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available as free full text and a link to the citation is here.
Here are a few
noteworthy points:
DM can be defined as
an A1C of 6.5 or above, FBS of 126 or above OR two hour PC of 200 or
above.
Prediabetes, a risk
for not only DM itself but cardiovascular disease, can be defined as
A1C of 5.7-6.4, FBS 100-125 OR a two hour PC of 140-199.
An A1C target of
less than or equal to 7 is recommended for most patients. This
recommendation is controversial. An emerging opinion in the
controversy is that while 7 may be a reasonable target, levels below
that may have risks that exceed benefits. Microvascular benefit may
increase along a continuum of lower and lower A1C levels, even if
below 7. Levels pushed below 7 by pharmacologic means, however,
(at least using insulin or sulfonylureas) appear to be associated
with macrovascular harm. A target of 8 is suggested for certain
individuals such as older patients, those prone to hypoglycemia, and
those with advanced complications.
According to the
document, pharmacologic agents or bariatric surgery warrant
consideration for obese patients if desired weight cannot be achieved
by lifestyle changes. Weight loss drugs are controversial because
any benefits appear to be counterbalanced by adverse outcomes for all
agents adequately studied. The article has an extensive discussion
of the data concerning bariatric surgery.
Hypoglycemia is now
recognized as a driver of cardiovascular disease. The article
discusses possible mechanisms which include sympathetic nervous
system activation, increase in the QT interval, endothelial
dysfunction, platelet activation, coagulation factor activation and
activation of inflammatory mediators.
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