Management of Diabetes Melitus

Our mentor, the late Dr. Robert L. Jackson, felt that the treatment of diabetes should be as physiologic as possible, matching the treatment to the actual functioning of the pancreas. He determined that patterns, even those obtained with the archaic use of urine tests, were useful in determining the correct dose of medication to cover the food and activity of the active child (and adult). As machines are now made available to match the body’s functioning release of insulin in real time, and the blood glucose levels after a period of time, knowledge of these values will be useful in directing the algorithms used in the pump, the artificial pancreas, or the injected or oral diabetes medications. A rapid, reactive response is needed when the person is in diabetic ketoacidosis (DKA), in hyperglycemic hyperosmolar nonketotic syndrome (HHNS), or having a severe hypoglycemic reaction. Daily use of diabetes medications to maintain a hemoglobin A1c lower than 6.5% (American Diabetes Association, 7%) does not need to be as dramatic, especially when the decision making is done by the patient or family member. The physiologic or pattern approach to management not only gives a safety factor, but also has proven quite useful in maintaining a high degree of control over long periods of time (evidence by the average, from the worst to the best hemoglobin A1c in our tertiary care diabetes clinic, is 7.4%). As a tertiary care clinic, we get individuals with newly diagnosed diabetes, people who are failing on oral agents, people who have already developed complications, and others that are difficult to control. We therefore have had extensive experience with numerous patients for more than 40 years. We have attempted to put our years of experience in this book and to make this book user friendly for a variety of health professionals. Although the first edition was written as a guide for the working nurse who cared for a patient with diabetes, we recognized, over the years, that the book has become a working

reference for all health professionals, including those professionals specializing in the field, and as a textbook for professionals wanting to know more about the disease and how to manage it by using the pattern approach. I am reminded of an airplane ride in which I became involved in a conversation with a physician seated close by. During the course of the conversation I found that she was using our book as a guide for managing patients with diabetes. When I disclosed that I was one of the authors, tears welled up in her eyes

and she thanked me for the help it had given her and her patient population. When Richard and I discovered that some physicians, in addition to nurses and other health professionals, were using this book, we decided to develop the edition for broader use and for better ease of use. What you will find in the

proceeding pages is the result.

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endokrinologi , farmakologi ,

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Therapeutic Strategies in Metabolic Syndrome

We are in the midst of a worldwide epidemic of obesity and its consequences, in particular type 2 diabetes and cardiovascular disease. Clinical studies have recognized that risk factors for these conditions frequently cluster in individuals, leading to the development of the concept of the metabolic syndrome. This was soon followed by considerable controversy as to whether the syndrome is a distinct entity or not. In addition, multiple definitions and diagnostic criteria have made interpretation of data occasionally problematic. I expect that this controversy will continue, though all parties on both sides of the argument are clearly in agreement on one thing – we need action to halt the progression from risk factor development to clinical events and death. Despite the controversies on terminology, therefore, it is important to focus on the goal of effective treatment, hence the development of this book. Although our goal is to have an in-depth analysis of treatment strategies, we felt it important to first review the epidemiology and pathophysiology of the syndrome, in order to lay the groundwork for developing treatment concepts. We have also strongly emphasized the importance of lifestyle (and perhaps societal) change that is needed to halt this epidemic. Clearly, preventing and treating obesity effectively should liberate us from the syndrome. However, whether we use population strategies or individualized pharmacotherapy for obesity, the greatest impact is likely to be seen in treatments that alleviate risk factors involved in the pathogenesis of cardiovascular events such as blood pressure, lipids, inflammation

and thrombogenesis. To that end, we have focused on the impact of treatment on these factors. It is also important to recognize the impact of current treatments for individual risk factors on other components of the syndrome. This is most clearly recognizable in the effect of glucose-lowering drugs, particularly insulin sensitizers if insulin resistance is an important underlying feature of the syndrome. Some of these drugs, as well as insulin itself, paradoxically cause weight gain, yet favorably impact other features of the syndrome. Is that good or bad? The answers are currently surrounded by controversy, the essence of which we hope we have captured adequately in the text. We look forward to further clarification from ongoing clinical trials. I am most grateful to the outstanding group of authors who have contributed scholarly and up-to-date reviews in a timely fashion. Finally, I would like to dedicate this book to the city of New Orleans and to its fragile

recovery from disaster.

Vivian Fonseca
June 2008

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Endocrinology Williams 12th

Welcome to the twelfth edition of Williams Textbook of Endocrinology. Robert Williams inaugurated this enduring textbook more than 50 years ago, and the goals have remained essentially unchanged (i.e., to publish “a condensed and authoritative discussion of the management of clinical endocrinopathies based upon the application of fundamental information obtained from chemical and physiological investigation”). Of course, today we would add results of cellular and genomic investigation, as well as the wealth of clinical trial data, as aids in clinical management.

The immense and often overwhelming body of new information from multiple disciplines, in fact, makes this synthetic endeavor more relevant than ever to help guide endocrinologists in the care of their patients. To encourage the goal of both highest quality scientific rigor and knowledge synthesis, we continue to ask the most distinguished authors to synthesize entire areas of clinical endocrine science. The mandate for concise yet authoritative and comprehensive presentations acknowledges both the time pressures on today’s physicians and the desire to make the text affordable and easily navigated. This edition has involved extensive revisions of the previous text, and 22 new authors have joined our expert faculty. A uniform style facilitates identification and ready use of clinical algorithms. We express our deep gratitude to the co-workers in our

offices: Anita Nichols, Lynn Moulton, Grace Labrado, Louise Ishibashi, and Sherri Turner, whose energetic efforts have made this work possible. We also thank our colleagues at Elsevier—Joan Ryan, Pamela Hetherington, and Dolores Meloni—who skillfully navigated the dynamic world of medical publishing while assuring achievement of our goals. Their efforts have been essential in ensuring the successful publication of this high-quality textbook, which has become the classic text for all professionals engaged in caring for patients with endocrine disorders. Finally, we would like to recognize and congratulate Dr.

Melvin Grumbach for his outstanding contributions to Williams Textbook of Endocrinology, beginning with the fourth edition that was published in 1968.

Shlomo Melmed

Kenneth S. Polonsky
P. Reed Larsen
Henry M. Kronenberg

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biokimia , endokrinologi ,

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