a longer-acting insulin.

     

The Pathway from Diabetes and Obesity to Cancer,on the Route to Targeted Therapy

ObjectiveTo review the epidemiologic studies that describe the relationships among diabetes, obesity, and cancer; animal studies that have helped to decipher the mechanisms of cancer development; and some of the therapeutic targets undergoing investigation.MethodsAn electronic search was performed of Medline, Scopus, Google Scholar, and ClinicalTrials.gov to identify English-language articles and studies published from 1995 through 2010 relating to obesity, insulin, insulinlike growth factors, diabetes mellitus, and cancer.ResultsEpidemiologic studies have reported that diabetes and obesity are linked to an increased risk of certain cancers in association with higher levels of insulin, C-peptide, and insulinlike growth factor 1. Animal models have demonstrated that increased insulin, insulinlike growth factor 1, and insulinlike growth factor 2 signaling can enhance tumor growth, while inhibiting this signaling can reduce tumorigenesis. Therapies that target insulin and insulinlike growth factor 1 signaling pathways have been developed and are currently in clinical trials to treat cancer.ConclusionsInsulin, insulinlike growth factor 1, and insulinlike growth factor 2 signaling through the insulin receptor and the insulinlike growth factor 1 receptor can induce tumorigenesis, accounting to some extent for the link between diabetes, obesity, and cancer. Knowledge of these pathways has enhanced our understanding of tumor development and allowed for the discovery of novel cancer treatments. (Endocr Pract. 2010;16:864-873)     

Hypoglycemia in childhood type 1 diabetes mellitus: Understanding and managing the dark side of intensive insulin therapy

Background: Despite the availability of advanced insulin delivery systems, blood glucose-monitoring equipment, and insulin analogue formulations, hypoglycemia remains a significant concern in the treatment of children and adolescents with type 1 diabetes mellitus (DM). Furthermore, patients who manage their blood glucose levels most effectively may also be the ones at greatest risk for hypoglycemia.Objective: The aim of this article was to review current issues surrounding the pathophysiology and frequency of hypoglycemia in children and adolescents with type 1 DM.Methods: Relevant articles for this review were identified through a search of MEDLINE (1992–2007; English-language articles only). The search terms used were children, adolescents, hypoglycemia, diabetes, insulin, and continuous subcutaneous insulin infusion.Results: The threat of severe hypoglycemia remains a major obstacle to the effective treatment of type 1 DM. Basalbolus therapy, using continuous subcutaneous insulin infusion or multiple daily injections, is the most effective and flexible method available for maintaining good glycemic control in children as well as in adults. Insulin analogues can be used effectively in these regimens and may be helpful toward addressing risks for hypoglycemia. Patient education should also be given a high priority in addressing the risk of hypoglycemia in children and adolescents with type 1 DM. The development of continuous glucose-monitoring systems offers the potential for an even brighter future for this group of patients.Conclusions: Recent advances in DM technology reduce but do not eliminate the risk of hypoglycemia in youth with type 1 DM. These observations underscore the need for a closed-loop insulin delivery system in which the rate of insulin infusion is regulated by real-time changes in glucose concentrations. (Insulin. 2007;2:157–165)Key words: type 1 diabetes mellitus; hypoglycemia; children; adolescents; insulin analogue; continuous subcutaneous insulin infusion; multiple daily injections; basal-bolus therapy.Accepted for publication 09052007     

Efficacy of High-Fiber Diets in the Management of Type 2 Diabetes Mellitus

ObjectiveTo review outcomes of randomized controlled clinical trials exploring the efficacy of different types of diets containing various amounts of fiber in the management of type 2 diabetes mellitus.MethodsWe searched PubMed, Medline, and Google Scholar for published data from the past decade (through December 2009) on dietary patterns and risk of type 2 diabetes mellitus. Only randomized controlled trials investigating the effect of whole grains, fiber, or vegetarian diets on type 2 diabetes were included. Search criteria included whole grain, fruit, vegetable, fiber, and meat intake regarding insulin sensitivity and glycemic responses in healthy, prediabetic, and diabetic persons.ResultsA total of 14 randomized clinical trials were included. Addition of insoluble or soluble fiber to meals, increased consumption of diets rich in whole grains and vegetables, and vegan diets improve glucose metabolism and increase insulin sensitivity. The greatest improvement in blood lipids, body weight, and hemoglobin A_1c level occurred in participants following low-fat, plant-based diets.ConclusionsIncreased consumption of vegetables, whole grains, and soluble and insoluble fiber is associated with improved glucose metabolism in both diabetic and nondiabetic individuals. Improvements in insulin sensitivity and glucose homeostasis were more evident in participants following a plant-based diet compared with other commonly used diets. (Endocr Pract. 2011;17:132-142)     

Inpatient Management of Diabets Mellitus Among Noncritically Ill Patients at the University Hospital of Puerto Rico

ObjectiveTo describe the state of glycemic control in noncritically ill diabetic patients admitted to the Puerto Rico University Hospital and adherence to current standard of care guidelines for the treatment of diabetes.MethodsThis was a retrospective study of patients admitted to a general medicine ward with diabetes mellitus as a secondary diagnosis. Clinical data for the first 5 days and the last 24 hours of hospitalization were analyzed.ResultsA total of 147 noncritically ill diabetic patients were evaluated. The rates of hyperglycemia (blood glucose ≥ 180 mg/dL) and hypoglycemia (blood glucose < 70 mg/dL) were 56.7 and 2.8%, respectively. Nearly 60% of patients were hyperglycemic during the first 24 hours of hospitalization (mean random blood glucose, 226.5 mg/dL), and 54.2% were hyperglycemic during the last 24 hours of hospitalization (mean random blood glucose, 196.51 mg/dL). The mean random last glucose value before discharge was 189.6 mg/dL. Most patients were treated with subcutaneous insulin, with basal insulin alone (60%) used as the most common regimen. The proportion of patients classified as uncontrolled receiving basal-bolus therapy increased from 54.3% on day 1 to 60% on day 5, with 40% continuing to receive only basal insulin. Most of the uncontrolled patients had their insulin dose increased (70.1%); however, a substantial proportion had no change (23.7%) or even a decrease (6.2%) in their insulin dose.ConclusionThe management of hospitalized diabetic patients is suboptimal, probably due to clinical inertia, manifested by absence of appropriate modification of insulin regimen and intensification of dose in uncontrolled diabetic patients. A comprehensive educational diabetes management program, along with standardized insulin orders, should be implemented to improve the care of these patients. (Endocr Pract. 2014;20:452-460)     

Risk Factors for Hypoglycemia in Inpatients with Total Parenteral Nutrition and Type 2 Diabetes: A Post HOC Analysis of the Insupar Study

Objective: Treatment of hyperglycemia with insulin is associated with increased risk of hypoglycemia in type 2 diabetes mellitus (T2DM) patients receiving total parenteral nutrition (TPN). The aim of this study was to determine the predictors of hypoglycemia in hospitalized T2DM patients receiving TPN.Methods: Post hoc analysis of the INSUPAR study, which is a prospective, open-label, multicenter clinical trial of adult inpatients with T2DM in a noncritical setting with indication for TPN.Results: The study included 161 patients; 31 patients (19.3%) had hypoglycemic events, but none of them was severe. In univariate analysis, hypoglycemia was significantly associated with the presence of diabetes with end-organ damage, duration of diabetes, use of insulin prior to admission, glycemic variability (GV), belonging to the glargine insulin group in the INSUPAR trial, mean daily grams of lipids in TPN, mean insulin per 10 grams of carbohydrates, duration of TPN, and increase in urea during TPN. Multiple logistic regression analysis showed that the presence of diabetes with end-organ damage, GV, use of glargine insulin, and TPN duration were risk factors for hypoglycemia.Conclusion: The presence of T2DM with end-organ damage complications, longer TPN duration, belonging to the glargine insulin group, and greater GV are factors associated with the risk of hypoglycemia in diabetic noncritically ill inpatients with parenteral nutrition.Abbreviations: ADA = American Diabetes Association; BMI = body mass index; CV% = coefficient of variation; DM = diabetes mellitus; GI = glargine insulin; GV = glycemic variability; ICU = intensive care unit; RI = regular insulin; T2DM = type 2 diabetes mellitus; TPN = total parenteral nutrition     

Insulin for Type 2 Diabetes Mellitus: Separating the Myths from the Facts

Background: Reluctance to use insulin is a well-established problem among patients with type 2 diabetes mellitus (DM). Many of the concerns that prompt patients to resist insulin are rooted in myths that arose because of the medical profession's difficult history with this medication.Objectives: The goals of this article were to articulate those myths, describe their impact on patient and clinician reasoning, and explain how clinicians can reassure patients and help them make a more informed choice about insulin therapy.Methods: Materials used for this article were identified through a search of PubMed for the years 1993 to 2007. English-language articles were selected using the search terms diabetes mellitus, psychological insulin barriers, and clinical inertia.Results: There are patient- and physician-specific barriers to insulin initiation that providers must be aware of to successfully counsel patients. Physician issues include worries regarding the effect insulin initiation in patients will have on practice resources (eg, impact patient crises have during initial stages of insulin therapy, concern there is inadequate time or personnel to teach insulin therapy); fear that patients will become angry, alienated, or leave the practice; and concern about the potential for patient hypoglycemia and weight gain. Patient-centered issues focus on the fear of weight gain, social embarrassment/stigma, hypoglycemia, lifestyle changes/restrictions, painful injections, and feelings of failure and guilt that treatment has progressed to needing insulin. Clinicians can alleviate many patient concerns by becoming aware of the personal and social dimensions of insulin therapy. Numerous strategies are available for the clinician to use for successful implementation of insulin therapy in patients with type 2 DM.Conclusion: By investigating the new, simpler, more straightforward algorithms for initiating insulin and using them in patient care, it will be possible to help patients make an informed decision when the time comes to start insulin therapy.