Clinical Gems

Much of the literature concerns the important problem of type 2 diabetes and depression and, in comparison with type 1 diabetes, little about the psychological disturbances associated with specific phases of type 2 diabetes.

‘Brittle’ diabetes is a controversial and fortunately uncommon disorder, described especially in the UK and USA, usually occurring in young women, with onset at puberty, and defined as a patient whose life is ‘constantly disrupted by episodes of hypo- or hyperglycemia, whatever their cause.’

That there is a close link between long-term conditions and psychological functioning is to state the obvious. But the complexity of the relationship, especially in a condition that spans a lifetime, such as diabetes, has only relatively recently been explored.

Plant sterols, hydrogenated to stanols, reduce cholesterol absorption. At the recommended intake of 2 g/day they can lower total cholesterol by 12–14% and LDL by 13–16% (e.g. 0.3 mmol/L, 12 mg/dL) in both type 1 and 2 patients.

Statins in renal disease: ezetimibe and fibric acid drugs.

Always considered the mainstay of dyslipidemia management, significant reductions in LDL levels are difficult to achieve with diet except with long-term adherence to a regimen that most Western people would consider punitive.

Simple screening tests will identify most secondary causes of hyperlipidemia.

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.

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.

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...