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Clinical Gems

Our clinical gems come from the top selling medical books, and text books because knowledge is everything when it comes to diabetes.

Practical Diabetes Care, 3rd Ed., Excerpt #32: Lipids Part 2 of 6

These subtle differences together may account for some of the increased cardiovascular risk in type 2 diabetes. The level of increased risk is the subject of much academic discussion. In large diabetic populations studied in the past, coronary risks were often found to be approximately doubled compared with non-diabetic groups, and the concept of diabetes as a coronary risk equivalent is almost embedded – type 2 patients who have not yet suffered a coronary event have a similar coronary risk as non- diabetic patients who have already had an event. The therapeutic corollary of this view is that all patients require equally intensive secondary prevention treatment.

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Practical Diabetes Care, 3rd Ed., Excerpt #31: Lipids Part 1 of 6

Dyslipidemia in diabetes is usually the simplest cardiovascular risk factor to control. There are few patients whose lipid profile cannot be optimized, or at least markedly improved, with a combination of lifestyle interventions and single or combination drug therapy. The increasingly stringent targets recommended for high-risk patients, usually with pre-existing cardiovascular disease, proteinuria or both, are also attainable, but judicious combination therapy will be needed in some. There is persuasive evidence that low LDL levels maintained in the long term are associated with stabilization or even reversal of carotid and coronary atheroma, though we have yet to see the impressive intravascular ultrasound images correlate with event reduction in RCTs.

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Practical Diabetes Care, 3rd Ed., Excerpt #30: Hypertension Part 5 of 5


David Levy, MD, FRCP Diuretics Thiazide diuretics have been the mainstay of antihypertensive treatment since the first potent thiazide was introduced in 1957, and have often been the agents against which other drug classes have been compared in important clinical trials [18]. They are especially useful in low-renin (salt-sensitive) states, for example older people, and black or obese patients. Resistant hypertension (see below), common in these groups, is frequently due to inadequate diuretic therapy. Despite half a century of use, disagreement continues about their optimum dosing and whether blood pressure lowering effects and cardiovascular benefits are common to all agents in the class. There is continuing controversy about their potential metabolic disadvantages – concern about these, together with their low pharmaceutical profile, prevents their being used in many patients – but there is no evidence that these in any way blunt their cardiovascular benefits, even in people with diabetes (Box 11.7). They are as effective in reducing coronary events as any other class of antihypertensive agents, but in ALLHAT were more effective in reducing heart failure and stroke than lisinopril or amlodipine...

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