The hyperglycemia, hyperinsulinemia, insulin resistance, and obesity syndrome associated with type 2 diabetes can have debilitating consequences. The biguanide metformin has a mechanism of action that is complementary to those of insulin and the sulfonylureas, suggesting that combination therapy that includes metformin may result in improved glycemic control. The purpose of this retrospective chart review was to determine the effects of adding metformin in an uncontrolled fashion to existing therapy in obese patients with type 2 diabetes who had suboptimal glycemic control and insulin resistance. For the review, the records of 124 patients were divided into two groups: group 1 included 71 patients who were taking insulin with or without a sulfonylurea, and group 2 consisted of 53 patients who were taking a sulfonylurea alone. Metformin was added to patients' existing therapy in conjunction with downward titration of the sulfonylurea and insulin doses. A retrospective chart review was conducted at the end of 6 months for group 1 and at the end of 12 months for group 2 to determine the change from baseline in measures of diabetes control (ie, insulin and sulfonylurea dose, glycated hemoglobin [Hb A1c] value, body mass index [BMI], and lipid profiles). In group 1, the mean insulin dose decreased from 46.4 U/d at baseline to 6.1 U/d at the end of follow-up. Eighty-three percent of the patients were able to discontinue insulin therapy completely. Similarly, group 2 had statistically significant reductions in mean sulfonylurea dose. Both groups also achieved statistically significant reductions in Hb A1c, BMI, and total cholesterol level. The addition of metformin to treatment with insulin or sulfonylureas, either alone or in combination, significantly improved glycemic control and cholesterol levels and promoted weight loss in obese type 2 diabetic patients with insulin resistance. Less than 5% of patients reported mild, transient gastrointestinal side effects, none of which required cessation of metformin therapy. Five patients discontinued metformin due to lack of efficacy.

Combined Modality Therapy↗

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Self-management, patient compliance, and the physician.

Two-hundred ambulatory private office patients with IDDM were surveyed to determine the acceptability of home blood glucose testing, and the factors which permit the physician to predict which patients will use this adjuvant to self-management. The method proved acceptable to 80% of those with GODM and 63% of the MODM patients. Predictability factors, a contingency patient-physician contract, and a protocol for urine and blood testing in conjunction with a treatment algorithm are discussed.

Adult↗

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Impact of transfer from animal-source insulins to biosynthetic human insulin (rDNA E coli) in patients with diabetes mellitus.

Six hundred forty-eight patients (50.5% men; 49.5% women) with diabetes mellitus on animal-source insulin therapy for at least five years were studied. In this patient population, approximately 68.7% had Type I insulin-dependent diabetes mellitus and 31.3% had Type II noninsulin-dependent diabetes mellitus, nonetheless requiring insulin therapy. Patients were voluntarily transferred from animal-source insulin to biosynthetic human insulin derived by recombinant DNA technology from genetically altered Escherichia coli [human insulin (rDNAE coli)] and were monitored regularly thereafter. At a mean interval of 14 months after transfer to human insulin (rDNAE coli), these patients had gained 0.8 kg in body weight (P less than 0.01). There was a significant decline in systolic (P less than 0.01) but not in diastolic blood pressure. Insulin requirements while on animal-source insulin averaged 47.6 +/- 22.9 U/day (mean +/- SD); this requirement was not significantly different after transfer to human insulin (rDNAE coli) (47.0 +/- 21.2 U/day). The distribution of regular and modified insulin types prescribed did not change after patients were transferred from animal-source insulin to human insulin (rDNAE coli). However, a significant increase in the number of insulin injections from 1.79 +/- 0.59 to 1.96 +/- 0.61 injections/day was observed (P less than 0.001). Fasting glucose levels declined significantly from 202 +/- 87 mg/dl on animal-source insulin to 178 +/- 66 mg/dl on human insulin (rDNAE coli) (P less than 0.001). Postprandial glucose levels (at two hours) also declined from 227 +/- 83 mg/dl to 212 +/- 80 mg/dl. Glycosylated hemoglobin (HbA1c) decreased from 9.57 +/- 2.01% while taking animal insulin to 8.97 +/- 2.00% on human insulin (rDNAE coli) (P less than 0.001) Serum cholesterol and triglyceride levels insulin (rDNAE coli). Serum high-density lipoprotein cholesterol (HDL-cholesterol) levels increased from 54.2 +/- 15.1 mg/dl on animal insulin to 57.2 +/- 15.5 mg/dl on human insulin (rDNAE coli) (P less than 0.001). These data demonstrate that transfer of patients from animal-source insulins to human insulin (rDNAE coli) was associated with: (1) an improvement in glycemic control parameters; (2) a slight increase in the number of insulin injections in some patients, but no overall alteration in insulin requirements; and (3) no adverse trends in indicators of cardiovascular risks, such as serum lipids. Indeed, overall cardiovascular risk may have declined not only as a result of improvement in glycemic control, but also owing to a reduction in systolic blood pressure and an elevation in HDL-cholesterol levels.

Animals↗

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