INSULIN

Insulin and its analogs lower blood glucose levels by stimulating peripheral glucose uptake, especially by skeletal muscle and fat, and by inhibiting hepatic glucose production. Insulin inhibits lipolysis, proteolysis, and enhances protein synthesis.

A COMBINATION OF INSULIN AND ORAL HYPOGLYCEMIC AGENTS is given if diabetes is already severe and treatment with OHAs is not anymore that effective.

PITFALLS OF THE COMBINATION

- Hypoglycaemia

- Bleeding at the injection site

I. Is there a role of anticoagulants in hypertension in diabetic patients?

YES. As to the description of anticoagulants, they are used to stop platelets, or heavy cells, present in blood plasma from forming clots. They are most used in those who are at risk for heart attack, stroke, or aneurisms. A blood thinner can be composed of several different chemical formations. Thus, they are useful treatment for hypertension in diabetic patients since one of the causes of hypertension is atherosclerosis.

II. What is the ideal hypertensive drug for diabetic patients?

Strategy of drug therapy in hypertensive diabetes:

The ideal strategy for treating hypertension in persons with diabetes is still not clear. Initial drugs for those with a blood pressure ≧140/90 mm Hg should be with a drug class shown to reduce CVD events in patients with diabetes which include ACE inhibitors, ARBs, low-dose thiazide diuretics, ß-blockers, and calcium channel blockers. Though there is no conclusive evidence favoring one class of drugs, as large number of studies in patients with diabetes (both type 1 and type 2) and hypertension (either mild or more severe) demonstrating improvement in a range of outcomes, including progression of nephropathy, cardiovascular events, and mortality, it is now an established practice to begin hypertensive patients with diabetes and without microalbuminuria on an ACE inhibitor. When microalbuminuria or more advanced stages of nephropathy is present, both ACE inhibitors (T1DM and T2DM patients) and ARBs (T2DM patients) are considered first-line therapy for preventing the progression of nephropathy. However, other strategies including diuretic and b-blocker-based therapy are also supported by evidence. If the target BP goal of ＜130/80 mmHg is not obtained with the initial doses of first-line drugs, increases in doses are recommended, or the addition of a second drug from a different group should be considered. Regardless of the initial treatment, it must be emphasized that most patients will require more than two drugs to achieve the recommended target of ＜130/80 mmHg, and many will require three or more. Achievement of the target BP may be more important than the particular drug regimen used. Thiazide diuretics have been shown to improve cardiovascular outcomes and may address the volume or salt-sensitive components of hypertension, complementing the mechanisms of action of other drugs, so these are appropriate choices for a second or third drug and can be used for initial therapy in patients without additional cardiovascular risk factors (e.g. dyslipidemia) or proteinuria. Actually the JNC VII suggests diuretics, either use alone or in combination, should be the initial drug to be used in patients with hypertension. NDCCBs can be used when ACE inhibitors, ARBs, or ß-blockers are not tolerated or are contraindicated or when a second or third drug is required. Actually classes of drugs for which there are no long-term data on efficacy in improving outcomes can be used when there is intolerance to other classes, when there are specific indications for their use apart from treatment of hypertension (for example, a1-blockers for patients with benign prostatic hypertrophy and diltiazem for rate control in atrial fibrillation), or when additional drugs are required to achieve the target for blood pressure.

Treatment decisions should, of course, be individualized based on the clinical characteristics of the patient, including comorbidities as well as tolerability, personal preference, and cost, and in elderly hypertensive patients, blood pressure should be lowered gradually to avoid complications.