Screening for diabetes is absolutely the most important thing that people on the front lines can do, and then we will talk about treatment for the rest of the time, focusing on the oral agents in particular, and I am talking about type II diabetes, type I diabetes is something that I think, first of all it??nt to identify for several reasons, one because they need to be screened actively, probably every year for diabetes and also because they need a lot more aggressive management of hypertension and hyperlipidemia which these people tend to also have. So this is again, 13,000,000 people that were currently not identified.
These are the criteria, I call them new because they are new in the last couple of years, it used to be that diabetes was defined by a fasting blood sugar of 140, this has been recognized to be a kind of a ridiculous number so now the fasting blood sugar of 125 or greater on two occasions satisfies criteria for diabetes. The reason this was changed from 140 to 125 or 126 is that the incidence of complications, specifically related to diabetes like retinopathy, nephropathy, neuropathy begins to increase sharply when the blood sugar reaches this level, this is a level a lot of people are comfortable leaving people at, and if you have seen diabetes and seen blood sugars and most of you have, the4se are numbers that don??The incidence of diabetes goes up sharply with age. So anyone over the age of 45 regardless of any other risk factors should be screened at least every three years with a fasting blood sugar, because it??e the rate of diabetes as whites, Mexican and Puerto Ricans have 2 ?? times the risk and Native Americans have up to five times the risk, this is an enormously increased risk group. I have actually been surprised at the number of Native Americans that you might find in your clinic who don??now have accepted and the rates of complications are reduces dramatically even when modest improvements in blood sugar control. So these preprandial sugars and bed time sugars should be around 100, a little bit higher at night in case somebody has a risk for getting hypoglycemic at night, and then AIC control goals, these are unfortunately going to differ a little bit because everyone?? great as someone who already has had one, so they are treated as aggressively as someone with established coronary disease with the need to get their LDLs less than 100 and aggressive blood pressure control, about 130/85, because blood pressure control is as or more important than glucose control in reducing the risks for all the complications of diabetes and these are the standard other things we implement, yearly eye exam, screening for nephropathy with spot urine to check for protein, looking at feet, and getting them to stop smoking.
This is an introduction to the pathophysiology of diabetes which helps me explain why we treat with the different medications we treat. It happens we have a medication to treat each part of the pathophysiology. So diabetes is not just an elevation in blood sugar, it used to be that we only had insulin or medications which increased insulin to get the blood sugars down, but it turns out there are actually a lot of components to diabetes which are helpful to understand when you choose an antidiabetic medication. So obviously, in diabetes, the pancreas has a relatively deficiency of insulin. Regardless of how much insulin that person needs, the pancreas is not keeping up, so there is always some degree of insulin deficiency and there is a huge spectrum, in type I diabetics or the juvenile onset diabetics, they have no insulin secretion but many of our older diabetics with standard type II diabetes make quite a bit of insulin, it??e first is diet, weight loss and exercise. Although I will talk about oral agents, these are actually by far the most effective things for diabetes and I tell all my patient??hese therapies really make the whole situation worse. They can lower the blood sugar, but over time, they are going to create more of a problem, and now that we have other therapies available, we try to use second line agents or even third line agents. Diet and exercise reduce the demand for insulin. If you eat less, you don?? people don??ly this year.
The precautions, and if you have a well informed patient who comes back and says, but I read in the product information sheet about this lactic acidosis, what is that, I would feel very comfortable that this is not going to happen if you choose your patient carefully. So lactic acidosis is a build up of lactate, it?? of this recommendation because there is potential for kidney failure, also with IV contrast agents such as you give in an infused CT scan those can also precipitate temporary renal insufficiency and so the medications should be stopped just during that period of time, usually about 24 to 48 hours. So the vast majority of people actually don??ation you take with each meal, it inhibits the ability of the intestine to break down sugars, complex sugars into absorbable units. So the sugar stays in the intestinal tract, so that it doesn??em together they are not completely additive but you can think of it as 50 points per pill just to keep it simple.