Treatment of Concominant Conditions Related to DM! (cont.)

 TREATMENT OF CONCOMINANT CONDITIONS RELATED TO DIABETES MELLITUS

1. Coronary Heart Disease
2. Dyslipidemia
3. Hypertension
4. HIV and AIDS
5. Antipsychotic Therapy
6. Hypoglycemia
7. Diabetic Ketoacidosis (DKA)
8. Hyperosmolar Hyperglycemic state
9. Retinopathy
10. Neuropathy
11. Foot Ulcers 

3.HYPERTENSION

Uncontrolled blood pressure plays a major role in the development of macrovascular events as well as microvascular complications, including retinopathy and nephropathy in patients with Diabetes Mellitus.

Medications:

There are several other principles regarding the treatment of hypertension in Diabetes patients.

• Angiotensin-converting enzyme (ACE) inhibitors or Angiotensin II receptor Blockers are recommended as initial therapy because of their beneficial effects on renal function.
• Combination therapy with ACE Inhibitor and Dihydropyridine calcium channel blockers has shown to reduce cardiovascular morbidity and mortality versus those receiving ACE Inhibitor therapy combined with Thiazide Diuretic.
• However, thiazide diuretics work synergistically with ACE Inhibitors and angiotensin II receptor blockers and can be added  on for those who fail to reach blood pressure goals with a single agent goal as long as the patients estimated glomerular filtration rate remains at 30mL/min/1.73m2 or higher.
• Alternatively, a loop diuretic can be used.

Recommended Goals:

• The ADA recommends that systolic blood pressure goals for patients with DM be individualized but generally set at less than 130mmHg. The diastolic blood pressure goal for patients with DM is less than 80mmHg.
• It can be expected that most patients require more than one agent to reach blood pressure goal.
• Renal function and serum potential levels should be monitored closely in all patients taking an ACE inhibitor, Angiotensin II receptor blocker and/or diuretic.

Contraindication:

• ACE inhibitors and angiotensin II receptor blockers are contraindicated in pregnancy and in those with  bilateral renal therapy.`

4.HUMAN IMMUNODEFICIENCY VIRUS (HIV) and ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)

• Patients with risk factor for diabetes are more likely to develop diabetes when exposed to highly active antiretroviral therapy.
• Universal screening for all HIV Patients for diabetes is controversial, but most clinicians support screening for those with risk factors, especially if those risk factors include positive family history and central adiposity.
• Disturbances in glucose homeostasis are known side effects of protease inhibitor therapy.

Medications:

• Indinavir and Ritonavir block insulin-mediated glucose disposal causing insulin resistance, but Amprenavir and Atazanavir have no effects on this pathway.
• Indinavir also increases hepatic glucose production and release and causes insulin to lose its ability to suppress hepatic glucose production.
• Nelfinavir, lopinavir and Saquinavir causes a 25% reduction in beta-cell function, reducing first-phase insulin release.

Contraindications:

• Drug selection for treating protease inhibitors-induced hyperglycemia should address the mechanism behind the adverse effects.
• Protease inhibitor therapy should be avoided in patients with pre-existing glucose abnormalities and in those with a first-degree relative with diabetes.
• Metformin should be used with caution in patients taking the nucleoside reverse transcriptase inhibitors Stavudine, Zidovudine and Didanosine because of an increased risk for lactic acidemia.

5.ANTIPSYCHOTIC DRUG THERAPY

• An association has been discovered between the second-generation antipsychotics and the development of diabetes.
• Risk seems to be the highest with Clozapine and Olanzapine, but data are conflicting for Risperidone and Quetiapine.
• Aripiprazole and Ziprasione for yet have no shown an increased risk for diabetes with their use.

Recommendations:

• Nutrition and physical activity counselling is recommended for all patients with mental illness who are overweight or obese, especially if they are second generation anti-psychotics.
• After the therapy, patients' weight should be assessed at weeks 4, 8, and 12 and then every 3 months.
• In an event of increase in patients weight greater than or equal to 5%, of the patient's baseline weight, the therapeutic adjustment should be considered.
• For patients who develop worsening glycemia or Dyslipidemia while on antipsychotic therapy, it is recommended that a switch to second generation antipsychotic with less weight gain or diabetes potential be considered.