Type_2_diabetes

Diabetes mellitus type 2 or Type 2 Diabetes (formerly called non-insulin-dependent diabetes mellitus (NIDDM), or adult-onset diabetes) is a metabolic disorder that is primarily characterized by insulin resistance, relative insulin deficiency and hyperglycemia. It is often managed by engaging in exercise and modifying one\'s diet. It is rapidly increasing in the developed world, and there is some evidence that this pattern will be followed in much of the rest of the world in coming years. The CDC has characterized the increase as an epidemic.Gerberding, Julie Louise (2007-05-24), Diabetes, Disabling Disease to Double by 2050, CDC, <http://www.cdc.gov/nccdphp/publications/aag/ddt.htm>. Retrieved on 14 September 2007 In addition, whereas this disease used to be seen primarily in adults over age 40, in contrast to Diabetes mellitus type 1, it is now increasingly seen in children and adolescents, an increase thought to be linked to rising rates of obesity in this age group, although it remains a minority of cases. DIABETES RATES ARE INCREASING AMONG YOUTH NIH, November 13, 2007

Unlike Type 1 diabetes, there is little tendency toward ketoacidosis in Type 2 diabetes, though it is not unknown. One effect that can occur is nonketonic hyperglycemia which also is quite dangerous, though it must be treated very differently. Complex and multifactorial metabolic changes very often lead to damage and function impairment of many organs, most importantly the cardiovascular system in both types. This leads to substantially increased morbidity and mortality in both Type 1 and Type 2 patients, but the two have quite different origins and treatments despite the similarity in complications.

Diabetes mellitus
Types of Diabetes
Diabetes mellitus type 1 Diabetes mellitus type 2 Gestational diabetes Pre-diabetes: Impaired fasting glycaemia Impaired glucose tolerance
Disease Management
Diabetes management: •Diabetic diet •Anti-diabetic drugs •Conventional insulinotherapy •Intensive insulinotherapy
Other Concerns
Cardiovascular disease Diabetic comas: •Diabetic hypoglycemia •Diabetic ketoacidosis •Nonketotic hyperosmolar Diabetic myonecrosis Diabetic nephropathy Diabetic neuropathy Diabetic retinopathy Diabetes and pregnancy
Blood tests
Blood sugar Fructosamine Glucose tolerance test Glycosylated hemoglobin

Contents 1 Pathophysiology 2 Diagnosis 3 Screening and prevention 3.1 Accuracy of tests for early detection 3.2 Benefit of early detection 4 Treatment 4.1 Treatment goals 4.2 Self monitoring of blood glucose 4.3 Dietary management 4.4 Exercise 4.5 Antidiabetic drugs 4.5.1 Oral drugs 4.5.2 Insulin preparations 4.6 Alternative medicines 4.7 Antihypertensive agents 4.8 ACE inhibitors 4.9 Hypolipidemic agents 4.10 Gastric Bypass Surgery 5 Footnotes 6 External links

Pathophysiology

Insulin resistance means that body cells do not respond appropriately when insulin is present.

Other important contributing factors:

• increased hepatic glucose production (e.g., from glycogen degradation), especially at inappropriate times
• decreased insulin-mediated glucose transport in (primarily) muscle and adipose tissues (receptor and post-receptor defects)
• impaired beta-cell function—loss of early phase of insulin release in response to hyperglycemic stimuli
• Cancer survivors who received allogenic Hematopoietic Cell Transplantation (HCT) are 3.65 times more likely to report type 2 diabetes than their siblings. Total body irradiation (TBI) is also associated with a higher risk of developing diabetes.

This is a more complex problem than type 1, but is sometimes easier to treat, especially in the initial years when insulin is often still being produced internally. Type 2 may go unnoticed for years in a patient before diagnosis, since the symptoms are typically milder (no ketoacidosis) and can be sporadic. However, severe complications can result from improperly managed Type 2 diabetes, including renal failure, blindness, wounds that are slow to heal (including surgical incision), and arterial disease, including coronary artery disease. The onset of Type 2 is most common in middle age and later life, although is being more frequently seen in adolescents and young adults due to the increasing prevalence of obesity in these groups. A type of diabetes called MODY is occasionally also seen in adolescents.

Diabetes mellitus type 2 is presently of unknown etiology (i.e., origin). Diabetes mellitus with a known etiology, such as secondary to other diseases, known gene defects, trauma or surgery, or the effects of drugs, is more appropriately called secondary diabetes mellitus. Examples include diabetes mellitus caused by hemochromatosis, pancreatic insufficiencies, or certain types of medications (e.g. long-term steroid use).

About 90–95% of all North American cases of diabetes are type 2 Zimmet, P., Alberti, K. G. M. M., Shaw, J. Global and societal implications of the diabetes epidemic. Nature 2001, 414, 782-787., and about 20% of the population over the age of 65 has diabetes mellitus type 2. The fraction of type 2 diabetics in other parts of the world varies substantially, almost certainly for environmental and lifestyle reasons, though these are not known in detail. Diabetes affects over 150 million people worldwide and this number is expected to double by 2025. There is also a strong inheritable genetic connection in type 2 diabetes: having relatives (especially first degree) with type 2 increases risks of developing type 2 diabetes very substantially. In addition there is also a mutation to the Islet Amyloid Polypeptide gene that results in an earlier onset, more severe, form of diabetesSakagashira, S., Sanke, T., Hanabusa, T., Shimomura, H., Ohagi, S., Kumagaye, K. Y.,Nakajima, K. & Nanjo, K. Missense mutation of amylin gene (S20G) in Japanese NIDDM patients. Diabetes 1996, 45, 1279-1281.^,Seino, S. S20G mutation of the amylin gene is associated with Type II diabetes in Japanese. Diabetologia 2001, 44, (7), 906-909.. About 55 percent of type 2 are obeseEberhart, M. S.; Ogden, C, Engelgau, M, Cadwell, B, Hedley, A. A., Saydah, S. H., (November 19, 2004). "Prevalence of Overweight and Obesity Among Adults with Diagnosed Diabetes --- United States, 1988--1994 and 1999--2002". Morbidity and Mortality Weekly Report 53 (45): 1066-1068. Centers for Disease Control and Prevention. Retrieved on 2007-03-11.  —chronic obesity leads to increased insulin resistance that can develop into diabetes, most likely because adipose tissue is a (recently identified) source of several chemical signals to other tissues (hormones and cytokines). Other research shows that type 2 diabetes causes obesity.Camastra S, Bonora E, Del Prato S, Rett K, Weck M, Ferrannini E (1999). "Effect of obesity and insulin resistance on resting and glucose-induced thermogenesis in man. EGIR (European Group for the Study of Insulin Resistance)". Int J Obes Relat Metab Disord 23 (12): 1307-13. PMID 10643689. 

Diabetes mellitus type 2 is often associated with obesity, hypertension, elevated cholesterol (combined hyperlipidemia), and with the condition often termed Metabolic syndrome (it is also known as Syndrome X, Reavan\'s syndrome, or CHAOS). It is also associated with acromegaly, Cushing\'s syndrome and a number of other endocrinological disorders. Additional factors found to increase risk of type 2 diabetes include agingJack, L., Jr., Boseman, L. & Vinicor, F. Aging Americans and diabetes. A public health and clinical response. Geriatrics 2004, 59, 14-17., high-fat dietsLovejoy, J. C. The influence of dietary fat on insulin resistance. Curr Diab Rep 2002, 2,435-440. and a less active lifestyleHu, F. B. Sedentary lifestyle and risk of obesity and type 2 diabetes. Lipids 2003, 38,103-108..

Diagnosis

The World Health Organization definition of diabetes is for a single raised glucose reading with symptoms, otherwise raised values on two occasions, of either.World Health Organization. Definition, diagnosis and classification of diabetes mellitus and its complications: Report of a WHO Consultation. Part 1. Diagnosis and classification of diabetes mellitus. Retrieved on 2007-05-29.:

• fasting plasma glucose ≥ 7.0 mmol/l (126 mg/dl)

or

• With a Glucose tolerance test, two hours after the oral dose a plasma glucose ≥ 11.1 mmol/l (200 mg/dl)

Screening and prevention

Interest has arisen in preventing diabetes due to research on the benefits of treating patients before overt diabetes. Although the U.S. Preventive Services Task Force (USPSTF) concluded that "the evidence is insufficient to recommend for or against routinely screening asymptomatic adults for type 2 diabetes, impaired glucose tolerance, or impaired fasting glucose"U.S. Preventive Services Task Force (2003). "Screening for type 2 diabetes mellitus in adults: recommendations and rationale". Ann. Intern. Med. 138 (3): 212-4. PMID 12558361.  National Guidelines Clearinghouse: Complete SummaryHarris R, Donahue K, Rathore SS, Frame P, Woolf SH, Lohr KN (2003). "Screening adults for type 2 diabetes: a review of the evidence for the U.S. Preventive Services Task Force". Ann. Intern. Med. 138 (3): 215-29. PMID 12558362. , this was a grade I recommendation when published in 2003. However, the USPSTF does recommend screening for diabetics in adults with hypertension or hyperlipidemia (grade B recommendation).

In 2005, an evidence report by the Agency for Healthcare Research and Quality concluded that "there is evidence that combined diet and exercise, as well as drug therapy (metformin, acarbose), may be effective at preventing progression to DM in IGT subjects".Santaguida PL, Balion C, Hunt D, et al (2005). "Diagnosis, prognosis, and treatment of impaired glucose tolerance and impaired fasting glucose". Evidence report/technology assessment (Summary) (128): 1-11. PMID 16194123. 

Accuracy of tests for early detection

If a 2-hour postload glucose level of at least 11.1 mmol/L (≥ 200 mg/dL) is used as the reference standard, the fasting plasma glucose > 7.0 mmol/L (126 mg/dL) diagnoses current diabetes with:

• sensitivity about 50%
• specificity greater than 95%

A random capillary blood glucose > 6.7 mmol/L (120 mg/dL) diagnoses current diabetes withRolka DB, Narayan KM, Thompson TJ, et al (2001). "Performance of recommended screening tests for undiagnosed diabetes and dysglycemia". Diabetes Care 24 (11): 1899-903. PMID 11679454. :

• sensitivity = 75%
• specificity = 88%

Glycosylated hemoglobin values that are elevated (over 5%), but not in the diabetic range (not over 7.0%) are predictive of subsequent clinical diabetes in US female health professionals.Pradhan AD, Rifai N, Buring JE, Ridker PM (2007). "Hemoglobin A1c predicts diabetes but not cardiovascular disease in nondiabetic women". Am. J. Med. 120 (8): 720-7. doi:10.1016/j.amjmed.2007.03.022. PMID 17679132.  In this study, 177 of 1061 patients with glycosylated hemoglobin value less than 6% became diabetic within 5 years compared to 282 of 26281 patients with a glycosylated hemoglobin value of 6.0% or more. This equates to a glycosylated hemoglobin value of 6.0% or more having:

• sensitivity = 16.7%
• specificity = 98.9%

Benefit of early detection

Since publication of the USPSTF statement, a randomized controlled trial of prescribing acarbose to patients with "high-risk population of men and women between the ages of 40 and 70 years with a body mass index (BMI), calculated as weight in kilograms divided by the square of height in meters, between 25 and 40. They were eligible for the study if they had IGT according to the World Health Organization criteria, plus impaired fasting glucose (a fasting plasma glucose concentration of between 100 and 140 mg/dL or 5.5 and 7.8 mmol/L) found a number needed to treat of 44 (over 3.3 years) to prevent a major cardiovascular eventChiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M (2003). "Acarbose treatment and the risk of cardiovascular disease and hypertension in patients with impaired glucose tolerance: the STOP-NIDDM trial". JAMA 290 (4): 486-94. doi:10.1001/jama.290.4.486. PMID 12876091.  ACP Journal Club review.

Other studies have shown that life-style changesLindström J, Ilanne-Parikka P, Peltonen M, Aunola S, Eriksson JG, Hemiö K, Hämäläinen H, Härkönen P, Keinänen-Kiukaanniemi S, Laakso M, Louheranta A, Mannelin M, Paturi M, Sundvall J, Valle TT, Uusitupa M, Tuomilehto J (2006). "Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study". Lancet 368 (9548): 1673-9. doi:10.1016/S0140-6736(06)69701-8. PMID 17098085. ACP Journal Club review and metforminKnowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM (2002). "Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin". N. Engl. J. Med. 346 (6): 393-403. doi:10.1056/NEJMoa012512. PMID 11832527.  ACP Journal Club review can delay the onset of diabetes.

Treatment

Diabetes mellitus type 2 is a chronic, progressive disease that has no clearly established cure. There are two main goals of treatment of the disease:

1. reduction of mortality and concomitant morbidity (from assorted diabetic complications)
2. preservation of quality of life

The first goal can be achieved through close glycemic control (i.e., blood glucose levels); the reduction effect in diabetic complications has been well demonstrated in several large clinical trials and is well established beyond controversy. The second goal is often addressed (in developed countries) by support and care from teams of diabetic health workers (physician, PA, nurse, dietitian or a certified diabetic educator). Endocrinologists, family practitioners, and general internists are the types of physicians most likely to treat people with diabetes. Knowledgeable patient participation is vital and so patient education is a crucial aspect of this effort.

Type 2 is initially treated by adjustment in diet and exercise, and by weight loss, especially in obese patients. The amount of weight loss which improves the clinical picture is sometimes modest (2-5 kg or 4.4-11 lb); this is almost certainly due to currently poorly understood aspects of fat tissue activity, for instance chemical signaling (especially in visceral fat tissue in and around abdominal organs). In many cases, such initial efforts can substantially restore insulin sensitivity.

Treatment goals

Treatment goals for diabetic patients are related to effective control of blood glucose, blood pressure and lipids to minimize the risk of long-term consequences associated with diabetes. They are suggested in clinical practice guidelines released by various national and international diabetes agencies.

The targets are:

• Hb_A1c of 6% (2006) "Standards of medical care in diabetes--2006". Diabetes Care 29 Suppl 1: S4–42. PMID 16373931.  to 7.0%Qaseem A, Vijan S, Snow V, Cross JT, Weiss KB, Owens DK, et al. Glycemic Control and Type 2 Diabetes Mellitus: The Optimal Hemoglobin A1c Targets. A Guidance Statement from the American College of Physicians. Ann Intern Med. 2007 Sep 18;147(6):417-422. Full text

• Preprandial blood glucose: 4.0 to 6.0 mmol/LCanadian Diabetes Association Clinical Practice Guidelines Expert Committee (2003 volume=27 Suppl 2). "Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada". Can J Diabetes. Retrieved on 2007-11-25. 

• 2-hour postprandial blood glucose: 5.0 to 8.0 mmol/L

In older patients, clinical practice guidelines by the American Geriatrics Society) states "for frail older adults, persons with life expectancy of less than 5 years, and others in whom the risks of intensive glycemic control appear to outweigh the benefits, a less stringent target such as 8% is appropriate".Brown AF, Mangione CM, Saliba D, Sarkisian CA (2003). "Guidelines for improving the care of the older person with diabetes mellitus". Journal of the American Geriatrics Society 51 (5 Suppl Guidelines): S265–80. doi:10.1046/j.1532-5415.51.5s.1.x. PMID 12694461. 

Self monitoring of blood glucose

Main article: Blood glucose monitoring

Self-monitoring of blood glucose may not improve outcomes in some cases, that is among "reasonably well controlled non-insulin treated patients with type 2 diabetes".Farmer A, Wade A, Goyder E, et al (2007). "Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial". doi:10.1136/bmj.39247.447431.BE. PMID 17591623.  Nevertheless, it is strongly recommended for patients in whom it can assist in maintaining proper glycemic control, and is well worth the cost (sometimes considerable) if it does.

Dietary management

Main article: Diabetic diet

Modifying the diet is known to help control glucose (or glucose equivalnet, eg starch) intake, and in consequence, blood glucose levels. Additionally, weight loss is often recommended in persons suffering from type 2 diabetes for the reasons discussed above.

Exercise

In September 2007, a joint randomized controlled trial by the University of Calgary and the University of Ottawa found that "Either aerobic or resistance training alone improves glycemic control in type 2 diabetes, but the improvements are greatest with combined aerobic and resistance training than either alone."Sigal RJ, Kenny GP, Boulé NG, et al (2007). "Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes: a randomized trial". Ann. Intern. Med. 147 (6): 357–69. PMID 17876019.  Non-technical summarySong S. Study: The Best Exercise for Diabetes. Time Inc. Retrieved on 2007-09-28. The combined program reduced the HbA1c by 0.5 percentage point. Other studies have established that the amount of exercise needed is not excessive, but must be consistent and continuing. Examples might include a brisk 45 minute walk every other day.

Antidiabetic drugs

There are several drugs available for type 2 diabetics -- most are unsuitable or even dangerous for use by type 1 diabetics. They fall into several classes and are not equivalent, nor can they be simply substituted one for another. All are prescription drugs.

Metformin 500mg tablets

Main article: anti-diabetic drug

The most important drug now in use for Type 2 Diabetes is the Biguanide metformin which works primarily by reducing liver release of blood glucose from glycogen stores as well as provoking some increase in cellular uptake of glucose in body tissues. Both historically, and currently, commonly used are the Sulfonylurea group, of which several members (including glibenclamide and gliclazide) are widely used; these increase glucose stimulated insulin secretion by the pancreas.

Newer drug classes include:

• Thiazolidinediones (TZDs) (rosiglitazone, pioglitazone, and troglitazone) (withdrawn from the US market) which increase tissue insulin response
• α-glucosidase inhibitors (acarbose and miglitol) which interfere with absorption of some nutrients
• Meglitinides which stimulate insulin release (nateglinide, repaglinide, and their analogs) quickly; they can be taken with food, unlike the sulfonylureas
• Peptide analogs which work in a variety of ways:
  • Incretin mimetics which increase insulin output from the beta cells among other effects. These includes the Glucagon-like peptide (GLP) analog exenatide
  • Dipeptidyl peptidase-4 (DPP-4) inhibitors increase Incretin levels (sitagliptin) by decreasing their deactivation rates
  • Amylin agonist analog, which slows gastric emptying and suppresses glucagon (pramlintide)

Oral drugs

A systematic review of randomized controlled trials found that metformin and second-generation sulfonylureas are the preferred choices for most with type 2.Bolen S et al. Systematic Review: Comparative Effectiveness and Safety of Oral Medications for Type 2 Diabetes Mellitus. Ann Intern Med 2007;147:6 Failure of response after a time is not unknown with most of these agents: the initial choice of anti-diabetic drug has been compared in a randomized controlled trial which found "cumulative incidence of monotherapy failure at 5 years of 15% with rosiglitazone, 21% with metformin, and 34% with glyburide". Kahn SE, Haffner SM, Heise MA, et al (2006). "Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy". N. Engl. J. Med. 355 (23): 2427-43. doi:10.1056/NEJMoa066224. PMID 17145742.  Of these, rosiglitazone users showed more weight gain and edema than did non-users. Rosiglitazone may increase risk of death from cardiovascular causes. NEJM -- Effect of Rosiglitazone on the Risk of Myocardial Infarction and Death from Cardiovascular Causes. Retrieved on 2007-05-21. Pioglitazone and rosiglitazone may also increase the risk of fractures.MedWatch - 2007 Safety Information Alerts (Actos (pioglitazone)). Retrieved on 2007-05-21. MedWatch - 2007 Safety Information Alerts (Rosiglitazone). Retrieved on 2007-05-21.

For patients who also have heart failure, metformin may be the best available drug.Eurich DT, McAlister FA, Blackburn DF, et al (2007). "Benefits and harms of antidiabetic agents in patients with diabetes and heart failure: systematic review". BMJ 335 (7618): 497. doi:10.1136/bmj.39314.620174.80. PMID 17761999. 

Insulin preparations

If antidiabetic drugs fail (or stop helping), insulin therapy may be necessary – usually in addition to oral medication therapy – to maintain normal glucose levels.

Typical total daily dosage of insulin is 0.6 U/kg. More complicated estimations to guide initial dosage of insulin are:Holman RR, Turner RC (1985). "A practical guide to basal and prandial insulin therapy". Diabet. Med. 2 (1): 45–53. PMID 2951066. 

• For men, [(fasting plasma glucose [mmol/liter]–5)x2] x (weight [kg]÷(14.3xheight [m])–height [m])
• For women, [(fasting plasma glucose [mmol/liter]–5)x2] x (weight [kg]÷(13.2xheight [m])–height [m])

The initial insulin regimen can be chosen based on the patient\'s blood glucose profile.Mooradian AD, Bernbaum M, Albert SG (2006). "Narrative review: a rational approach to starting insulin therapy". Ann. Intern. Med. 145 (2): 125-34. PMID 16847295.  Initially, adding nightly insulin to patients failing oral medications may be best.Yki-Järvinen H, Kauppila M, Kujansuu E, et al (1992). "Comparison of insulin regimens in patients with non-insulin-dependent diabetes mellitus". N. Engl. J. Med. 327 (20): 1426-33. PMID 1406860.  Nightly insulin combines better with metformin than with sulfonylureas.Yki-Järvinen H, Ryysy L, Nikkilä K, Tulokas T, Vanamo R, Heikkilä M (1999). "Comparison of bedtime insulin regimens in patients with type 2 diabetes mellitus. A randomized, controlled trial". Ann. Intern. Med. 130 (5): 389–96. PMID 10068412.  The initial dose of nightly insulin (measured in IU/d) should be equal to the fasting blood glucose level (measured in mmol/L). If the fasting glucose is reported in mg/dl, multiply by 0.05551 to convert to mmol/L.Kratz A, Lewandrowski KB (1998). "Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Normal reference laboratory values". N. Engl. J. Med. 339 (15): 1063–72. PMID 9761809. 

When nightly insulin is insufficient, choices include:

• Premixed insulin with a fixed ratio of short and intermediate acting insulin; this tends to be more effective than long acting insulin, but is associated with more hypoglycemia.Holman RR, Thorne KI, Farmer AJ, et al (2007). "Addition of Biphasic, Prandial, or Basal Insulin to Oral Therapy in Type 2 Diabetes". N. Engl. J. Med. 357. doi:10.1056/NEJMoa075392. PMID 17890232. Raskin P, Allen E, Hollander P, et al (2005). "Initiating insulin therapy in type 2 Diabetes: a comparison of biphasic and basal insulin analogs". Diabetes Care 28 (2): 260-5. PMID 15677776. Malone JK, Kerr LF, Campaigne BN, Sachson RA, Holcombe JH (2004). "Combined therapy with insulin lispro Mix 75/25 plus metformin or insulin glargine plus metformin: a 16-week, randomized, open-label, crossover study in patients with type 2 diabetes beginning insulin therapy". Clinical therapeutics 26 (12): 2034-44. doi:10.1016/j.clinthera.2004.12.015. PMID 15823767. . Initial total daily dosage of biphasic insulin can be 10 units if the fasting plasma glucose values are less than 180 mg/dl or 12 units when the fasting plasma glucose is above 180 mg/dl". A guide to titrating fixed ratio insulin is available (http://www.annals.org/cgi/content/full/145/2/125/T4).

• Long acting insulins such as insulin glargine and insulin detemir. A meta-analysis of randomized controlled trials by the Cochrane Collaboration found "only a minor clinical benefit of treatment with long-acting insulin analogues for patients with diabetes mellitus type 2".Horvath K, Jeitler K, Berghold A, Ebrahim Sh, Gratzer T, Plank J, Kaiser T, Pieber T, Siebenhofer A (2007). "Long-acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus". Cochrane database of systematic reviews (Online) (2): CD005613. PMID 17443605.  More recently, a randomized controlled trial found that although long acting insulins were less effective, they were associated with less hypoglycemia.

Alternative medicines

Carnitine has been shown to increase insulin sensitivity and glucose storage in humans. Geltrude Mingrone, Aldo V. Greco, Esmeralda Capristo, Giuseppe Benedetti, Annalisa Giancaterini, Andrea De Gaetano, and Giovanni Gasbarrini (1999). "L-Carnitine Improves Glucose Disposal in Type 2 Diabetic Patients". Journal of the American College of Nutrition 18 (1): 77-82. . It is important to note that this was with a constant blood infusion, not an oral dose, and that the clinical significance of this result is unclear.

Taurine has also shown significant improvement in insulin sensitivity and hyperlipidemia in rats."Taurine improves insulin sensitivity in the Otsuka Long-Evans Tokushima Fatty rat, a model of spontaneous type 2 diabetes". American Journal of Clinical Nutrition 71 (1): 54-58. 

Neither of these have shown permanent positive effects, nor a complete restoration to pre-diabetes conditions, only improvement. Their clinical importance in humans remains unclear.

Antihypertensive agents

Main article: Antihypertensive

The goal blood pressure is 130/80 which is lower than in non-diabetic patients.Chobanian AV, Bakris GL, Black HR, et al (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA 289 (19): 2560-72. doi:10.1001/jama.289.19.2560. PMID 12748199. 

ACE inhibitors

The HOPE study suggests that diabetics should be treated with ACE inhibitors (specifically ramipril 10 mg/d) if they have one of the following Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G (2000). "Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators". N. Engl. J. Med. 342 (3): 145-53. PMID 10639539. :

• hypertension
• hypercholesterolemia or reduced low high-density lipoprotein cholesterol levels
• cigarette smoking
• microalbuminuria

After treatment with ramipril for 5 years the number needed to treat was 50 patients to prevent one cardiovascular death. Other ACE inhibitors may not be as effective.Pilote L, Abrahamowicz M, Rodrigues E, Eisenberg MJ, Rahme E (2004). "Mortality rates in elderly patients who take different angiotensin-converting enzyme inhibitors after acute myocardial infarction: a class effect?". Ann. Intern. Med. 141 (2): 102-12. PMID 15262665. 

Hypolipidemic agents

Main article: Hypercholesterolemia#Diabetic_patients

Gastric Bypass Surgery

A 20-year study of the Greenville gastric bypass found that 80% of those with type 2 diabetes before surgery no longer required insulin or oral agents to maintain normal glucose levels. Weight loss occurred rapidly in many people in the study who had had the surgery.The 20% who did not respond to bypass surgery were, typically, those who were older and had diabetes for over 20 years.http://www.diabeteshealth.com/read/2005/04/01/4261.html

Footnotes

External links

• Diabetes UK - Largest organisation in the UK working for people with diabetes
• American Diabetes Association
• National Diabetes Information Clearinghouse
• Diabetes Section of The Hormone Foundation

v • d • e Endocrine pathology: endocrine diseases (E00-35, 240-259)
Thyroid	Hypothyroidism (Iodine deficiency, Cretinism, Congenital hypothyroidism, Goitre, Myxedema) - Hyperthyroidism (Graves disease, Toxic multinodular goitre, Teratoma with thyroid tissue or Struma ovarii) - Thyroiditis (De Quervain\'s thyroiditis, Hashimoto\'s thyroiditis, Riedel\'s thyroiditis) - Euthyroid sick syndrome
Pancreas	Diabetes mellitus (type 1, type 2, coma, angiopathy, ketoacidosis, nephropathy, neuropathy, retinopathy) - Hypoglycemia - Hyperinsulinism - Zollinger-Ellison syndrome - insulin receptor (Rabson-Mendenhall syndrome)
Parathyroid	Hypoparathyroidism (Pseudohypoparathyroidism) - Hyperparathyroidism (Primary, Secondary, Tertiary)
Pituitary	Hyperpituitarism (Acromegaly, Hyperprolactinaemia, SIADH) - Hypopituitarism (Simmonds\' disease/Sheehan\'s syndrome, Kallmann syndrome, Growth hormone deficiency, Diabetes insipidus) - Adiposogenital dystrophy - Empty sella syndrome
Adrenal	Cushing\'s syndrome (Nelson\'s syndrome, Pseudo-Cushing\'s syndrome) - CAH (due to 21-hydroxylase deficiency) - Hyperaldosteronism (Conn syndrome, Bartter syndrome) - Adrenal insufficiency (Addison\'s disease) - Hypoaldosteronism
Gonads	ovarian dysfunction (Polycystic ovary syndrome, Premature ovarian failure) - testicular dysfunction (5-alpha-reductase deficiency) - testosterone biosynthesis (17-beta-hydroxysteroid dehydrogenase deficiency) - general (Hypogonadism, Delayed puberty, Precocious puberty)
Other	Autoimmune polyendocrine syndrome - Carcinoid syndrome - Short stature (Laron syndrome, Psychogenic dwarfism) - Gigantism - Androgen insensitivity syndrome - Progeria - Multiple endocrine neoplasia (1, 2)

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