Clinical Gems

David Levy, MD, FRCP Introduction Infections in patients with diabetes are a persistent trap for both the inexperienced and world-wise physician. Whenever someone with diabetes presents unwell, always consider the possibility of infection. High blood glucose levels predispose to some acute infections, especially postoperatively, but other mechanisms are involved, for example …

David Levy, MD, FRCP Drugs acting on the incretin system (entero-insular axis) (Fig. 6.2) The incretin effect Bayliss and Starling inferred the existence of gut-derived substances affecting carbohydrate metabolism more than a century ago, but the incretin effect was not described until 1969: the observation that for a given achieved level …

David Levy, MD, FRCP Introduction The pharmacological management of blood glucose in type 2 diabetes remains the most contentious area of diabetes management, and although until relatively recently in the USA the only agents to treat blood glucose were insulin and sulphonylureas, this limited repertoire in no way inhibited the controversy, …

David Levy, MD, FRCP General Recommendations on Macronutrients Carbohydrate Recommended daily allowance is about 130 g. Low glycemic index foods (e.g. barley, oats, beans, lentils, rye bread) can reduce HbA1c by about 0.4% (4 mmol/mol) compared with high glycemic index foods. More importantly, high whole-grain, cereal fiber, bran and germ intake …

David Levy, MD, FRCP Introduction: Type 2 Diabetes as a Progressive Condition Glycemia in type 2 diabetes progressively deteriorates with time, usually thought to be related to progressive beta-cell failure. This was demonstrated dramatically in the United Kingdom Prospective Diabetes Study (UKPDS 1998), but the glycemic trends have been less marked …

David Levy, MD, FRCP Insulin Pump Treatment (CSII) First used at the end of the 1970s, insulin pump therapy is standard treatment for type 1 diabetes, although use varies between countries (e.g. about 1–2% in the UK, probably more now; about 25% in USA, up to 40% in Norway). Only rapid-acting …

David Levy, MD, FRCP Introduction Insulin treatment in type 1 diabetes is substitution/replacement hormone treatment, but replacement is much more variable and difficult to achieve than in other hormone deficiencies (e.g. thyroid, adrenal, gonadal hormones) because of the minute-by-minute variation in insulin secretion by the intact pancreas, which cannot yet be …

David Levy, MD, FRCP Patients in the Intensive Care Unit Hyperglycemia, whether associated with known diabetes or not, carries a poor prognosis in critically ill patients through multiple mechanisms, including vascular disease, polyneuropathy, an increased tendency to infection, dyslipidemia, and abnormal anti-inflammatory and coagulation responses. Consistent near-normoglycemia has therefore been a …

David Levy, MD, FRCP INTRODUCTION There has been a recent resurgence of interest in the management of diabetes in hospitalized patients. Guidelines in the USA are well-established, and in the UK the ‘ThinkGlucose’ campaign has highlighted the importance of good diabetes care in hospital. Note that good diabetes care does not …

David Levy, MD, FRCP INTRODUCTION Every day many patients with established or newly diagnosed diabetes pass through emergency departments. Few require admission, but all need careful evaluation and management: emergencies in diabetes can develop rapidly, and they carry a risk of mortality. Deciding who needs admission requires clinical skill and experience. …