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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 #30: Hypertension Part 5 of 5

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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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Practical Diabetes Care, 3rd Ed., Excerpt #29: Hypertension Part 4 of 5

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David Levy, MD, FRCP      Preferred treatment: angiotensin blockade It is universally accepted that angiotensin blockade should be preferentially used in hypertensive diabetic patients. Although the evidence for greater cardiovascular risk reduction compared with other drug groups is not overwhelming, the renoprotective benefits in type 2 diabetes, and reduction in renal end …

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Practical Diabetes Care, 3rd Ed., Excerpt #28: Hypertension Part 3 of 5

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David Levy, MD, FRCP      Pharmacological treatment: general features The value of ranking antihypertensive agents The near-universal adoption of treatment algorithms using strong recommendations for first-, second-and third-line treatments, habitual for the past 30 years or more, has been challenged by the European Society of Hypertension (ESH, 2007, 2009). The logic of …

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Practical Diabetes Care, 3rd Ed., Excerpt #26: Hypertension Part 1 of 5

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David Levy, MD, FRCP      Introduction Despite more clinical trials than any other aspect of diabetes, many questions still remain about hypertension. Treatment targets continued to fall after UKPDS (1998), but even in contemporary trials with the most stringent treat-to-target protocols they are rarely achieved (see Chapter 8). Because antihypertensive agents, like …

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Practical Diabetes Care, 3rd Ed., Excerpt #25: Diabetic Neuropathy Part 5 of 5

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David Levy, MD, FRCP      Erectile dysfunction This is the commonest neuropathic complication: 20% of men have erectile dysfunction (ED) at diagnosis, increasing to 34% at 12 years (UKPDS). The prevalence in a newly diagnosed Kuwaiti population was 30%, and nearly 50% in a large survey of Canadians attending their primary-care physicians …

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Practical Diabetes Care, 3rd Ed., Excerpt #24: Diabetic Neuropathy Part 4 of 5

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David Levy, MD, FRCP      Mononeuropathies and other focal syndromes Peripheral mononeuropathies Upper limb Carpal tunnel syndrome (median nerve) Carpal tunnel syndrome is very common (remember the association with primary hypothyroidism, especially in type 1 diabetes) and may present with atypical symptoms, as it is often superimposed on diabetic polyneuropathy. Consider it …

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Practical Diabetes Care, 3rd Ed., Excerpt #23: Diabetic Neuropathy Part 3 of 5

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David Levy, MD, FRCP      Charcot neuroarthropathy Charcot neuroarthropathy is a serious and poorly understood condition associated with rapid destruction of bones and joints and resulting in bone fragmentation. It occurs only in patients with advanced sensory and autonomic neuropathy, and is characteristic of long-duration type 1 diabetes with other microvascular complications, …

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Practical Diabetes Care, 3rd Ed., Excerpt #22: Diabetic Neuropathy Part 2 of 5

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David Levy, MD, FRCP      Foot ulceration The ulcerated, infected and possibly gangrenous foot is a common reason for hospital admission. Anatomically, diabetic foot ulceration is restricted to the region distal to the ankle; proximal lesions are more likely ischemic, vasculitic, venous, or to have another underlying cause. Most ulcers are predominantly …

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Practical Diabetes Care, 3rd Ed., Excerpt #21: Diabetic Neuropathy Part 1 of 5

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David Levy, MD, FRCP      Introduction The devastating consequences of diabetic neuropathy are seen every day both in hospital – more bed days are taken up with the consequences of diabetic foot ulceration than any other diabetic complication – and in primary care, where sensory symptoms, especially pain, and autonomic neuropathy, especially …

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