Practical Diabetes Care, Third Edition

333 Pages·2011·3.717 MB·English

by  David Levy(auth.)

Practical
Diabetes Care
Cover illustration: Continuous glucose monitoring study (FreeStyle
Navigator(R), Abbott) of a type 1 male one year after a combined
pancreas-pre-emptive kidney transplant. Diagnosed age 10, duration
30 years; advanced neuropathic complications, stage 4 CKD. Near-
c onstant glucose levels 5 mmol/L overnight, with post-meal levels rarely
above 10 mmol/L. Blood glucose oscillations during the day in part
may be caused by glucose intake in response to perceived hypoglycae-
mia, not documented during this study. Almost non-diabetic HbA 5.8%
1c
(40 mmol/mol).
Practical Diabetes Care, Third Edition David Levy
© 2011 David Levy. ISBN: 978-1-444-33385-5
Practical
Diabetes Care

THIRD EDITION
David Levy MD FRCP
Consultant Physician, Gillian Hanson Centre
Whipps Cross University Hospital;
Honorary Senior Lecturer
Queen Mary University of London
London, UK
A John Wiley & Sons, Ltd., Publication
This edition first published 2011, © 2011 by David Levy.
1st edition 1998 (Greenwich Medical Media/Cambridge University Press)
2nd edition 2006 (Altman Publications)
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Library of Congress Cataloging-in-Publication Data:
Levy, David, 1954- author.
Practical diabetes care / David Levy, MD, FRCP, Consultant Physician, Gillian Hanson Centre,
Whipps Cross University Hospital; Honorary Senior Lecturer, Queen Mary University of London,
London, UK.—Third Edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4443-3385-5 (pbk. : alk. paper)—ISBN 978-1-4443-9113-8
(ePDF)—ISBN 978-1-4443-9115-2 (Wiley online library)—ISBN 978-1-4443-9114-5 (ePub)
1. Diabetes—Treatment. 2. Primary care (Medicine) I. Title.
[DNLM: 1. Diabetes Mellitus—therapy. 2. Diabetes Mellitus—diagnosis.
WK 815]
RC660.H553 2011
616.4’62—dc22 2010047258
ISBN: 978-1-4443-3385-5
A catalogue record for this book is available from the British Library.
This book is published in the following electronic formats: ePDF 9781444391138; Wiley Online
Library 9781444391152; ePub 9781444391145
Set in 9/12pt Palatino by MPS Limited, a Macmillan Company, Chennai, India
1 2011
Contents
Preface, xi
Numbers, conversions and tables, xvii
1 Classification and diagnosis, 1
Introduction, 1
Classification, 3
Diagnosis of diabetes in non-pregnant adults, 11
IGT and clinical trials to prevent
progression of IGT to diabetes, 16
Screening for diabetes, 18
Prevention of type 1 diabetes, 19
References, 19
Further reading, 21
2 Diabetes in the emergency department, 22
Introduction, 22
Hyperglycaemic emergencies: diabetic ketoacidosis
and hyperglycaemic hyperosmolar state, 23
Management of the clinically well, newly presenting
type 1 patient, 25
Precipitating factors, 25
Ketones in DKA, 26
Intensive care unit?, 28
Investigations, 28
Management, 29
Follow-up, 34
Hypoglycaemia, 36
The acute diabetic foot, 44
References, 45
Further reading, 46
v
vi Contents
3 Management of inpatient diabetes, 47
Introduction, 47
Acute coronary syndromes (ST-segment elevation
acute myocardial infarction, non-ST-segment elevation
acute myocardial infarction and unstable angina), 48
Atrial fibrillation, 54
Patients in the intensive care unit, 54
Non-critically ill patients, 55
Stroke, 55
Enteral feeding (nasogastric, percutaneous
endoscopic gastrostomy), 56
Glucocorticoid treatment, 57
Inpatient screening routine, 58
Perioperative management, 59
References, 62
Further reading, 63
4 Type 1 diabetes: insulin treatment, 64
Introduction, 64
Total daily insulin dose requirements, 66
Glycaemic targets in type 1 diabetes, 66
Insulin products, 67
Insulin prescribing, 68
Insulin preparations, 69
Basal-bolus/multiple-dose insulin, 72
Biphasic (fixed-ratio) mixtures, 73
Insulin pump treatment (CSII), 74
Checklist of practical points whenever there is a
problem with blood glucose control, 76
Continuous glucose monitoring, 77
New developments, 80
References, 81
Further reading, 81
5 Type 2 diabetes: general introduction, 83
Introduction: type 2 diabetes as a progressive
condition, 84
The general approach to the newly diagnosed type 2
patient, 84
Lifestyle intervention: diet and exercise, 87
Drug treatment of type 2 diabetes, 92
References, 99
Further reading, 101
Contents vii
6 Type 2 diabetes: pharmacological treatment of
hyperglycaemia, 102
Introduction, 103
Metformin (British National Formulary, Section 6.1.2.2), 104
Sulphonylureas and meglitinides (prandial insulin
regulators) (British National Formulary,
Section 6.1.2.1), 108
Thiazolidinediones (glitazones) (British National Formulary,
Section 6.1.2.3), 112
(cid:2)-Glucosidase inhibitors (British National Formulary,
Section 6.1.2.3), 117
Drugs acting on the incretin system (entero-insular axis), 118
DPP-4 inhibitors (gliptins) (British National Formulary,
Section 6.1.2.3), 124
Pramlintide, 125
Combination non-insulin treatment, 125
Insulin treatment in type 2 diabetes, 126
New developments, 135
References, 136
Further reading, 138
7 Infections in diabetes, 139
Introduction, 139
Types of infections, 140
Chest infections, 141
Infections after surgery, 141
Urinary tract infections (British National Formulary,
Section 5.1.13), 142
Abdominal infections, 146
Soft-tissue infections, 146
Diabetic foot infections, 147
Uncommon infections characteristic of diabetes, 153
References, 154
Further reading, 155
8 Diabetic renal disease, 156
Overview of diabetic kidney disease, 157
Quantification of urinary albumin excretion, 162
Management of microalbuminuria, 166
Management of diabetic nephropathy, 169
Other management problems in diabetic nephropathy, 174
Renal replacement therapy, 178
Pancreas, kidney–pancreas and islet transplantation, 179
viii Contents
References, 180
Further reading, 182
9 Diabetes and the eye, 183
Introduction, 184
Retinopathy in type 1 diabetes, 184
Retinopathy in type 2 diabetes, 185
Classification of retinopathy, 186
Non-proliferative diabetic retinopathy, 186
Pre-proliferative retinopathy, 190
Proliferative retinopathy, 190
Maculopathy, 191
Advanced diabetic eye disease, 192
Cataract, 193
Retinal vascular occlusions, 193
New developments, 194
References, 195
Further reading, 195
10 Diabetic neuropathy, 197
Introduction, 197
Diagnosis of neuropathy, 198
Management of diabetic polyneuropathy, 203
Foot ulceration, 204
Charcot neuroarthropathy, 210
Painful diabetic neuropathy, 211
Other painful neuromyopathic syndromes in diabetes, 214
Mononeuropathies and other focal syndromes, 216
Autonomic neuropathy, 219
References, 224
Further reading, 226
11 Hypertension, 227
Introduction, 227
Thresholds and targets for treatment, 231
Management, 231
Blood pressure measurement, 234
Pharmacological treatment: general features, 238
Preferred treatment: angiotensin blockade, 243
Angiotensin receptor blockers, 247
Calcium-channel blockers, 248
Beta-blockers (British National Formulary, Section 2.4), 251
Diuretics, 252
Contents ix
Other agents, 255
Resistant hypertension, 255
References, 259
Further reading, 260
12 Lipids, 262
Introduction, 263
Lipids in type 1 diabetes, 263
Lipids in type 2 diabetes, 264
Increased cardiac risk in type 2 diabetes, and a re-evaluation
of the ‘coronary equivalent’ concept, 265
Lipid profiles in poorly controlled diabetes and effects
of intensive glycaemic treatment, 265
Screening for secondary causes of hyperlipidaemia, 266
Primary therapeutic target: LDL-cholesterol, 269
Management, 271
Severe hypertriglyceridaemia, 286
References, 287
Further reading, 288
13 Psychological aspects of diabetes, 289
Introduction, 290
Type 1 diabetes, 290
Type 2 diabetes, 295
References, 299
Further reading, 300
Index, 301
Preface
It was rash and naive to say in the preface to the second edition (2006)
that we were entering a post-millennial phase of stability in the practical
management of diabetes. No sooner had it gone to press than the results
of megatrials started appearing in pairs and sometimes trios. Insulin
studies in type 2 diabetes began to invade almost every imaginable (and
a few almost unimaginable) regimen, and after a quiet phase in the early
2000s, new and alluring medications began to arrive (though a few oth-
ers fell spectacularly by the wayside).
In the midst of this rapid expansion, a cohort of massive studies, qui-
etly brewing since the beginning of the millennium, finally exploded.
The seismic activity was due to the publication of four important ran-
domised trials – VADT, ACCORD and ADVANCE in the latter part of
2007 and early 2008, BARI 2D in mid-2009 – and the complementary
findings of the long-term UKPDS follow-up. Accordingly, guideline pro-
duction and revision accelerated to near-maniacal levels, to the point at
which practitioners are now challenged over the choice of second-, never
mind third- or fourth-line glycaemic treatments. The uniform, and for
some uncomfortable, conclusion from VADT, ACCORD and ADVANCE
is that after 10 years or more of diagnosed type 2 diabetes, especially in
the presence of macrovascular complications, undue efforts at glycaemic
control confer no macrovascular and only slight microvascular benefit,
and may even increase mortality; this should have been wise practice in
elderly patients even without this evidence. BARI 2D tells us unequivo-
cally that insulin treatment confers no advantage over insulin-sensitizing
treatment in diabetic people with symptomatic coronary artery disease.
The statistical navel-gazing resulting from the troubling conclusions of
the ACCORD glycaemic study is still in full swing as I write this intro-
duction, and it may be that these critical points will never adequately
be explained, though it certainly won’t be for want of trying. Perhaps
of all the ACCORD substudies, ACCORD Eye, published just before the
book went for copy-editing, represents the apogee of intricacy in diabe-
tes RCTs and, while I would not wish nightmares on anyone, should give
xi
xii Preface
hard-headed mechanistic evidence-based practitioners at least pause for
thought that the more ‘definitive’ a trial is touted to be, the more com-
plex and subtle its conclusions are likely to be. I date this phenomenon to
the early 2000s when even the huge, but conceptually simple, ALLHAT
hypertension trial failed to land the knockout blow of determining once
and for all the ‘right’ first-line treatment for high blood pressure, but we
should have taken the hint from the University Group Diabetes Project
decades before. Quite simply, there is probably not a right first-line treat-
ment for any long-term condition.
I have rewritten much of the material on type 2 diabetes to try to reflect
these trials, though the results of VADT and Steno-2 do not in any way
let us off the hook over blood pressure, lipids, albuminuria and lifestyle
intervention, especially smoking cessation. Barely recovering from this
onslaught, we felt the aftershocks in 2009 and 2010: the proposal that
HbA measurements really could be used to diagnose diabetes (and,
1c
more contentiously, pre-diabetes as well), and the ACCORD lipid and
blood pressure substudies, which showed that people with unremark-
able lipid profiles gain unremarkable benefits from statin–fibrate com-
bination treatment, and I think more significantly hinted that ‘lower is
better’ might not even apply to blood pressure.
Still, the UKPDS follow-up permits us to be ‘aggressive’ (the only use I
will permit myself of this pervasive and self-serving word) over glucose
treatment in ‘early’ type 2 diabetes, whatever that means. All these results
now sit uncomfortably with protocol-driven strategies for type 2 diabe-
tes management that fail to take into account the extraordinary variety
of this condition; we can take this as a liberating opportunity, as I would
prefer, or we can try to emulate the artificial intelligence consensus that
all we need is more and more comprehensive and prescriptive procotols,
guidelines and guidance. However, there was a refreshing and radically
different approach in the 2009 reappraisal of the 2007 European Society
for Hypertension Guidelines, well worth a complete read-through (don’t
be put off by the formidable bureaucratic title), and an eminently sensible
and patient-orientated approach [1].
On the plus side, bariatric surgery is finally established in the UK, albeit
in an unsystematic way, and the advent of the incretin-related therapies
means that in some we can achieve the elusive combination of avoiding
weight gain while improving glycaemic control and reducing the risk of
hypoglycaemia; but we have seen the false dawn of safety and durabil-
ity of treatments many times over the years, and we need due caution
and humility. Insulin pump treatment finally looks as if it is beginning
to take hold, though troubling differences in local availability persist
in the UK, despite its endorsement by the National Institute for Health
and Clinical Excellence (NICE), a requirement, so far as I am aware, not